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Joint Committee on Health debate -
Wednesday, 4 Jul 2018

Hospital Services: Discussion

This morning we are meeting officials from the Department of Health and the HSE to discuss the ongoing overcrowding issues in hospitals and the delays in admissions and outpatient appointments. On behalf of the joint committee, I welcome Mr. Paul Bolger, who is the director of the scheduled and unscheduled care performance unit of the Department of Health; Ms Susan Scally, who is a principal officer with responsibility for unscheduled care; and Ms Linda O’Rourke, who is an assistant principal officer with responsibility for scheduled care. I also welcome Mr. Liam Woods, who is the HSE's national director of acute hospitals; Ms Colette Cowan, who is the chief executive officer of the University of Limerick hospital group; and Mr. Bernard Gloster, who is the chief officer for community health organisation area 3.

I draw the attention of witnesses to the fact that by virtue of section 17(2)(l) of the Defamation Act 2009, they are protected by absolute privilege in respect of their evidence to the joint committee. However, if they are directed by the committee to cease giving evidence on a particular matter and they continue to do so, thereafter they are entitled only to qualified privilege in respect of their evidence. They are directed that only evidence connected with the subject matter of these proceedings is to be given. They are asked to respect the parliamentary practice to the effect that, where possible, they should not criticise or make charges against any person, persons or entity by name or in such a way as to make him, her or it identifiable. I advise the witnesses that any opening statements they have made to the committee may be published on the committee's website after this meeting. Members are reminded of the long-standing parliamentary practice to the effect that they should not comment on, criticise or make charges against a person outside the Houses or an official by name or in such a way as to make him or her identifiable.

I ask Mr. Paul Bolger of the Department of Health to make his opening statement.

Mr. Paul Bolger

I thank the Chairman and the members of the joint committee for the invitation to attend today's meeting. My colleagues in the scheduled and unscheduled care performance unit and I are pleased to be in attendance. I am the director of the unit, which was established in the Department of Health at the end of last year. The core objective of the unit is to improve access for patients to acute hospital services and to reduce waiting times for scheduled and unscheduled care. I am joined by Ms Susan Scally, who is a principal officer with responsibility for unscheduled care, and Ms Linda O’Rourke, who is an assistant principal officer with responsibility for scheduled care. Ms Mary McCarthy, who is sitting behind me, recently joined the unit as a principal officer with responsibility for scheduled care.

I propose to focus briefly on the current position with regard to waiting lists for inpatient day case procedures and outpatient procedures. I will outline the actions taken to date to improve performance and the plans for the remainder of 2018. If it is okay, I will update the committee on the waiting list figures to the end of June, which I received after I submitted my opening statement yesterday evening. I will provide a brief overview on the work that is under way to increase the number of beds in the system in response to the health service capacity review. My team and I fully recognise the impact on patients of long waiting times to access hospital services and the need to make real improvements. The health service will treat 3.3 million people as outpatients this year. It will deliver 1.7 million hospital operations or procedures outside of the additional work of the National Treatment Purchase Fund, NTPF. It is estimated that 435,000 of these 1.7 million hospital procedures, or just more than 25%, are from the waiting lists.

While this level of activity is not fully meeting the demand, progress is being made in improving access. The investment that has been made in this area of health care is delivering better results for patients. If we are to match the increase in demand for services and to reduce waiting times substantially and sustainably, the reform programme set out in Sláintecare needs to be implemented.

The actions outlined to reduce waiting times, improve the accuracy of waiting lists and invest in additional capacity are, nonetheless, important and will improve access for patients.

The programme for Government contains specific commitments to improve waiting times for hospital procedures. In total in 2017, €17.5 million was provided to the NTPF to purchase treatment for long waiting patients and in budget 2018 this investment was increased to €50 million. NTPF activity recommenced in April 2017 and, in July 2017, the number of patients waiting for such a procedure stood at a high of 86,100. By the end of 2017, the numbers waiting had reduced to just under 81,500. Inpatient figures at the end of June stood at 78,000, that is, patients waiting for a hospital inpatient or day case procedure, IPDC. This represents a drop of 8,100 or 9.4% in the 11 months since July last year.

In April this year, the Minister for Health published the inpatient and day case action plan 2018, a joint initiative of the Department of Health, the NTPF and the HSE. Under this plan, the number of patients waiting for an inpatient or day case treatment is targeted to fall below 70,000. It is estimated that during 2018, approximately 133,100 patients will be added to the published waiting list. To achieve the target of under 70,000, the IPDC action plan commits to remove approximately 145,000 patients from the waiting list this year through a combination of HSE and NTPF activity. The NTPF accounts for 20,000 procedures.

Several factors, including the cancellation of elective treatment and the increase in emergency procedures due to significant emergency department, ED, pressures, have resulted in fewer procedures for patients on waiting lists in our public hospitals. However, through the active monitoring of the action plan and the close collaboration with the HSE and the NTPF, it has been agreed that the NTPF will now target an additional 2,300 procedures in 2018, or a total of 22,300, to ensure targets are met. This level of activity represents a significant increase on 2017, where some 8,200 patients were removed from the IPDC list arising from NTPF activity.

The NTPF, working closely with the HSE, has invited all hospital groups to develop proposals to maximise the use of existing facilities and capacity. The NTPF advises that it has received 70 different proposals across all hospital groups. Arising from this, from January to June this year, more than 3,500 offers for treatment in a public hospital have been accepted and 2,400 patients have been treated.

The outpatient waiting list remains a significant challenge to be addressed in 2018. At the end of May there were 511,000 waiting for an outpatient appointment but this was reduced by the end of June. To address the issue of increasing outpatient waiting list numbers, the Department of Health, the HSE and the NTPF are finalising an outpatient action plan for 2018, which is due to be published shortly. This plan will support the HSE’s compliance with its national service plan targets, reduce the growth in the number of patients waiting for outpatient services, improve the accuracy of the waiting list, and trial a number of NTPF-funded interventions, including weekend and out-of-hours clinics. The validation of waiting lists is an important part of the successful management of waiting lists and clinics. Since the end of 2017, the HSE and individual hospitals have undertaken validation of waiting lists. To build on this momentum, last month the Minister approved the establishment of a central validation function in the NTPF to centralise the validation of all waiting lists across the HSE. The fund envisages being in a position to commence validation of patient files from September of this year.

Work on the development of an integrated waiting list solution, tailored specifically to meet the needs of our health system, is being advanced this year. The NTPF has examined the feasibility to progressing to an integrated system. This report is being reviewed by my unit with a view to establishing a high-level governance structure at system level to lead on implementation.

Ireland is experiencing a growing demand for health care services, which is evident in the increasing number of patients being added to waiting lists and the increased pressure on our hospital EDs. Increasing capacity is therefore central to improve access, both through our emergency departments and for scheduled care and waiting lists. As part of budget 2018, the Government provided an extra €30 million in 2017 and a further €40 million in 2018 to alleviate pressure on our EDs last winter. To the end of May 2018, total attendances were up 3.5% and admissions up 2.2%, compared to the same period in 2017. For those aged over 75, in the first five months of the year attendances rose by 5% and admissions by 5.5%, compared to the same period in 2017. This increased demand has contributed to an 11% increase in the number of patients on trolleys, compared with the same period in 2017. Delayed discharges also remained elevated during the winter period. The trolley figures during April and May began to stabilise relative to the preceding months in 2018. The national daily average 8 a.m. trolley count has been falling since March, with 340 in March, 297 in April, 251 in May and 224 in June.

The health service capacity review indicates that Ireland has among the highest acute bed occupancy rates in the developed world at 94%, significantly ahead of the OECD average of 77%. The national development plan provides for a major increase in capacity across the health system, including the development of new dedicated elective-only hospitals in Dublin, Galway and Cork. The aim of these hospitals is to both increase capacity and provide for a better separation of scheduled and unscheduled care.

Increasing capacity alone will not address the challenges faced, but on the basis of significant reform over the next decade, the report recommends an additional 2,600 acute beds by 2031. The NDP provides for the full complement of beds by 2028, three years ahead of schedule. As a first step toward implementing the health service capacity review recommendations, the Minister asked the Department to work with the HSE to identify the location and mix of beds which could be front-loaded in 2018 and into 2019 and 2020 to alleviate overcrowding. This proposal will seek to increase capacity in both acute hospitals and community settings. The implementation of this proposal will require a mix of capital investment, including a programme of modular builds. A key element of the proposal is the identification of the workforce requirement and the development of plans to meet these requirements. These proposals are currently under consideration by the Department and the Minister.

I thank the committee for the opportunity to provide a summary of activity under way. My team and I will endeavour to answer, to the best of our knowledge, any questions from the members.

I thank Mr. Bolger. Mr. Liam Woods is the national director of acute hospital services. I ask him to make his opening statement on behalf of the HSE.

Mr. Liam Woods

I am joined today by my colleagues, Ms Colette Cowan, CEO, University of Limerick Hospital Group, and Mr. Bernard Gloster, CHO area 3, covering Clare, Limerick and north Tipperary.

Each year our emergency departments, see close to 1.3 million patients and, on average, 25% of these patients are admitted. The total number of ED attendances has increased year on year while bed capacity has remained largely unchanged. This has created significant challenges for hospitals which manifest primarily in emergency departments but it is also creating challenges in terms of elective access. In the current year alone, ED attendances are up by 2.3% compared to the same period last year. This is on top of an increase in ED attendances of almost 3% during 2017 and 4.3% in 2016.

A key additional challenge facing our hospital and GP services is the sustained increase in the number of older patients presenting to ED. During 2017, hospitals reported an increase of almost 6% in the number of older patients attending ED with some EDs experiencing upwards of 10%. This year to date, a further increase in this age group has been observed with the number of presentations up by a further 3.4% compared to the same period last year. Typically, patients aged over 75 have more complex care requirements, are more likely to need to be admitted to hospital for treatment and will have longer lengths of stay. This means that the available capacity is under increased pressure as we do not have sufficient patient discharges every day.

The numbers waiting on trolleys at 8 a.m. fell by 3% during 2017 when compared to the full year 2016. The number of patients on trolleys between October and December was consistently lower than for the same period in 2016. These improvements were directly linked to increased capacity in a number of hospitals and sustained focus by hospital groups and community health organisations on reducing delayed discharges and improving patient flow. Targeted funding for emergency services in 2017 enabled consistent improvements in the wait time for funding under the fair deal scheme and an increase of up to 300 beds during the year. The trolley improvements were maintained to year end 2017.

The issues of overcrowding and the length of time patients wait in ED are a concern for both patients and staff, compromising a safe environment for assessing and treating patients. In 2017, the HSE sought to tackle both issues through investment in emergency departments, with UL opening its new emergency department in June 2017, and upgrades were undertaken in St. James's Hospital and at Mullingar. The major capital development of 80 beds, theatres, and an expanded ED in Our Lady of Lourdes Hospital, Drogheda, is opening on a phased basis in 2018.

The HSE has continued to focus on full compliance of no patient waiting over 24 hours and improvements have been made as compliance with this metric is now 95%. A key challenge for most hospitals is the lack of sufficient isolation facilities or single rooms required to ensure that infection control issues are managed appropriately. As a result patients can wait for significant periods for suitable accommodation.

In 2017, funding of €5 million was provided to support the cost of upgrades in EDs and wards aimed at addressing infection control, security and environmental issues. The first four months of 2018 have seen the number of patients on trolleys increase due to increased attendances and the age and acuity of patients presenting. However, there has been a stabilisation from April onwards with May showing an improvement against the same period in 2017 of 2.5%.

The number of confirmed influenza cases and influenza outbreaks during the 2017-18 flu season exceeded all previous records in Ireland, including the 2009 pandemic. The impact was particularly severe for those over 65 years of age, with 2,218 confirmed influenza hospitalised cases and 85 intensive care unit, ICU, admissions in that age group. Key challenges this year have been the sustained increase in influenza cases, insufficient isolation facilities and delays in the discharge of patients to home and other community settings. A further challenge was the incidence of influenza in nursing homes, which prevented new admissions from hospitals for periods in early 2018. Funding of €40 million was made available in winter 2017-18 to support surge pressures. Of that, €30 million was allocated to support additional home care packages, transitional care and aids and appliances, while the remaining €10 million was allocated to support the opening of an additional 260 beds during 2018.

Notwithstanding the extraordinary measures taken over the winter period to manage emergency activity, there is evidence to suggest that access to elective care is being crowded out. The Chairman and members will be well aware of the challenges that the HSE and, more importantly, patients are facing in terms of accessing outpatient and inpatient or day case services in public hospitals in spite of the significant volume of activity undertaken in hospitals on an annual basis, with 3.3 million patients seen as outpatients and 1.7 million procedures carried out. The latest waiting list information shows that at the end of June 2018, there were 511,000 patients waiting for a first outpatient appointment and 78,000 patients awaiting a surgical procedure.

Although a significant volume of patients are waiting for treatment, we have begun to make progress in this area. That is evidenced by a fall of more than 8,000 or 9.4% from the high of 86,100 in July 2017 in the number of patients waiting for a hospital inpatient or day case procedure. The latest figures also show that 58% of patients awaiting an inpatient or day case procedure are waiting less than six months and 83% are waiting less than 12 months. The progress in reducing the number of patients waiting for a hospital procedure comes as a result of Government investment in the area, supported by increased focus and collaboration across the HSE, the Department of Health and the National Treatment Purchase Fund, NTPF. In budget 2018, €50 million was provided to the NTPF to provide treatment for public patients. The inpatient and day case action plan published in April is a joint initiative between the Department, the NTPF and the HSE with the aim of reducing the overall number of patients waiting for treatment. Among its central goals are that by the end of 2018 fewer than 70,000 patients will await treatment, down from the historic peak of 86,100 in July 2017, and that 10,000 fewer patients will be waiting longer than nine months. Under the action plan, the NTPF has committed to provide 20,000 procedures for patients through the purchasing of additional activity in public or private hospitals. The HSE, working with the NTPF, has invited all hospital groups to develop proposals to maximise the use of existing facilities and capacity. For example, in the University Limerick hospitals group, dedicated cataract theatre capacity is being opened in Nenagh Hospital and the NTPF will fund treatment for patients there in 2018.

Although progress is being made in reducing inpatient and day case waiting lists, the outpatient waiting list remains a significant challenge, with 511,000 waiting for an outpatient appointment. Each year, 3.3 million patients attend hospital outpatient clinics. Slightly more than 70% of patients wait less than 12 months and approximately 60% wait less than nine months, while just under 50% wait less than six months. In order to address the issue of rising outpatient waiting list numbers, the HSE and the NTPF are in the process of finalising an outpatient action plan for 2018. The plan will support the HSE’s compliance with the national service plan targets, reduce the growth in the number of patients waiting for outpatient services, improve the accuracy of waiting lists and trial several NTPF-funded interventions, including weekend and out-of-hours clinics.

It is worth noting that almost 500,000 outpatients did not attend their appointment in 2017. The validation of waiting lists is, therefore, an important part of the outpatient action plan and the successful management of waiting lists and clinics. Since the end of 2017, the HSE and individual hospitals have undertaken validation of waiting lists. In order to ensure a consistent approach in that regard, the NTPF, through engagement with the HSE, has developed a proposal to establish a central validation office in the NTPF, which will centralise the validation of all waiting lists across the HSE. The NTPF has begun to engage with the HSE at national and individual hospital level to progress this proposal and envisages being in a position to commence validation of patients from September of this year.

Key enablers to the development of more sustainable solutions for access to services are the implementation of the Sláintecare report and the recommendations of the health service capacity review. The capacity review acknowledges that our acute capacity is not sufficient to meet our current demands, with hospitals operating at almost 100% capacity. The report sets out a clear plan for the delivery of 2,600 beds, as well as sustained investment in primary and social care services. The HSE is working closely with the Department to agree a robust implementation plan for core recommendations of the review, with clear milestones for delivery of changes in the model of care delivery and investment in additional capacity. The HSE has established a capacity steering group and more recently a task finish subgroup to progress this programme of work.

I and my colleagues will endeavour to answer any questions members may have.

I will now open the discussion to members, who I will take in groups of two. I ask the witnesses to bank the questions and address them in order. The first two contributors will be Senator Colm Burke and Deputy Donnelly.

I will contribute at a later stage.

In that case, Deputy Kelly will be the second contributor.

I have to leave soon to do an interview. If I am back in time, I will take my slot and, if not, I will take the one after that. My apologies.

I call Senator Colm Burke.

I thank the witnesses for their attendance and the presentation. The report provided by Mr. Woods refers to the 2,600 additional beds required and the issue of elective hospitals. Project 2040 contains plans in that regard. What progress has been made on the elective hospitals projects? For instance, Cork was identified as requiring a new hospital. A committee was formed to further the project but I understand it has not yet met. What progress has been made in that regard? This is an urgent matter and if the relevant people are not meeting to identify sites, etc., how can the project be delivered?

The report refers to 477,000 people not attending for appointments. What progress has been made in regard to updating how people are notified of appointments, such as by text and so on? Many areas of the HSE now notify patients by text but all areas should do so. Obviously, that would reduce the number of people who get the date of their appointment wrong for various reasons, such as ill health, and may not notify the hospital of that. Some 477,000 is a significant number of non-attendances, almost 10,000 per week, and is a significant drain on the service. For example, if 50% of patients do not turn up for their appointment at a particular clinic, a huge amount of time is wasted.

There is a substantial waiting list for gynaecological services in Cork. Some 40% of those on the waiting list for the entire country are in that area. What progress has been made in reducing the number waiting for gynaecological services in Cork and what further action needs to be taken?

In the past two weeks, I have become aware of a very serious problem in regard to access to psychiatric services for young people. A young person was admitted to Cork University Hospital in April of this year but has not been seen by a psychiatric consultant as there are none covering that geographical region of Cork. Consequently, the young person cannot access the CAMHS programme. His parents are extremely concerned and he wishes to get access to services. There appear to be territorial boundaries such that a consultant in charge of one area will not see a patient from another area. In the era of modern medicine, it is outrageous that this 15 or 16 year old boy requires access to services but cannot access them because of entrenched positions.

I need some clarification in that regard. This is an area in which we have seen a number of serious incidents involving young people and there is a need for access to services. The consultant who was there has either retired or resigned. There was a locum in place for period who has now gone and there is no consultant covering the area. Young people who want to gain access to the service cannot do so. There is a need for some accountability on the matter. I have referred to someone who is on a waiting list. The issue is extremely urgent.

I welcome the delegates, particularly my two local HSE representatives.

We have talked these issues to death in the Chambers. It has been ongoing for decades and the blame game goes on all of the time. I have read the Department's statement, but what is the plan? The HSE does not act in a silo. We need to refocus some of our attention onto the Department. We now know about issues with the budget for this year. What are the plans in that regard? It will have an impact on our discussion. When is the Department cutting things off or is it just going to run on? The answer could decide whether we are to have a general election. I am not joking when I say that. There is a significant budget overspend. How is the Department going to manage it, given the topic we are discussing? Let us not have a generic, rubbish answer. The officials are obviously planning for it. I have been in Departments long enough myself. What are they going to do this year that will be different from they did every other year? Are they going to do something different? They should tell us now in order that we can prepare for it.

Does the Department think the recent and forthcoming changes to structures in the HSE are having and will have any impact on service provision? I would appreciate it if Mr. Bolger answered that question. There is a lot of change. A new board is being appointed before a chief executive, something I suggested to the Minister and in fairness he took up my suggestion. It looks like there will be the reintroduction of regional structures, which is necessary. There are new positions being advertised, as well as lots of stuff going on. Is all of this change having an impact and, if so, is the impact negative?

My final question is about a budgetary issue from a departmental vision point of view. When I look at eldercare services in particular, I have a real issue. It is a real bugbear of mine that from a financial and a service provision point of view, there are escalating costs associated with home care as compared to helping people in nursing homes and also with people spending a night in an acute care setting. The vision is not working to deal with people in the first tier and possibly the second and to provide a third. This would reduce the problems of some of those working in the HSE because it would reduce the volume of people who end up in hospital and acute care settings. That question is also for Mr. Bolger.

My other questions are for Mr. Woods, in particular. I live in County Tipperary. The two biggest issues for waiting lists and accident and emergency departments are South Tipperary General Hospital and Limerick Regional Hospital. They are on either side so we are getting it both ways. It is a real issue. Maybe Ms Cowan could outline to the committee how we got a fabulous new accident and emergency department which myself and the Chair visited. It is three times the size of the old accident and emergency department yet the volume of people attending it increased dramatically over its capacity. I presume there was research done into why that was the case. If it was not at that scale in the beginning there are obviously underlying issues.

On the pathways for the groups of hospitals across the country, I will use my own mid-west region as an example. We have Limerick, Nenagh and Ennis. I congratulate them on what they did on cataracts. It is a great example and should be done around the country. The centre is going to be in Nenagh. The issue for me is that the pathways by which patients are being managed in the groups of hospitals across the country needs to change. More people need to be moved out of the model 1 hospitals out to model 2 and 3 hospitals quicker for aftercare and pre-care and there are real issues in how that is happening. There was only one ambulance in Thurles at the weekend, where there were 50,000 people. Intermediate care vehicles are something I have been talking about for years; it is a bit of a joke really. A small bit of investment there would move people pretty quickly. We would not have the same level of issues in Limerick if we had people moved out to Nenagh and Ennis quicker. Why is that not happening?

This is a rapid fire round. Have there been any changes to how the HSE manages relations with GPs? Are lists kept in respect of GP referrals to accident and emergency departments? Maybe not for public consumption but at least for the HSE, are heat maps done of GP referrals to accident and emergency departments? What are we doing to ensure that hospitals are run seven days a week instead of five days a week in respect of consultants and work? Can Mr. Woods update me on the history, decision making and current deployment of modular units across the country? This was decided some time ago. There is a proposition from Limerick to put in a modular unit. Will that be supported? Will Mr. Woods answer me here and now? Modular units are proposed for other parts of the country. When was that first mooted in the HSE, what are the locations and have decisions been made on them?

I have specific issues in respect of paediatrics. This is a public matter so there is no issue about naming him. Two weeks ago, a 14 year old boy called Matthew Quinn, who I went and met, was on the Six One news about waiting lists. He has Down's syndrome and is waiting for a hip replacement for two years. He slipped and needs an operation. For two years he has been flipped between Crumlin and Tallaght. I have read there are issues in the relationships between the two hospitals and in respect of paediatric services. Meanwhile, a 14 year old boy with Down' syndrome who was asking me to help him get a new leg is waiting for an operation. What is going on there? This is only one case.

This is the real kicker. Recently there was a lot of media coverage in respect of the hospital network in the mid-west.

By comparative standards, looking at the staffing ratios in the mid-west versus other parts of the country - and this was in the media for some time - there are 14% less staff in the acute services. How did this happen? Why was it allowed to happen? Why was the mid-west not supported? Will this be addressed? Five hundred and sixty staff correlates to the highest mortality rate in Ireland. Did anyone in the HSE know this? The cost for those staff - doctors, nurses, specialists - is €22 million. When will this be addressed? Why are the mid-west's employment levels, according to these figures, which I have not seen challenged - and if they must be challenged, they should have been challenged by now - that much below the employment levels of all other acute services across the country? The Chairman knows what I am talking about.

Perhaps Mr. Woods might like to address Senator Burke's questions first and then Deputy Kelly's.

Mr. Liam Woods

Sure. Regarding additional beds and elective hospitals, I think the question asked related particularly to the south. As the Senator may be aware, a group has been formed in the south around that specific hospital. Its work would include looking at issues such as site selection. Work is also ongoing centrally on the nature of an elective hospital and the kind of work that would proceed in it. There is health planning work to be completed to determine the nature and shape of such a facility, and it has commenced. Our planning function, both clinically and in hospital terms, is working on this.

That is fine, but the group has not met.

Mr. Liam Woods

Sorry, I did not mean to say it had met. I know that a group has been formed. It has not met yet, as I understand it. It is due to meet in the near term.

I heard that four months ago.

In fairness to the Senator, he did.

Mr. Liam Woods

I believe the leadership of that, which is in the south-south west group, which in fact I myself sit on, is undertaking to arrange a meeting in the next couple of weeks.

Perhaps someone might come back to me to tell me-----

Mr. Liam Woods

I will of course.

-----when the group has met.

Mr. Liam Woods

Regarding the reference to outpatient departments, non-attendance at emergency departments, EDs, and the use of texting, we have held sessions ourselves to seek to ensure that good practice in some locations is used more widely. We ran a session in Mary Immaculate College in Limerick on this in the not too distant past. We are focused on getting good practice in place in order that we have optimal pickup and that patients have an opportunity both to be aware that their appointments are coming and to notify the relevant party if they have difficulties with the appointments. The use of texting is partial, not universal, and needs to roll out more fully. I accept that in this day and age we could and should look to do it more completely. The wider point about learning is one on which we are very focused because we have very good practice in sites around the country.

Senator Burke referred to gynaecology in Cork and nationally. We have asked all hospital groups to put forward proposals as part of the work with the NTPF this year for undertaking work both within their own facilities and where they do not have capacity outside in the private environment. This would include gynaecology in Cork. A commitment was made last year to undertake work, as I recall, in gynaecology in Cork. I might offer to bring the Senator back a specific report on volumes in Cork and what is intended this year, but that was open to submission from the group, and I recall it has made proposals in the current year. On the specific reference to Cork University Hospital and perhaps CAMHS, I might ask my colleague, Mr. Bernard Gloster, to address the Senator. The Senator referred to an individual case.

Mr. Bernard Gloster

Sure. Obviously, I am not aware of the individual case. Cork is in community healthcare area 4. As I am sure the Senator knows, Cork and Kerry combined have the second highest under-18 population in the country at 168,542. They currently have a clinical whole-time equivalent workforce in the child and adolescent mental health services of 76.97, so just under 77 whole-time equivalents. Their rate of seeing new referrals is not out of kilter with those of the rest of the country nor is their rate of referrals seen per clinical whole-time equivalent, WTE, available. They are high on the waiting list end. They have 630 on a waiting list, with 192 of those waiting over 12 months. The 630 on the waiting list is out of a national figure of 2,600, so there are pressure points there. Of the interventions that were made, probably the most critical is that nationwide this year a new grade was introduced into the psychology service of assistant psychologist, and 100 posts were deployed across the country in that respect. I do not have the exact figure for Cork but I will follow up on the Senator's concern and query with my colleague, the chief officer, and ask him to write to the Senator directly about it.

The problem we have is that there seems to be an entrenched position. A consultant not working in a particular area - I am talking about a geographical area now - cannot be transferred to another area. That is the advice I am being given. I have written to Gerry O'Dwyer, the CEO, on this matter, and the response I received from Ger Reaney by telephone was that there is no consultant there. Therefore, this patient cannot be seen until a consultant is in place. I was not aware until that phone call that there is an entrenched position whereby people will not be seen unless a consultant is in situ.

Mr. Bernard Gloster

As I said, to be fair, I do not know the specific case. I do know that in many areas, where someone presents in acute circumstances, as opposed to someone on perhaps a more routine waiting list, every effort will be made by the collective service in the county to try to assist. However, I appreciate-----

That is not what is happening.

Mr. Bernard Gloster

-----what my colleague has told the Senator about there being no consultant available in the area and others not moving. I just do not have the detail to be able to assist the Senator further with the matter. However, I will certainly take it back up with both my colleague, Ger Reaney, and the national mental health office in the HSE. I know from my own area in the mid-west that when there is a vacancy for or a gap in a position, while it obviously causes significant delays because people cannot cross over for the sheer volume of work they are doing in their own areas, I would not say that would apply where an acute emergency would arise. However, I will elaborate on that further for the Senator.

There were some questions directed at Mr. Bolger.

Mr. Paul Bolger

Deputy Kelly asked about the plan for this year, whether the Department thinks changes at the structural level are having an impact and asked a final question about elderly care. I will answer the first two and pass the question about elderly care to my colleague, Ms Scally, who is leading a review of delayed discharges and that area.

The Deputy asked what the plan is and what we are doing differently. One of the key things we have done this year is to establish a new unit within the Department which has a clear focus on scheduled and unscheduled care. This is my unit, and these are some of the members of the unit. This is our clear focus and this is what we are interested in: driving improvement in scheduled care, which concerns waiting lists, and unscheduled care, which concerns trolleys. To talk about how we are working, I will focus on three areas: what we are doing in terms of activity, what we are doing about finances and what we are doing to bring forward improvements.

We have sought to address activity by setting out and agreeing clear targets with the HSE and the NTPF, particularly in respect of inpatient and day-case activity. We publish these figures with a very clear and, I think, very understandable target for the end of the year, which is 70,000 people. We do not just say, "We will see you in December" and hope to be successful in meeting that target; we actually monitor the target every month. We have trajectories that we expect the HSE and the NTPF to deliver each month and we monitor these. The benefit of the monitoring is that, by working collectively with the HSE and the NTPF - we meet fortnightly at official level and meet with the Minister every month or six weeks on this issue - we are able to address or overcome any administrative challenges or any other challenges that arise. There have been some examples of issues that we have been able to address. Second, and more important, we are in a position, as I outlined in my statement, to introduce remedial plans when we are not making progress in line with the trajectory.

This year, at the end of April, we were able to sit down following the winter and say: "This is where we expected you to be in terms of your activity to meet the 70,000 target and this is where you are." At that time there was a shortfall of between 2,000 and 2,500 procedures. We were then in a position to go back to the NTPF through the HSE and say what types of steps could be taken to address that. The plan that has been agreed, to which I referred, is that there will be an additional 2,300 procedures for which the NTPF will be able to offer treatment this year.

The second element is finances, and it links into that area in terms of remedial plans. This year we have held back all the new funding relating to activity. All the new development is held in the Department and it is released when we are satisfied the measures that were introduced have been delivered. This brings an additional level of control to the process from our perspective. It ensures that the priorities the Government has set out and funded are delivered. Second, it gives the opportunity to avail of new opportunities as they may arise. The best example we have this year is that there were certain projects that were not progressing fast and were not going to draw down funding this year. They were the modular build in Clonmel, a delay in opening beds in Kilkenny and a centralised validation function we established. By having greater control we were able to address that finance and then reallocate the money that was allocated for those to open the cataract theatre in Nenagh from July. That is an example of how we are actively monitoring the finances and making changes mid-year to deliver.

The third piece is improvement. We are taking an evidence based approach and we are fortunate that we are able to build upon the work of colleagues that was undertaken last year relating to the capacity plan. That sets out the clear challenge the system is facing. One of the big tasks of Susan Scally and her team for the first six months of the year was working with the HSE to develop proposals for where additional capacity could be introduced into the system. We have also established a centralised validation function within the NTPF. This is a very important function. At one level it will ensure that the waiting lists and the challenges we are addressing are accurate. It will also offer consistency to patients throughout the country in terms of communications and timelines. A great deal of work has been done by the Department, the NTPF and the HSE to simplify communications with patients and to send out clear letters of one page that make it very clear what the person has to read, what the person has to do and what the person has to return. We have trialled that with a number of groups and it has had an impact.

The next matter is working on the basis of the lessons learned process for next year. In the context of planning for the coming winter, the key question is what lessons we can learn from last year. It is not so much what happened last year, but the question we are engaging with the HSE on is what happened over and above what it had planned to happen. We have had much discussion about this. Liam Woods referred to influenza and we referred to some other issues. It is not so much that we had a longer influenza season; it is about what was being planned, what happened and what lessons we can learn from that as we plan for next year. To bring that together on what we are trying to do in terms of the improvement aspect, the ED task force is now in place and what is planned for September this year is an unscheduled care forum that will bring together members of the ED task force and, more importantly, people from around the hospital system and perhaps internationally to look at what processes worked-----

I am sorry, but the witness might specifically answer the question. What happens as it goes over budget towards the end of the year? We see the profiling already so it will happen. What will be done differently from last year? What will happen when the Department knows that the HSE is running over budget? That will happen in October or November so what will the Department do differently from then on from last year?

Mr. Paul Bolger

What we are doing is not waiting until it gets to that point.

It will not go over budget.

Mr. Paul Bolger

It is not that it will not go over budget. The funding for the NTPF is the opportunity to ensure we address that. We have a clear target of 70,000 patients by the end of the year.

I am asking about the budget.

Mr. Paul Bolger

Is it the budget for the hospitals?

It is the budget given to the HSE. The Department sees from the profiling that it is running over budget. Is anything different going to happen this year from the Department, yes or no? If it is, I ask the witness to tell us.

Mr. Paul Bolger

The first thing that is different is that we have held the funding back in respect of new developments funding. In terms of the bigger piece of the overall management of the budget, that is slightly outside my remit, if it is okay to say that. However, we are being very clear that we have set out a plan for 70,000 patients and we are not expecting to see a fall-off in activity with regard to the hospitals. What we have done this year in terms of the NTPF is that we are planning to continue activity into October, November and December whereas in the past activity would drop off in those months. From my perspective there are no plans to shut off activity in the scheduled care side.

Perhaps the Secretary General can answer the question if Mr. Bolger cannot. It looks like nothing is going to change.

Mr. Paul Bolger

The first piece that has changed is the funding piece. The third piece is that the Deputy asked about the structures and changes and what impact they are having. We have set up a new governance structure with the HSE and the NTPF. In my area, all I can say is that I do not think it is having an impact at present. There has not been a huge amount of change in our particular area and we continue to meet the people on a regular basis. In a large organisation such as the HSE there is always a period of change. It is something we are very conscious of and, as I said, the increased engagement is a big part of that.

The other members have to ask questions so would Mr. Woods answer my questions?

Mr. Liam Woods

To pick up on a couple of themes-----

There were the intermediate vehicles, the ambulance, the pathways with regard to tier 2 and tier 3 hospitals, the GPs, the modular, which I am very interested in, and the situation in the mid-west.

Mr. Liam Woods

I have noted those. The Deputy asked about elderly care and the cost of home care, nursing home care and hospital care, and a logical movement. I wish to make one point about structure. Providing care on a joined-up basis in the way the Deputy mentioned can be assisted by structure, but structure itself will not enable anything for a patient. That is probably agreed.

The Deputy asked about the new ED in Limerick and whether the volumes were anticipated. Colette Cowan can elaborate on this if it would be helpful, but certainly there was an initial peak before it fell off. Then there was a gradual rise which is associated with care patterns in the mid-western region. The underlying challenge, and the Deputy referred to it elsewhere in his questions, is that there is a growing demand for service. In the mid-west that is presenting at a higher rate than elsewhere in terms of ED services. The pathways-----

There has to be a reason for that.

Mr. Liam Woods

Yes. The Deputy asked questions about GPs, GP lists, referral patterns for individual practices nobody understood, the work of Shannondoc, which Bernard Gloster might be able to speak to, and whether that was understood in terms of a source of admission into hospitals or referrals to hospitals. It is, and such data exist within individual hospital patient administration systems. With regard to the pathways question and the movement of patients from a level 4 to a level 3 or level 2 facility or, indeed, into the community, the models of care are developed clinically. The Deputy's question or statement is very sensible. It is a direction we are seeking to travel, to provide as much care as possible at the lowest level of acuity and as close to home as possible or in home if possible. Clinical pathways that have been and are being developed across the HSE are supporting that. That is the intention of planning. It is why the bulk of the winter funding went into home care support. The Deputy's point about the economics of that is well made. I agree that the best value and the best location of care are at home.

The ambulance service and transport issue in the mid-west is a good example of that. Mayo, Letterkenny and Tralee would have similar pressures in terms of accessing ambulance transport-----

I was driven to hospital-----

Deputy Kelly, to be fair to our other members you have had an opportunity to ask many questions. We will get answers but we need to move on to other members.

Mr. Liam Woods

In terms of ambulance and intermediate community care vehicle, ICV, cover, there has been an increase in that and it continues. It also remains under pressure. As the Deputy rightly says, the demand for increased bypass facilities to more major centres is a demand the ambulance service faces as well as the growth in calls. In the mid-west region there is a pressure which Colette Cowan can speak further on around patient transport. There is an advantage in having Nenagh and Ennis which allows for the movement to a more appropriate setting. Sometimes the challenge in that is transport. There has been a growth in expenditure on private transport at times to support that, which we would prefer to run through the public system if the national ambulance service can support it. It has done so, but it remains under strain.

On GP relationships, there is work ongoing with GPs in terms of their referral practices and protocols around referral in some specialties as part of our outpatient planning.

There is a very good example in neurology where effectively a consultant, clinical leads and GPs have agreed protocols and the effect in practice has been to reduce outpatient numbers significantly and reduce waiting very substantially. That is being expanded to other areas both in terms of specialty and across the country.

On the issue of a seven day working week pattern, there clearly is already some seven day working in terms of waiting list work. Some of the proposals we are receiving are about running clinics on weekends and at night time. Consultant contracts allow for seven day working patterns as do some other clinical contracts. Not all contracts provide for this and there is work to be done in that area in the system overall. The best capacity we can access most quickly is our own that is used most intensively. I take the point Deputy Kelly makes and there is some work taking place on the issue.

On the issue of modular units across the country and whether a modular unit in Limerick and the University of Limerick hospitals group will be supported, there is a proposal from the UL hospitals group on a modular unit, as the Deputy is aware. The HSE has submitted that, with other proposals, to the Department and would be supportive of it, subject to deliberations at Government level around increasing capacity in Limerick. Underlying part of Deputy Kelly's question is the capacity constraint in the UL hospital groups, which we understand. It has been well researched and clinically validated and we need to invest. We would be supportive of growing capacity in Limerick, and that would include modular units. I should add that we are in discussions with the Government which, with the Minister, will need to make decisions in the coming weeks to determine the outcome of that. We are supportive of capacity as we know it is needed. To be fair to colleagues in the Department, they are equally aware of it.

The Deputy raises a specific case of an individual child and an issue between Crumlin and Tallaght hospitals. If I can, I would like to answer the Deputy directly on that individual case. I do not have the details with me but I can do that. The more general question the Deputy asks is about co-operation between the facilities and the pathway of care. I get that and I will revert to the Deputy on that if I can.

The Deputy's final question was on staffing ratios and staff funding. I am aware of the piece of work to which the Deputy referred but this is connected to the general point around capacity. I have already acknowledged there is a capacity issue in the mid-west region. I might ask my colleague, Ms Colette Cowen, to address the specifics relating to the report.

Ms Colette Cowan

For the information of members, the new emergency department opened on 29 May 2017 and has now been opened for one year. This time last year, approximately 179 patients would go through the emergency department each day. This year we have seen a growth of 5.5% in activity and 210 patients on average per day go through the emergency department. Last Friday, we had a high of 229 patients attend the emergency department for treatment. There is a number of reasons for that. Of interest is that in comparison to last year we have an increase of 2,000 patients aged over 75 attending the emergency department. This is a significant jump of 5.9%. Of the 2,000 patients over 75 years who attended for treatment, the figures indicate that 30% will be admitted and remain in the hospital for a number of days to get the full capacity of care they need. This is a major change. We are aware that with population growth, we will have an increased need to treat older people in services. It is known that the Limerick area has the highest number of people aged over 85 living alone. These older people will acknowledge that they tend to come to the emergency department because it is a safe place for them to get treatment.

We have activity from the GP and Shannondoc referrals, which can be high at times. It is important to note in respect of general practitioners, however, that they are working flat out. They are working long hours and they rely on us for the diagnostic access, which means they tend to send patients in for treatment and care. We are in discussion with GPs on the development of an urgent care centre. In recent weeks, a few of them visited an urgent care centre in the United Kingdom with some of my team and some of Mr. Gloster's team as part of the effort to find a diagnostic model that support the GP service. I am aware that general practitioners are currently commencing or in negotiations on their contract, which is pivotal. If one wants to assist the emergency department in the mid-west region we need the GP and the primary care service enhanced and supported in their role. I know the negotiations are under way.

Regarding staffing ratios in the mid-west region, I have a very bright clinical director working for me who analysed a great deal of data from the HSE's national human resources department shared his analysis of them. Out of his analysis came his concern regarding the number of whole-time equivalent staff in the mid-west region. We have discussed the matter and we will do further briefing and analysis with national HR to ensure we have the exact facts around those figures because we will need to examine the issue if it is the case that the number is so high. Given that data can be subject to different interpretations, we need to be factual on that.

There must be something going on given the scale of it.

Ms Colette Cowan

It is challenging to get people to come and work in the mid-west, although not from the point of view of nurses. That applies in particular to attracting consultants to return to work because - and this is my personal view - their salary scale is not correct and must be reviewed. Extensive work is required on how we attract staff at that level to work in the service in this country. We will table a paper on that if it is of help regarding whole-time equivalents because I trust the person who raised this issue and did the analysis on it. I need to work more with national HR on it.

I thank Ms Cowan. We will move on to the next two speakers, Deputies Stephen Donnelly and Louise O'Reilly

I thank the Chairman. I will not need 45 minutes, as the previous questioner took.

I asked the questions.

Deputy Kelly had 45 minutes and I ask him not to interrupt other speakers.

I am not interrupting the Deputy, but he made a smart comment for no reason. I asked the questions. The time it took to answer them is another thing.

May the rest of us talk?

The Deputy should not make smart comments. It demeans him.

Please, Deputy.

I thank the witnesses for coming today. I would like to go back to the basics and ask what the problem is because if one looks at our healthcare system from the outside, this should not be happening. We have young boys and girls waiting for operations for spina bifida. The average spinal curvature in cases involving scoliosis in Europe is 50 degrees, whereas in Ireland it takes so long to access surgery that curvature reaches 100 degrees and leads to preventable lifelong problems. We have people waiting more than one year to be accessed for wheelchairs. We heard at a meeting last week that a child aged two and a half years for whom there are suspicions of autism will not be offered treatment until he or she reaches six years in some parts of the country. We are all aware that on a human level this is destroying people's lives.

In orthopaedics I ended up dealing with people in Cappagh Hospital because the waiting lists had become so long. One of the clinicians told me that there was a reluctance in some cases to take on new patients. The waiting lists were so long and the patients were in such severe pain that there was a fear that they would kill themselves or become addicted to morphine before they got to see a consultant and had surgery. The human cost is extraordinary and we must ask why. We spend as much money as almost any other country on healthcare. In that case, the answer cannot be that we do not spend enough money.

The capacity review done by PA Consulting for the Department of Health shows that the average age in Ireland is considerably lower than in most other countries and we should, therefore, need considerably less healthcare assets than most other countries. It also shows we have roughly the same number of general practitioners, acute beds, nurses and doctors as other countries. What the data show us is that we spend more money than almost any other country on healthcare; we have approximately the same amount of healthcare assets as other countries; we should need fewer healthcare assets because we are younger; and yet we have some of the worst waiting lists in Europe. In fact, a recent pan-European report showed that the Government waiting time targets of 18 months, if met, which the Government cannot do, would give us the worst waiting times in Europe. That does not make sense. If we spend more money than other people, we should need fewer healthcare assets than other people. We have as many healthcare assets as other people and yet people are waiting in agony in circumstances which do not pertain in other countries. Why is that happening here? What are we doing so terribly badly, which other countries have sorted out, that is leading to this pain and suffering all over the country?

I welcome the deputations and thank them all for coming in.

The bed capacity review identified a clear need for additional beds in the system. Mr. Bolger said in his submission that the Minister asked the Department to work with the HSE to identify the location and mix of beds that could be front-loaded in 2018 and into 2019 and 2020. What I have to say might save the Department a great deal of work. The Irish Nurses and Midwives Organisation has identified that 1,000 beds were closed. I do not intend to get into the politics of who closed them and why, but they are closed and clearly available to be reopened. These beds are situated throughout the country. We know of 19 in Letterkenny. I know my colleagues, Deputy Pearse Doherty and Senator Mac Lochlainn, have been campaigning on that. Anyway, the beds are right across the system. Perhaps the deputations can give me their views on where these beds are and how easily they can be accessed. Does the Department intend to front-load them in 2018? The submission is somewhat light on the detail and on where the beds will go. Obviously, those responsible have clear sight of the plans for the 2018 beds and most certainly the 2019 beds, whatever about the other plans. Will the witnesses provide the number and location of the beds?

That leads to my next question. Will the witnesses identify how many of those beds are closed due to staff shortages? I have a view on the relevant numbers.

That leads on to my next question, which is on the funded workforce plan. My understanding is that the Department agreed a funded workforce plan with the nursing unions last year. The Department did not hit those targets, which comes as no surprise, and, in fact, missed them by a considerable amount. Much and all as the Department did not achieve its targets in 2017, there is no funded workforce plan for this year. I understand this matter has been referred to the Workplace Relations Commission. What I do not understand is why there has been a delay in fulfilling what I understand to be an agreement between the Minister and the trade unions representing nurses. Department officials do not need me to tell them but I will explain it for the benefit of saying it. The Department cannot open the beds or solve any of the crises, however these multiple crises were created, unless the hospitals have the staff to do so.

We know the Bring Them Home campaign was a spectacular failure. We know the HSE did not achieve the rather modest targets set out in the funded workforce plan. If we can identify the beds – that would be brilliant – then perhaps the deputations could identify, in the absence of a funded workforce plan, how we will be able to staff those beds.

Will Mr. Woods comment on the practice of counting fourth year student nurses as whole-time equivalent, WTE, staff members? In my time, they were not counted as WTE staff. If the HSE has started doing that now, will Mr. Woods explain why? It is not that I am a cynic, of course; I am simply an optimist with experience. Anyway, to the cynical eye, it looks a little like an attempt to massage the staffing figures. I sincerely hope it is not, but Mr. Woods might explain whether that practice has commenced and, if so, why.

Children are waiting for scoliosis surgery. Targets were established and missed. We know the four month waiting target has been missed by a factor of years for some people and for 88 people in total. I spoke to a parent on Monday. She came in to see me in my office. Parents are referring to the practice of what they call aggressive management of lists - these are their words and not necessarily mine. A letter is sent out to the parents of children who have scoliosis severe enough to require surgery asking whether they still want the surgery. I can tell the committee in advance that they still want surgery for their children but they do not get enough time to respond. They refer to this as aggressive management of the waiting list and they are deeply unhappy about it. They see it as a means of perhaps knocking people off the list. Again, that is a mechanism by which the figures could be massaged. Will the deputations comment on that? That seems to be particular to this cohort but that could simply be because these were the people I was talking to recently. We could debate all day whether the practice of sending out letters asking people whether they still want a procedure is a valuable use of time. Certainly, in the case of children with scoliosis it is a reasonable expectation that they will want surgery. The parents are reporting that they get such a short timeframe to respond and this is causing them serious problems.

Mr. Bolger went through all the figures on the National Treatment Purchase Fund. My views on the NTPF are already on record and there is no need for me to rehearse them. The NTPF accounts for 20,000 procedures. I have several questions about the NTPF. Am I right in saying that of the 20,000 procedures a total of 10,000 have been done? Halfway through 2018, how many have been done? What value-for-money metrics does the Department use to assess whether it is getting value for money from the NTPF? How is value for money established? Can the Department point me towards the value-for-money figures, facts and statistics? I simply cannot find them anywhere. Reference is made to how the NTPF will account for 20,000 procedures this year. Can the Department give the committee an indication of how many have been done and how many have been scheduled?

I will now invite in Deputy Margaret Murphy O'Mahony for a short intervention and then we will go back to the answers.

I welcome all the deputations. I offer my apologies in advance for leaving to go to the Chamber before the witnesses answer. I will watch the proceedings later.

Mr. Bolger said there was a drop in the number of people waiting. He said the figure is now at 78,000. The Department must admit that is still a shocking figure and needs to be worked on. Is there one thing that could solve this? Sometimes it is not all about funding. The answer may be along the lines of obtaining and retaining of staff. Let us imagine the deputations could pick one thing. What would solve it?

I am keen to hear the thoughts of the deputations on the outpatient service performance improvement programme. As we know, a validation officer rings patients on a list - sometimes the officer sends texts messages - and asks whether they are still interested in staying on the list. Some of my constituents have run into trouble with this. Some have said that since they have been living with the condition for so long, they might as well keep going. Another person was on holidays. Yet another was careless and the letter was left on a window, as could happen to any of us. I do not think it is a good system. Will the witnesses offer their thoughts, please?

I am keen to hear the views of the witnesses on putting more funding into local hospitals. We have a very good hospital in Bantry that could take the pressure off the larger hospitals in Cork if it was given more funding. At the moment we are trying to enhance the rehabilitation and endoscopy units there. What are the thoughts of the deputations on providing more funding for Bantry General Hospital and similar hospitals?

I agree with my colleague, Senator Colm Burke, with regard to the plans for a hospital in Cork. It was announced with great bells and whistles. Now, it seems to have died a death. I take the point made by Mr. Woods that a meeting is imminent. Will Mr. Woods keep the committee informed of any progress on the new hospital? Obviously, that is something I am most interested in as a Cork Deputy.

I thank the Deputy. I call Mr. Bolger.

Mr. Paul Bolger

I will try to take the questions in order. Deputy Donnelly asked why this is happening and what the driver is. If the capacity plan is looked at, while we can pick out different parts of it, it provides a clear evidence base of a system that requires a greater number of beds and a significant element of reform. What we have demonstrated this year through the work with the NTPF and the HSE-----

That is the statement I am challenging. That is what everybody assumes. They say that we do not have enough stuff so all of these poor people have to wait and suffer but if we spend more, have a younger population, need less and have the same amount already, explain to us what the capacity problem is?

Mr. Paul Bolger

It is very clear. The capacity plan has a clear evidence base. We can argue about the validity of the evidence base but I think it is accepted that there is an evidence-----

Mr. Paul Bolger

The Deputy may not accept it but-----

I am asking the witness to explain it because his job is to reduce these waiting lists.

Mr. Paul Bolger

When it comes to waiting lists, on a simple level what we need to do with anyone on a waiting list is to validate the waiting list and make sure everyone is on it and then they need to be seen and treated. That is what is required when it comes to treating people on the waiting list. What is clear from the waiting list at the moment-----

That is not the question I am asking.

Mr. Paul Bolger

No but what is clear from the waiting list at the moment is that we do not have the capacity within the system to treat the volume of people who are coming through it and that is what is manifesting itself in terms of people who either are on waiting lists or are waiting at emergency departments to spend some time in order to be admitted to hospital. That is what is happening.

I am only asking one question because this is at the core of the whole problem. There is this view that we need more stuff. We need more acute beds, doctors, nurses and maybe we do and maybe we do not but the reality is that per age-adjusted population, we already have more of all of this stuff than countries who do not have our waiting lists so they clearly are doing something better than we are with the assets they have. I absolutely am challenging what is quite a lazy view although I am not pointing Mr. Bolger out. Groupthink has settled in to the effect that we have people dying on waiting lists and have young boys and girls whose spines are curving because we do not seem capable of getting to them quickly enough. The answer is that we need more stuff and the NTPF, which Fianna Fáil supports and pushed for, is a sticking plaster, not a structural change. Given that this new unit has been set up, while it is great Mr. Bolger and his team are working on this, I am trying to force the thinking a little here. It is just not enough to say more is needed if other countries do not have the waiting lists we do with broadly the same assets. Beyond saying that we need more beds, doctors and capacity, what are we not doing that other countries clearly are because they are solving the problem with a similar level of assets to what we have?

Mr. Paul Bolger

I take the Deputy's point and I will take his question in two parts. There is a need for an investment and for additional capacity within the system. There is an evidence base there to support that. What we can see through the likes of the NTPF is that if investment is made in the right area, more patients can be treated. I agree the NTPF is a process that is in place to treat public patients and to look at maximising capacity across the board, including in both public and private hospitals and the long-term plan on that, as it is set out in the national development plan, is the development of elective-only hospitals. I disagree with the point that we do not need more capacity but I fully agree with the point that it is not just about more capacity and that we have to look at how we go about managing things differently.

When it comes to the inpatient on the day case side, the majority of it is treatment in hospitals. That is where people need to be treated in most cases. There are examples where certain elements of it can be moved into the community but in general, those people need to be treated in a hospital. In terms of outpatient treatment, and there is a lot of work going on in this area, there is a huge opportunity to move a lot of that activity and this is the basis of Sláintecare and other plans over the years. For example, we are told that most people who turn up for an outpatient appointment require two appointments. They perhaps need a diagnostic and a meeting with the consultant and in many cases they are referred from their doctor just to receive the diagnostics. I am not telling the Deputy anything particularly new here but the more of those services that are available in the community, the less pressure will be on the consultants in the hospital system who do need to see a certain proportion of the people. The capacity plan is clear that there is a need for additional capacity. It is not just about beds and that is a point we might get to in terms of some of the staffing. It is easy to identify additional beds. It is about beds, additional staff and capital investment but it is also about reform. That is what is happening. The challenge is that we do not have enough slots to treat all of the people.

Mr. Liam Woods

To return to the Deputy's original question as to what the problem is and where he quoted some data, the expenditure in the health system, whether it is understood at a European comparative level or OECD volumes at a glance in terms of doctors and nurses, I would look at the numbers of doctors in Ireland vis-à-vis elsewhere. We are considerably lower and bed numbers are considerably lower. The point about nursing is well made. The capital infrastructure in our environment is not comparable with some of the other environments with which we would be compared and we know that it does need serious investment.

Underlying the Deputy's question and hypothesis is a very fair challenge to say that if we look at orthopaedics, an area he referred to himself, it is very true to say that the model of care for orthopaedics, part of which was developed jointly by a consultant in Cappagh, would clearly identify that up to 85% of an outpatient list can be addressed by a musculoskeletal, MSK, physiotherapist and a consultant will deal with the balancing 15%. We need to shift the model of care and provide more of that in the community is the goal and that is happening. There is a primary care centre in Galway where an MSK physiotherapist has been appointed and it is having a very good effect in terms of referrals to hospitals and providing care in the community. That is the kind of investment that is not the same as saying we simply need more consultants.

The model of care for orthopaedics, the demand-supply analysis and the onset of growing demand based on obesity for knees, because the volume of knees to be done in the future will far exceed hips because of obesity, means we need to double the current number of orthopaedic surgeons we have, which is around 80. That is over a period of time but the other point about ageing is true because on an age-adjusted basis, we are still younger than many of our comparator environments. One of the challenges that we face, and Mr. Gloster can probably talk more on the operational side on older persons' services, is that we are growing old at a faster rate than others. The rate of change is what is being dealt with on the ground and that is a real factor. There are opportunities and I share the view that it is not just about getting more stuff, it is about getting the best that we can out of what we have and investing in capital sensibly. Deputy Kelly referenced working outside the normal day and looking at our level 2 hospitals. We are going to face frail, elderly and chronic condition challenges right across our whole healthcare environment, many of which may be able to be addressed in primary care and model 2 hospitals, as well as focusing the major hospitals on precisely what they need to focus on. I agree with the Deputy's point. I query some of the data because there are questions in that regard. Our capital infrastructure, which, based on the new plan is growing substantially and is helpful, is a key driver so that we can be what we need to be. The investment we need in equipment today is approximately €350 million to bring it to where we would want it to be. There are efficiency opportunities and productive opportunities within that.

In comparison with other environments, we are a cost-based funded hospital environment and many of the others are insurance and transaction-based and that may be having an effect on some of the comparative data. The shift to private spending by individuals in the Republic of Ireland has been quite high over the past few years and that contributes to the cost when we look at it at a macro level. Often that data is not talking about HSE costs but about global health spend, which is very appropriate but there are real variations in what the HSE spends and what society as a whole spends.

Four to five consultants would be as high as would be seen in an emergency department in Ireland. In Scotland they are aiming to have ten emergency department physicians per department to provide care. There is strong evidence on the consultant side that we need significant additional resources but I entirely take the point that the need to drive performance and improvement and model change within what we do is also a piece of that.

It will not work and it will be too slow to wait for new buildings to appear to resolve the service challenges that we face. I take the point.

I ask Mr. Woods to boil that down. We will have to agree to disagree about the data. This is the Department of Health's capacity review and it unambiguously shows that we do not have significantly fewer healthcare assets than others. It shows that we have more than some countries and less than others. Those are the facts. Given that we are younger and have approximately the same assets, what do other countries do that we do not? Has Mr. Woods identified a number of actions that they have taken which we have not, which do not cost much money? We are facing into the next budget. The fiscal space is tiny. It is a fraction of what Sláintecare envisages as being required for all of these beautiful reforms. We will be living in a very resource-constrained world. I am pushing this so hard because the extra capacity, about which we will have a longer conversation outside of this meeting, costs a fortune. What can we learn from countries which, with the same assets, have solved this problem that we have? What can we learn that does not cost a lot of money?

Mr. Liam Woods

We need to look at the fact base and what we can do. The international evidence base, as it refers to clinical practice and location of care, is precisely what we use in clinical planning. Orthopaedics is an example but there are many others. There is strong awareness in the HSE, both at population health planning and individual clinical practice levels, as to the need for services and the ideal locations for such service provision. The thinking which the committee engaged in with regard to the Sláintecare report, relating to the appropriate location of care, is an important dialogue which has been referred to on a number of occasions here. We see high appropriateness of admission in acute services. When we look at appropriateness of a day of occupation of a hospital bed, we see an opportunity to move people into community facilities or home, with support. We have to seize that if we are going to get the best value and the best health outcomes at the lowest cost to the taxpayer and to the Exchequer. Those models will drive where we need to go. That is about both investment and change; it is not one or the other. There is a requirement for both. I would be happy to get into a deeper dialogue about the learning relating to the models of care and integrated care delivery in chronic conditions. There is interesting work in the HSE on supporting chronic conditions on an integrated basis across hospitals and community care. That kind of work is a major part of getting the system right in the future for the population demands that we clearly have, which will grow significantly.

I thank Deputy Donnelly. Deputy O'Reilly posed some questions about closed beds and staff shortages.

They related to the funded workforce plan.

Mr. Liam Woods

I can take those questions and Mr. Bolger might come in. There was an issue relating to a bed capacity review and 1,000 beds being closed, referred to by the INMO. Working with colleagues in the Department, we have looked at all capacity and locations where we can open space. We have identified that. That will sometimes require alteration in a facility. There may sometimes be an opportunity in current physical infrastructure. We have looked at that and made proposals in that regard. We would have to look at the INMO list of 1,000 beds with regard to the infrastructure. There may be adjustments to where specific beds are. I am not aware of that. We have high awareness of what we have and what we can do within our current infrastructure. There is a wider issue of moving beyond that to the 2,600 beds required in the capacity study.

Mr. Woods might share that with us. Mr. Bolger's submission referred to increasing the bed capacity in 2018 and 2019. Mr. Woods has clear sight of 2018, or I would like to think he does.

Mr. Liam Woods

There are proposals with the Minister and Government. They will be subject to decision and publication according to Government timescales. I cannot comment on that. I believe that will be soon.

I am just asking how many beds the HSE could open this year. I am not asking Mr. Woods to divulge any secrets. If he has clear sight of where the beds are and how many there are, I am not sure he needs the Minister's permission to share that with us.

Mr. Liam Woods

I can provide the Deputy with a list by location of the 260 beds that, coming out of winter 2017, we will open in 2018. Further work will be required.

Are any of those the 19 in Letterkenny?

Mr. Liam Woods

I think there were ten beds in Letterkenny. I will confirm that.

Some 19 are closed. Are there plans to open them?

Mr. Liam Woods

The Deputy asked separately about closed beds. Beds are mainly closed for workforce, recruitment or maintenance reasons. I do not have the current number but we tend to run at approximately 150 closed beds. It tends to be 50:50 between recruitment and maintenance. I can give the Deputy the list.

That would be helpful.

Mr. Liam Woods

The Deputy referred to an issue of counting student nurses. The counting of staff in the HSE is a matter for human resources, HR. To explain what has happened with the counting of graduate nurses, and not divert from the Deputy's question, student nurses were counted as 0.5 and not one, up until the end of last year. In the whole-time equivalent reports from January, they are counted as one. They are not all in the acute environment but most are. There are approximately 870 whole-time equivalent reported students in the acute environment. Last year, at the same time, that was reported at 435. That is in our published whole-time equivalent data set. On the question of why that is, that was a change made within HR. In some senses, it is helpful for me because it levels out the headcount-----

How is that helpful if Mr. Woods has just doubled his figures overnight, by not recruiting another person?

Mr. Liam Woods

I meant to address the Deputy's suggestion of gaming numbers.

That is what it looks like.

Mr. Liam Woods

We have counted 870. That was 435 last year. The challenge for us, which comes up in the capacity study and in the Deputy's questions, is the retention of graduate nurses. We were quite successful with that last year compared with previous years. Maybe Ms Cowan will say more about that. It is a key target for us again this year. As the Deputy said, having appropriate nursing capacity is a critical requirement.

Who can explain why it went from 0.5 to one if Mr. Woods cannot?

Mr. Liam Woods

I will obtain an answer for the Deputy from our HR section. It controls the definition of staff numbers in the HSE.

I am sure Mr. Woods appreciates that this looks like gaming the numbers. That was his word, not mine. It completely looks like that. Overnight, with the stroke of a pen and without recruiting a single nurse, the HSE doubled the number.

Mr. Liam Woods

We need to be realistic and say we have what we have and that it is what it is. Whether we call it 0.5 or one, it is a set number of individuals.

There is a reason they were 0.5 previously. It is because they are student nurses and not whole-time equivalents, WTE. They were not paid as a WTE or considered a WTE because they were learning on the job.

Mr. Liam Woods

I will seek an answer to the Deputy's question.

I look forward to it.

Mr. Liam Woods

I will seek the logic. The Deputy asked about scoliosis surgery and aggressive waiting list management. Overall, the approach to managing waiting lists is set out by NTPF policy. While it should be focused and competent, if I heard "aggressive", it would be a concern. I am happy to check that out. The time targets are short for scoliosis, with a four-month clinical target, so it requires a fair amount of contact with individuals and families. We have to manage that, and that is part of the challenge that the Children's Hospital Group and individual hospitals are working on. I will certainly look at that and would be happy to hear more about any concern regarding aggression.

The Deputy referred to the WRC. There are matters before the WRC between the HSE and nursing unions. She referred to the recruitment level, the workforce plan and the total number of nurses. There are issues and we are working on them. From an acute hospitals perspective, I work with a funded position for all staff, including nursing. That is expressed in our pay and numbers, and is contained within the nursing workforce plan. There was a challenge late last year. Part of our success in that is putting in new development posts. In the acute system, 1,100 new posts are being funded this year, of which approximately 500 are nurses.

At all stages we are seeking to convert from agency nursing to employed nurses. Last year we converted about €7.5 million in agency cost into nursing cost, and we did the same with medical locums. There are issues and we are working on them.

The funded workforce plan for 2017 was available but none is available for 2018. Why is that?

Mr. Liam Woods

There is dialogue between the nursing unions and HR on that at the moment. I have a funded envelope for all staff, including nursing.

Has Mr. Woods a funded workforce plan for nursing?

Mr. Liam Woods

I do.

Then why are they down in the WRC trying to get one?

Mr. Liam Woods

I do not want to step into WRC dialogues but I believe-----

This is in the papers.

Mr. Liam Woods

-----HR is working on it.

There was another question on how many procedures were done up to June 2018 under the NTPF.

What value for money tools are used for this?

Mr. Paul Bolger

Up to the end of June, of the 20,000 offers, 3,457 were accepted for insourcing and 6,350 accepted for outsourcing initiatives. The NTPF also provides scope and 1,300 patients were treated through the fund for this.

Is it the case that we can leave the scopes out of that calculation?

Mr. Paul Bolger

Yes. We are close to 10,000 offers made.

What is the number for procedures carried out?

Mr. Paul Bolger

To date, 2,400 patients have been treated through insourcing initiatives and 5,260 through outsourcing initiatives. A number of patients were offered treatment in December 2017 and treated in January 2018. We try to keep the window between the offer being accepted and the treatment happening as narrow as possible.

We have responded to questions on value for money via parliamentary questions. A competitive process is in place under which the NTPF goes out to tender for treatment. They have to take into account the treatment required and the location of the patient. Different tenders are in place with different people around the country and this ensures the NTPF gets the best price. The fund reports to the board, its accounts are subject to audit and it appears before the Committee of Public Accounts. No specific value for money review has been done of the fund's initiatives but there are controls which ensure they get value for money. The controls ensure everything is competitive with open tenders for all processes.

Does the HSE use a benchmark? If a procedure costs €1,000 in the public service but €10,000 in the private sector, are the two figures compared? Many of the parliamentary questions to which Mr. Bolger referred were tabled by me and it is a bit like banging my head off a brick wall. We keep being told there are efficiencies in the private sector but I do not buy that.

Mr. Paul Bolger

I did not mean to make the Deputy feel like she was banging her head against a brick wall.

It was not meant to be a comment on the responses - I am sure people do their best. What comparison is used? I am not convinced that value for money exists in the private sector and I agree with Deputy Donnelly that the NTPF is, at best, a sticking plaster. How does Mr. Woods decide that it is good value for money? We have heard from the head of the NTPF, who is a public servant, to the effect that the private sector is always better. I am not convinced that it is and I have not been convinced by any of the answers I have received that the Department is convinced either.

Mr. Paul Bolger

There is a commissioning team in the NTPF and we do not get into comparing the various prices. The NTPF has prices which come through from the health purchasing office. It does not get block funding, as there would be for a public institution, but uses the same model as applies to treatment in the private sector. It agrees a price with a hospital and pays that price when it is satisfied that the treatment is undertaken. This provides a richer source of information for the NTPF to challenge prices. It does not take on all tenders that come through and has, at times, been unwilling to fund a particular procedure in a particular location if it is outside acceptable price limits. It has tight controls to ensure it gets the best value for money.

Mr. Bernard Gloster

Deputy Donnelly has left but he made some observations about the age-related aspect of waiting lists. Life expectancy in Ireland is slightly above the EU average. We are seeing a growth in the over-65 population of approximately 20,000 people every year, with a growth in the over-85 population of 2,500 per year. The health status of the older population is probably the most critical factor in terms of demand on services, with 86% of people over 65 having at least one chronic disease and 65% of people having two or more morbidities.

In the community healthcare sector, both for mental health and services for older persons, the value of a student nurse came with the fourth year placements. When it was originally negotiated it was on the basis of two students in and one whole-time equivalent, WTE, out. There was an expectation of full employment and that, accordingly, the students would finish at the end of the term but now there are so many vacancies that the students are staying on as preregistered between September and Christmas. There is never a time where there are no students in the system. The counting of a WTE is based on the traditional 37.5 hours and not related to the grade of student.

I would prefer to get the written answer promised by Mr. Woods. I ask for that to be provided before our meeting next week as we will be discussing this again.

We are discussing inpatient and outpatient waiting lists. There is an imbalance between the demographic changes in the population and capacity, by which I do not mean just bed capacity. We concentrate on bed capacity but there are huge capacity issues in other services, particularly in primary care.

How does CHO 3, with which Mr. Gloster is most familiar, anticipate the manpower issues in general practice arising from the retirement of GPs? How does it intend to recruit GPs and manage manpower? There are many issues relating to hospital avoidance and the GP was the gatekeeper to the health service in this regard, acting as a filter to sift through the information to decide who needed to go further for treatment or investigation. That system is breaking down now because of manpower issues and because GPs are working to capacity. How would a CHO area anticipate recruiting and retaining GPs and developing that service?

As for the reduction in the number of inpatient procedures by 8,600, which is 9.4%, what proportion is accounted for by actual treatments, and how many of those are just validations of lists? I refer to cases where people do not need the treatment any more - they have gone to Northern Ireland, have opted for private healthcare, are no longer seeking the treatment or perhaps have passed away. What proportion of that reduction reflects actual treatments as opposed to validation? Perhaps the witnesses might outline the common treatments that are being delivered through the National Treatment Purchase Fund. Are they just day cases or are they serious cases of hip replacement, knee replacement and those procedures that require a considerable length of time in hospital?

Mr. Woods and I believe Mr. Bolger referred to the 8 a.m. numbers for patients on trolleys. I have been looking at the trolley figures for the past number of years. The numbers are rising year on year. This year to date, the average number of people on trolleys per day is 500, which is not in keeping with the 8 a.m. figures the witnesses have provided. Are the 8 a.m. figures different to the trolley watch figures?

Why is University Hospital Limerick consistently the hospital with highest number of people on trolleys, with perhaps double the number of the nearest rival hospital? I have my own views on that. I think there is a much greater catchment area for the UL Hospitals group. There is no model 3 hospital in the group, only a model 4 hospital, so everybody tends to end up in casualty there before they are filtered. Perhaps the witnesses might comment on that.

Following Deputy Donnelly's contribution, I note that the average number of beds for countries in the Organisation for Economic Co-operation and Development, OECD, is 4,800 per million. We are at 2,800 per million. There is a huge disparity there. The bed capacity review anticipates that the population of the country will increase by a million over the next ten or 15 years. A million patients equates to 2,600 beds. The 2,600 beds that are proposed in the bed capacity review may only be keeping track of the increase in population. It many not actually be a net increase in the number of beds per person. Perhaps the witnesses might comment on that. Ever year, flu season arrives and winter initiatives come in. As a result of that, elective admissions are quite often cancelled between the months of November and March. How can the health service keep track of elective procedures if, because of bed capacity issues, a bed cannot be found to carry out an elective procedure for four months of the year?

I refer to Sláintecare. It has been 400 days since the Sláintecare report was published and we still have not got the Government response. The Government seems to concentrate on costs, but really Sláintecare is talking about reorganising and reforming the health service. It concerns integrating services and hospital reduction measures, that is, how patients can actually be treated in a better location than a hospital. It refers to treating them in a community setting and re-orientating the health service towards primary and community care. I know Ms Cowan has an interest in this. Perhaps she might comment on that.

Finally, I refer to the "Bring Them Home" measures directed at nurses. I think only three nurses have been recruited this year. There were 15 last year, 82 in 2016 and 20 in 2015. The witnesses might comment on the reasons why we cannot get our nurses to come back. I apologise for the large number of questions.

Is it all right if Deputy O'Connell and I ask questions before the answers?


Could I be included in that list? Otherwise I will have to put my name down for next week.

Deputy Durkan is next, actually.

Absolutely. I knew that if I came in early enough I might get to contribute.

We might wrap all those questions up together.

In my professional experience it is important to highlight the good work done by many of the staff in the appointments sections of our hospitals on a daily basis. They are often on the receiving end of the wrath of patients and GPs who ring up looking for appointments. I think it needs to be put on the public record that they do a fantastic job.

The situation regarding general medical and surgical appointments around the country is not too bad. They are within an acceptable timeframe. However, certain subspecialties, like urology, neurosurgery and ear, nose and throat, ENT, are a joke. Last week I raised the case of Ms Angela Phelan, a lady who was put on an urgent waiting list to see a urologist in University Hospital Waterford. She received a letter saying that she would be seen in 65 months, which is five years. That is not acceptable. By definition, "urgent" means high priority. It means acute, it means critical and it means that we need immediate action. I am surprised that there is not a raft of medical-legal cases in this country from people who are dying and suffering on urgent waiting lists, not routine waiting lists. It is not acceptable. For example, a routine appointment in the urology service in University Hospital Waterford takes nine years. That is almost two Dáil terms. How can the HSE stand over this and what is it going to do about it? That is my first question.

The second question concerns the child and adolescent mental health services, CAMHS. As a GP, I think it is becoming more and more difficult to access this service. GPs are being forced to jump through more hoops to get young people assessed. I have received letters and parents have approached me to say their child will not be assessed by CAMHS because after I send in the referral letter, the service rings the parents and says that the GP has not assessed this patient. I would not have referred the patient if I had not assessed them. Of course I assessed them. They are not even believing the referral letters they are getting from GP surgeries. That is not acceptable. I have been speaking out about this. I have spoken to the Minister of State at the Department of Health, Deputy Jim Daly, about this on numerous occasions. We need a 24-hour emergency access phone line for GPs to access CAMH services for vulnerable patients who are suicidal. It is a service that would not be abused and it is something that needs to be looked at.

I want to follow on from what Deputy Kelly said with regard to modular units. They are an excellent idea and I seek an update on the modular unit proposed for Mayo University Hospital.

My final point is concerns community and district hospitals. What is the HSE's plan? Does it have a plan to develop these facilities? In my opinion, they facilitate discharges from acute hospitals and prevent admissions to them. Is there a specific plan for community and district hospitals? With regard to what Ms. Cowan said about GP contract negotiations, that is a myth. There are no negotiations. They are non-existent. Let us get that clear.

I thank the Senator and call Deputy Durkan.

Long threatened comes at last. A number of points are being raised that we have raised here before. One thing I worry about is the morale of those within the health services, who always happen to be the fish within the goldfish bowl from a critical point of view. As the last speaker said, a lot of important work has been done and dedicated staff do a great job. However, there is some flaw in the system somewhere. I refer to the point raised by Senator Swanick a few moments ago about someone who gets an appointment for two, three or four years later. That is farcical and is an insult to the system. It is an insult to human intelligence and to the patient. Effectively what it says is the patient does not need any treatment at all and should come back in ten years. That is what should be done. The problem is that the person in question remains on a waiting list for a long time. As a result, when their condition deteriorates they come to the accident and emergency unit because they have to go somewhere. Such patients are concerned about their health and their families are concerned about them. To what degree can the witnesses identify and influence the deficiencies within the system that impede smooth progress from the moment that the patient comes into the GP to the referral? Has the HSE had an audit carried out to reveal them? It should not take six months from the GP's referral to get the consultant to meet the patient, and another three, four, five or six months before any action is taken. That is just about the most outrageous system I have ever heard of anywhere. If those results were seen in a factory somewhere or in any other organisation in society, it would not be tolerated at all. Yet in the most sensitive area, that of health, this is commonplace.

There is another issue on which I would like a response. I do not propose to wait here for the answers. I expect to get the answers at some stage between now and next week. Otherwise I will put down parliamentary questions. In case someone says I will not get the answers in parliamentary questions, I will.

The age profile of the population has been referred to as one of the main stumbling blocks as to why we cannot provide a proper health service. I agree with my colleague, Deputy Donnelly, that that is not correct. We have a younger cohort of population than almost any other country in Europe. The people who come into this country are young, in their 20s or their 30s. That is being balanced all the time. It is not sufficient to say we have many old people who have three or four procedures a year and so on. I do not buy into it.

Have the deficiencies in the system been identified? Is there a lack of GPs? Is there a lack of consultants? We have identified a lack of beds. Another 1,000 beds or so would make up the difference. I remember during the boom times ten years ago that there were unacceptable waiting lists, even though there was plenty of money available. I do not understand why we are not progressing. We are in the top three or four in terms of expenditure in the OECD countries, but we are the third or fourth worst in dealing with patients, waiting lists, downtime and so on. Why should that be? The point made by Deputy Donnelly is accurate, that there is something wrong somewhere.

Can the witnesses tell the committee how many of the facilities are vacant or idle at any given time in any week, and for how long, for example, clean air theatres and different types of theatres? When a patient comes into the system, is there a guarantee that patient will move through the system smoothly and out of the system again? Is it a lack of anaesthetists, nurses or beds or a combination of all? To what extent does each of these issues constitute a proportion of the totality of what is required? We need to know that. Any efficient body will need to know exactly where its weaknesses are and what can be done to speed it up.

Some hospitals have better records than others in terms of waiting times, bed accommodation and so on. Why is it that they are successful while others are not? There are obviously contributory factors. I do not expect to be told today but I expect to get the answer to that too.

I know there are many good people in the health service. I would like to have a health service that everyone would want to identify with, that every patient would be happy to be part and parcel of, and that as a result of that we would move forward, taking our responsibilities seriously and recognising them. Incidentally, I do not have a hang-up about the private or public sectors, but they should be able to compete with each other. It is always a good sign for both of them but it does not always happen. If it is found that the private sector is creaming off the top a certain number of patients who are easy to handle or whatever the case may be - I do not know - but I would like to know about it. We trotted this out before about primary care centres. I do not know. The jury is still out on the primary care centres. They are fine facilities and they look good. I am not so sure of the extent to which they are cutting off the flow of patients at the community level before they go to the hospital. I am quite sure they could.

Today's long-term patient on a long waiting list will be an emergency at some stage. We either deal with it in the first instance or we deal with in the last. I do not expect to get the answers today. I have parliamentary questions about all of them, and they might be answered in that way.

I appreciate the Chair's patience in waiting for me.

What about my patience? When my colleague, Deputy Donnelly, was asking Mr. Bolger why the situation was different here when he was comparing the spend per head with other countries, eventually Mr. Bolger said it was not just about beds but was about staff and reform. Will he elaborate on what reforms he was referring to?

Again in response to Deputy Donnelly's questions, Mr. Gloster mentioned life expectancy in Ireland being higher. While I do not want to misquote him and I know Deputy Donnelly has left, is Mr. Gloster saying that Deputy Donnelly was not comparing apples with apples, in that it is simple to take a top-line figure for a spend per head, but when there is universal access for children under six to GP services and a roll-out of vaccination programmes, there will obviously be a spend, so it is not as simple as just comparing the oversimplified figures that the Deputy supplied? Will Mr. Gloster elaborate on that? Maybe I misinterpreted what he said.

In response to my colleague, Deputy O'Reilly, Mr. Bolger said the Department does not get into comparing prices and that it does not take on all the tenders that come through. Thank God that someone is keeping an eye on the chequebook. He also said that he believes there are controls in place to get value for money. Again, thank God for that. When representatives from the HSE come in, it is always someone else who made a decision somewhere else. I go back to Mr. Woods and Deputy O'Reilly who was talking about whole-time equivalents and student nurses. Mr. Woods is the national director of acute hospital services operations in the HSE, yet he needs to talk to somebody in HR about who decided that a fourth-year nurse was one whole-time equivalent and not half. The vast majority of the times that we ask questions of people in the HSE, it is someone else's job. It happened recently with the CervicalCheck issue. People continually say that it is someone over here or someone over there. I am worn out with it always being someone else's question to answer.

The real questions I wanted to be answered were asked before I came in and obscure responses were given. Can somebody, perhaps Ms Cowan, outline why things have improved with the retention of graduates? Has it been looked at? Are there plans to focus in on the reasons that we are retaining more graduates and to increase the retention of graduates?

Deputy Durkan mentioned primary care centres. I am a firm believer in Sláintecare and in moving treatment into the community from the acute hospital setting. In Smithfield, Dublin, there is a good primary care minor injuries clinic that contributes to accident and emergency department avoidance. Many people are treated there, and there are good nurse practitioners working there, plastering up people with injuries and referring them to the Mater Hospital. It may not be true but I have heard this service in Smithfield is becoming very popular. I used to refer many people there myself when I was working in the community. I found it to be a brilliant service but people did not know about it at the time.

There is a cultural issue where people think they have to go to an acute hospital. It is just in us to think the best place to go is Crumlin with a sick child or the Mater with a broken arm. What steps is the HSE taking to try to address that cultural issue, so that people go to the primary care centre as opposed to the acute hospital? I also hear that patients who should go to St. James's, Tallaght or Blanchardstown are going to Smithfield and in turn ending up referred to the Mater, which receives many patients who would ordinarily be dealt with by the other hospitals.

There is now a capacity issue when it comes to the referral of patients because so many people are being taken in from Smithfield. How will this be addressed?

There are challenges in the area of step-down facilities. I have heard that when consultants sign off a patient as being fit to return home, they sometimes are reluctant to go to a step-down area. Have any of the witnesses a solution for this? Anecdotally, there is no reference to an exit plan when patients are admitted and it is not discussed until it is time to exit. This is often the case with older people. If a patient from Dublin 1 is discharged and then is sent to Mount Carmel Community Hospital, which is near where I live, for their step-down he or she might say he or she could not go all the way over there. Has the HSE put anything in place to try to address this in order that when a patient is admitted, he or she is told that after he or she has been fixed up, he or she will be sent to a particular step-down facility and that is how it works? I am not talking about forcing people to go anywhere but about bringing patients and their families along with the medical professionals on this journey.

I visited Carlow-Kilkenny hospital a couple of years ago, where they had GP referral to fast-track people through the emergency department. The Mater Hospital has something similar for older people, where a GP can refer them and it bypasses the emergency department. It works very well. Older people and their families are much happier with it and it is far preferable not to have older people with chronic conditions waiting in emergency departments, which is not suitable. What plans does the HSE have to replicate the system used in Carlow-Kilkenny and that in the Mater?

Recently I heard that 477,000 hospital appointments were missed. I understood that outpatient hospital appointment lists already factor in such no-shows. Will the witnesses elaborate on this? It is not the case that doctors are waiting in emergency departments twiddling their thumbs waiting on these 477,000 people. It is built into the figures that a certain percentage will not turn up.

Finally, Mr. Woods said that a roll-out of texts was the way forward. Surely that could be done over a weekend. We are back to IT. Even the most basic, small community pharmacy now has a text service for their patients. I cannot understand how it is that things are done very safely in the community with appropriate data protection and so on but when it comes to the HSE, we almost need two years to do everything and a team of people to implement something that I would have a young one do for me over the weekend. It is constantly the case that everything seems to take longer. No one seems to know who is responsible. It is like the deck chairs on the Titanic. I would like the witnesses to address those points. I apologise that I cannot stay to hear the answers. If the witnesses cannot answer them today, I would like them in writing soon.

I thank Deputy O'Connell. We have had contributions from four members and there are many questions. If Deputy Kelly has one quick question, I will not make him wait for all the answers.

No, the Deputy says one. He can pick one question.

I was pointing.

I did not get a full answer on the modular units. I want an explanation as to when the HSE first decided to use them and where it first decided to use them? Who in the HSE made the decision? Was the first one in Clonmel? How has that been rolled out? When will decisions be made on other modular units? The answer to that may lie halfway between Mr. Woods and Mr. Bolger. Where and when was the first decision made and by whom?

Perhaps we can go to the beginning and answer some of my questions first. One was specifically to Mr. Gloster.

Mr. Bernard Gloster

I will take the questions relating to community health care from the last four contributors. On the Chairman's question about GP recruitment, we have two vacancies in the mid-west that we are attempting to fill, one in north Tipperary and one in Thurles. On anticipating those, we have a fair indication as to when people are thinking about retirement. Many of the Chairman's GP colleagues will stay on for quite some years but we have a general indication. On what the system is trying to do about that, nationally, last year, the HSE's target was to have 187 GP trainees. The actual out-turn was 170. That gives an indication of the transition in respect of filling some of the places. This year's target is 198.

In the mid-west, one thing we have tried to do to mitigate the difficulties in recruiting is use the job-share scheme in some practices. A contractor might decide to go on reduced time in later years before they retire. Another doctor comes in and eventually takes on the practice. In the two or three cases where we have done that, it has been quite successful. It is a bit different from the assistant with a view to partnership.

The challenge in relation to GP recruitment will not become more level or ironed out until the contract issues have concluded. That is being attended to by the Minister and the Department and negotiations are ongoing.

We have tried to expand the range of supports available to GPs. The Chairman will be very familiar with the Shannondoc system in the mid-west area. It was originally intended as an out-of-hours emergency service and is effectively an extended day service in terms of people's expectations. There are more than 100,000 contacts to that service annually. Luckily, we have been able to provide additional supports. The Chairman is a particularly strong supporter of the community intervention team. Last year in the mid-west, GPs alone made 290 referrals to the community intervention team as distinct from sending people to hospital. That is one small snapshot of its work.

That is the direction in which things are going but I would not dispute that GP recruitment is very challenged. We are probably somewhat more fortunate in the mid-west in how the numbers have fallen but we are challenged.

Senator Swanick, who had to leave, made particular reference to the use of district hospitals or community nursing units. Between us, my eight colleagues across the country and I have 7,002 public beds and 1,982 of those are used as short-stay beds. All of them, other than those used for people coming in from home for respite, are predominantly associated with hospital flow of one type or another whether it is rehabilitation, step-down, transition and so on. Some 5,020 of them are in the long-stay system. We are very committed to the community nursing unit system. The Senator might be familiar with the Government commitment to the refurbishment programme or the new build programme for which the regulations were amended to take us to 2021. There is in excess of €500 million being spent to enhance that sector. The public community nursing units are very much a feature of our plans for the future.

Deputy O'Connell asked a specific question so as not to misunderstand my intervention in respect of Deputy Donnelly's point. For clarity, I was not necessarily arguing that Deputy Donnelly's observations on international comparators were in any way out of kilter. To be fair, he was relying on the capacity review for much of it. The point I was trying to make was that in the Irish context, while we have a younger population in some respects, one must look at the health status of the older population. Life expectancy is above the EU average in Ireland because fewer people are dying from circulatory and other diseases because of advances in medicine.

It does not mean that people do not have those diseases and, indeed, they have dependencies on the healthcare system as a result. That is why this year, we will deliver very high concentrations of support to older people in hospitals and the community, such as more than 17 million home support hours. It is not as simple as noting Ireland's young population compared with other countries and asking why things are different here. The status of our population and, in particular, the fact that 65% of those over 65 years of age have at least two chronic conditions, as members are aware, creates significant dependencies on every part of the healthcare system.

On the use of primary care centres, we are always looking for ways to encourage people to utilise what is available to them in the community.

Ms Cowan will address the issue raised by Deputy O'Connell in regard to the model used in Kilkenny. I am aware that general practitioners in the mid-west are fortunate to have other routes available to them, such as an acute medical assessment unit, a surgical assessment unit, a bed bureau and so on.

On step-down facilities, Deputy O'Connell referred to Mount Carmel Community Hospital. A very successful initiative was introduced for the winter of 2016-17, repeated in 2017-18 and effectively is now an all-year-round system. It is a transition care system that allows people to convalesce or be cared for outside an acute hospital while, for example, awaiting the completion of their fair deal process. We have had some very good successes in that regard and the system now runs throughout the year. Approximately €2.5 million per month is spent on it and over 200 cases per week are approved, each of which has an average length of stay in transitional care of 22 days. Were it not for the scheme, those patients would be likely to spend that time in the acute system. Deputy O'Connell rightly referred to care plan and consent issues in that regard. Some hospitals use the transitional care system more than others. Limerick is the highest and best user of the transitional care system. It is a very effective intervention and we probably will have to sustain it long into the future. To go back to Deputy O'Connell's point, we must also try to work with people on consent and care plans, which is not always easy for many reasons to do with families and choice and so on.

Mr. Paul Bolger

The Chairman asked what proportion of the 8,000 reduction in the number of inpatient procedures is accounted for by validation of lists. A level of activity underpins that change in the waiting list. I will revert to the committee with further details on the changes since last year. Since the start of this year, 54,000 people have been added to the list and 57,000 removed. That is the result of both HSE activity, which includes an element of validation, and NTPF activity. The 8,000 is the net result in terms of the waiting list.

The Chairman asked about the elective procedures targeted by the NTPF and whether that is being done on an inpatient day case basis. The inpatient day case action plan we published in April set out seven high-volume procedures to be targeted, namely, cataracts, hip and knee replacements, varicose veins, tonsils, cysts, coronary angiograms and the excision of lesions. An eighth category, gastrointestinal, GI, scopes, is slightly outside that grouping. In addition, the NTPF set aside funding for those waiting more than 18 months for a procedure. As mentioned, there is funding to enable hospitals to bring forward proposals to address specific waiting list challenges they face. The NTPF delivers the seven high-volume procedures, GI scopes and a range of other procedures. It has more than doubled the number of procedures it offers through the private sector from approximately 20 last year to 50.

Deputy Durkan referred to the length of time people wait for outpatient appointments. We have already touched on some of the initiatives under way. There has been much discussion of validation, which is a critical part of the system to ensure we have accurate lists to help with planning. Several members questioned the style and form that would take, such as, for example, patients having seven days' notice or being required to confirm by phone. Such queries indicate the rationale for the establishment of a centralised validation office, namely, that we will learn from best practice and that a standard approach led by the NTPF will be taken to the validation of waiting lists across the system.

My specific question on the validation of lists regarded the obvious decrease in the waiting list number as a result.

Mr. Paul Bolger


What element of that decrease results from the identification of persons who no longer require treatment as opposed to having been treated?

Mr. Paul Bolger

I do not have the figures in that regard from last July to now but I can revert to the committee with that detail. The NTPF has found that offers of treatment lead to a validation process.

Deputy O'Connell asked about the role of the NTPF. In my earlier responses, I made the point that the NTPF is a statutory body. Its function is to assess the price and it has a commissioning body in place to that end. We have a governance structure in place to manage that statutory body. There is no passing of the buck. It is clear that the NTPF has statutory responsibility for pricing but we have a clear governance structure for its management.

Deputy O'Connell also asked about the range of reforms required. The capacity review contains several scenarios, two of which are very stark. One concerns the introduction of a very extensive range of reforms, all of which are set out in the capacity review, and a subsequent requirement for 2,600 additional beds. The capacity review also points out that issues in terms of staffing and planning were not considered but it highlights future work that must be carried out and the reform programme that must be undertaken in the context of Sláintecare. All of the documents produced to date indicate that extra beds are needed. The capacity review sets out a very ambitious range of headline reforms and also points to other work that needs to take place, including the issue of theatre capacity, to which reference was made.

The population is projected to increase by 1 million. Ireland currently requires 2,600 beds per 1 million population. Thus, if our population increases by 1 million, we will need 2,600 beds just to stand still.

Mr. Paul Bolger

Yes. The capacity report attempted to capture that requirement. The report makes clear that 2,600 beds will be required following an extensive programme of reform. If there is no reform and we stand still, the plan indicates that more than 7,000 beds will be needed.

On specific reforms, Ms Scally will deal with areas under consideration in terms of increasing capacity. We have also outlined several important administrative reforms that are being introduced to improve system efficiency, such as the validation office and the badly-needed integrated waiting list. A delayed discharge review is now under way to understand the factors of relevance in that regard, such as whether it is a capacity issue or relates to the ability of the acute and community systems to communicate or a combination of both.

Ms Scally will provide details on modular units, which form an important part of the capacity plan.

They can be delivered much more quickly and, based on the experience of the UL group, the quality of accommodation that can be offered is different from what I imagined a modular build would have when we started on this project. It will play a significant part in the system going forward. We have identified a number of sites where modular builds could be used to increase capacity.

Ms Susan Scally

As Mr. Bolger said, the capacity proposals we have recently received from the HSE were developed in the context of the health service capacity review. We are looking at 94% occupancy at the moment across the hospital system. We are trying to bring it down to the international norm, which is approximately 85% occupancy. To do that we would need to inject an additional 1,200 beds immediately. The HSE has come forward with proposals which it developed, having consulted intensively with hospitals and carried out rapid analyses of demand and capacity.

I can give the committee a rough number for acute beds. There are potentially 600 beds and just under 300 community beds. The process is under deliberation at the moment and validation is ongoing, meaning the number may change as the process evolves.

The modular programme is a significant element of the capacity plan. The Minister wants to fast-track the delivery of these beds but there is a lead-in time for the construction of modular beds of between 12 and 16 months from the point approval has been given. It is important that all available mechanisms are used to ensure there are no bottlenecks or delays and Clonmel has been mentioned as a good example of where there have been delays.

A number of members referred to additional capacity. There is a need for reform in this area and the HSE is looking at a more integrated approach to patient care, in particular identifying a need to strengthen clinical interventions to improve care pathways, specifically around rolling out the acute floor model, strengthening palliative care in emergency departments, old person's frailty and reablement teams, and measures to support infection control, which was a major issue last winter.

Mr. Gloster spoke about delayed discharges and initiatives to support people returning home, including the winter initiative. The independent expert review of delayed discharges was undertaken under the aegis of the Minister of State at the Department of Health, Deputy Jim Daly. Graham Knowles, the chairperson of the UL hospital group, is chairing the committee, which will focus strongly on the monitoring data we use and the factors that impact on the length of stay for patients, specifically to deal with bottlenecks in care. There will be interim recommendations to the Minister of State at the end of August which will inform winter planning for 2018-19, with final recommendations by the end of September 2018.

There was a question on the 8 a.m. numbers as opposed to the trolley watch numbers.

Mr. Liam Woods

We can provide the detailed data we are using for 8 a.m. trolley numbers. There was a question on why UL was always the highest for trolleys. It has persistently had one of the highest attendances and it is rising faster than most other hospitals, which is a factor in the trolley numbers. Our report for May showed three other hospitals with higher trolley numbers. I was asked about the difference between trolleyGAR, which the HSE reports, and trolley watch. I would not focus on the data because the underlying condition is unacceptable but we can provide our own information.

The HSE does not use the trolley watch figures.

Mr. Liam Woods

We see those and we collect data three times a day, including Saturdays and Sundays. TrolleyGAR looks at three time intervals, namely, 8 a.m., 2 p.m. and 8 p.m., and on Saturdays and Sundays, and we publish that information. The INMO data are available daily at one time incident, though not at weekends.

Do the two sets of data mirror each other?

Mr. Liam Woods

They are close but there are differences. The trolley watch data count beds up the house, while the HSE data typically does not, though in some instances it does. The trolley watch data also count beds whose purpose has been changed, though it is still an actual bed. We have spoken with the INMO about this. We used to reconcile them with the INMO to provide the information to the public. The effect on flu and planning electives this year was significant, with 4,800 admissions relating to flu where there had only been 1,500 in the previous year. We know, as everybody does, that the flu comes annually but the scale of the impact was high and it was a mixed strain, which brought its own complexity.

We can count all the electives as we see all the cases performed through the patient administration systems and the HIPE records which we have. I was asked about cancelling. Many hospitals do not book in January or February but their systems track what is done and what is cancelled. Senator Swanick asked about the unacceptable waiting times in Waterford, where the patient to whom he referred had a 65-month referral. I am seeking clarification on this and will provide it to the Senator when I get it.

There was also a question about CAMHS access, which we discussed earlier. The Deputy made a proposal relating to a 24-hour access number for GPs and I will refer the query to our mental health services. There was a query about community and district hospitals, which Mr. Gloster addressed, and the GP contract. Another question was on the modular unit in Mayo and Deputy Kelly had a further query about the history of that. There were proposals in Mayo and a theatre proposal in Galway, which involves replacing an orthopaedic theatre and which is proceeding. Clonmel is the first example of additional capacity proposed for this tranche of modular builds but there are others on the table, which are the subject of deliberations with Government. As for the decision-making process, the creation of the idea is local, having come from the local hospital group in Clonmel. The decision-making process is subject to funding but this has been resolved in the case of Clonmel. It involves the HSE leadership team and directorate on expenditure over certain limits. Our estates function is involved in the practical progression of the development.

To clarify, the HSE locally within the group makes a decision to go through this, it goes up through the HSE and then it goes to the Department and it makes a capital decision.

Mr. Liam Woods

Yes, and because this is a leased facility it is a revenue decision. All proposals the HSE generates become subject to Estimates.

Mr. Woods might refer back to me about when it first made that proposal.

Mr. Liam Woods

I will.

Deputy Durkan made a couple of statements on wait times, with which I agree in terms of length of time. On any audit of the system of referral, to answer the Deputy's point the NTPF audits waiting list processes from time to time and consequently, there is an audit. We have dealt with the age profile point. The Deputy asked about how many facilities are down at any one time, perhaps referring to the opportunity to use more intensively theatre and other facilities that are available but not in use, potentially at night and the like. A theatre productivity programme has been undertaken in the HSE to ensure we get optimum capacity but it also extends into working day and bed capacity. Clearly, doing more operations requires more beds and more staff. That ties into the capacity dialogue on the 2,600 beds. The Deputy referred to performance at hospital level being an issue, and that is true. There are variations. This touches on Deputy Donnelly's question. On competition among providers being a good thing, that was a view.

Deputy O'Connell raised the retention of graduates and asked why retention of graduates was improving. I will ask Ms Cowan to answer that.

Ms Colette Cowan

Yes, and the Chairman had a similar question. The most important issue with graduate nurses is to capture them before they leave the country. In previous years we were slow at that and the young graduates would go to the UK and other places very quickly. The UK would send people here to interview them. We have put a process in place now. They are upwardly mobile young people who want to travel the world at some point in their career. We offer them permanent contracts with opportunities to take a career break within them. In the past week, three of them have contacted University Limerick hospitals group to come back from their travels after their career breaks. At least we are ensuring they will come back to a post here. From talking to intern students and having the personal history of students qualifying, they would say they are wary of permanent contracts but they will take them if they are offered. They are not interested in going straight into higher diploma education because they have just finished four years in college but they will do it two years' hence. They have a big problem with accommodation. They cannot get accommodation when they qualify or they cannot afford accommodation and they cannot travel from home because they cannot get access to transport in rural areas or they cannot get a driver test. These are clear problems for these young people, as I am sure they are in other sectors.

When we surveyed them they said they needed support when they come onto the floor and training to deal with the real front-line pressures. That is what turns them off sometimes and makes them leave the country. They need support to deal with public expectation because they are the first point of contact when people are under pressure. Also, there is a professional expectation of them and, in my view, one must mind them for the first 12 months and then offer them the higher diplomas or whatever they wish to do. They do not know in the first year after they come out of college into what they wish to expand. I believe we must incentivise them to stay through accommodation, transport and the like. That is not just nurses but professionals at every level in the country. As I said earlier, there is the same issue with trying to attract consultants back into the country. We need to make some other offering to get them to come back and work in our services. That will solve the waiting lists, theatre problems, opening of beds and so forth because our own staff will be retained.

Mr. Liam Woods

To finish, Chairman, there was a further question about the Smithfield local injuries unit from Deputy O'Connell, which is associated with the Mater Hospital. The Deputy correctly said it is very popular and is growing its volumes. In fact, the level of referrals now to local injury units nationally is 94,000 per year, so there is a strong growth in attendances at those units. That is true of Gurranabraher in Cork, where there is a unit on the hill. People do not know about this so we ran a social media campaign for local injury units last winter, which was very successful. It brought many patients to the units. We will continue to do that. On the issue of culture and awareness, the Deputy is right that many people still believe they need to go to the Mater Hospital rather than to the local injuries unit but that is changing and GPs have responded very positively to the extension of hours in Smithfield. Regarding the notion that the Mater Hospital ED is taking a specific additional burden of work arising from the work of the local injuries unit, the EDs in the area are all growing, including that of the Mater Hospital. There is no specific evidence that would say it is growing disproportionately more. As there are local injuries units of various types associated with St. James's Hospital, Tallaght Hospital and others, that facility is available elsewhere although the Smithfield one is a fine facility.

The Deputy asked if the HSE or the hospitals overbook outpatients. It is true that part of the booking practice is an awareness that people will not show up but there are also opportunities for us to use the available space more productively. However, the statement is correct. The Deputy referred to the roll-out of texting and said that somebody could do that over a weekend. The HSE must be cautious in terms of our general data protection regulation, GDPR, responsibilities and general data protection and be sensitive to consent issues with patients but within that context, we wish to use electronic means. We would like to have an electronic health record online for a patient, so clearly that is something we want to achieve.

With regard to the 477,000 no shows, how many of those are first visits and how many are repeat or roll-over visits where they come back in six months?

Mr. Liam Woods

I will have to refer back to you on that.

Can we get a figure for it?

Mr. Liam Woods


Thank you. Before I call Senators Kieran O'Donnell and Conway-Walsh, Deputy O'Reilly has a short question.

I have a brief observation as well for Ms Cowan regarding the high cost of living and the affordability of homes. I do not believe there was the same trouble recruiting at the height of the property bubble. There is more at play than simply the cost of living. I believe it is the conditions in which the nurses and every other grade are working that are contributing to making the HSE an unattractive place for people to work. That is the observation.

I had to return to my office to do some work and I was contacted by somebody from Roscommon who was watching these proceedings. The person is obviously very interested in the capacity issue because there are currently 12 people affected by a closed nursing home. He referred to delayed discharges. Obviously, opening beds and step-down and care of the elderly beds in the community is central to dealing with the delayed discharges problem. I will put to the witnesses the question that was put to me. Is it not somewhat counter-intuitive to close nursing home beds, as is happening in the case of the Rosalie unit in Castlerea? The HSE is closing beds on one hand while on the other, it is complaining, rightly, about delayed discharges. Nobody wants to have delayed discharges and we certainly do not like using the terminology that was used previously to describe those people. The person asked me whether there is a plan for those 12 people in the first instance. Also, how does one square that with what is now being called the capacity dialogue? It used to be the capacity piece. It was the piece and now it is the dialogue. How does the capacity dialogue in which we are all so enthusiastically and energetically engaged fit with saying on the one hand that we need to increase capacity, which we all recognise is true, and on the other, we are closing down the very beds those people should be able to access? It appears to be counter-intuitive.

Thank you, Chairman, for allowing me to speak again. I had not intended to return to the committee but I was contacted by the person from Roscommon.

I call Senator Kieran O'Donnell.

I have two questions for my colleagues in Limerick, Ms Colette Cowan, CEO of the University Limerick hospital group, and Mr. Bernard Gloster, CEO of the health service in the mid-west. Can Ms Cowan give me an update on the 96 acute-bed block, which is being funded through the capital plan?

Funding was achieved to allow the design to proceed. What is its current status? What is the timeframe? When will it be built? Will the witnesses give an indication that it will be built alongside the existing accident and emergency department, the new ED and above the dialysis unit?

I have discussed at length and over a long period with both the HSE and the Minister, Deputy Harris, the building of 16 modular builds - temporary builds - at University Hospital Limerick. What is their current status in terms of the planning process? From the point of view of logistics, and subject to funding forthcoming, when does the HSE expect to be ready to start building it, and how long will it take? I think what people in Limerick and the mid-west really need is certainty surrounding bed capacity. We have an issue of bed capacity in Limerick and the mid-west.

I wish to ask Mr. Bernard Gloster about St. Camillus Community Hospital. Once again, it is a matter of bed capacity. What is the current status of the €50 million St. Camillus project? Will Mr. Gloster give me an indication of the timeframe? I believe we in Limerick specifically occupy a unique position in the country. The Chairman will be aware of this. We have a bed capacity issue. It is a key issue apart from everything else. Ms Cowan and Mr. Gloster might deal with both those points for me.

I thank the witnesses for their presentations. I have a few questions. The first concerns University Hospital Galway and the spinal unit there. I will read the witnesses a line of correspondence from a senior consultant there: "As you know, our ability to access major elective spinal surgery in the University Hospital has virtually come to a halt due to the lack of resource allocation." What is being done to give the hospital the resources it needs in order to be able to carry out vital spinal surgeries? At the end of the list there are people who have been in excruciating pain for a number of years and are absolutely at their wits' end. If University Hospital Galway cannot do it, is there somewhere else across the Border or abroad where the surgery can be done? Can someone within the hospital system find a pathway or say, "The buck stops with me and I will find a way to take this person, or however many people, out of the excruciating pain with which they must live every day"? The National Treatment Purchase Fund is not an option because it states in the correspondence:

Regrettably, the spinal service is not in a position to give me a date or a review of surgery at this time. The man is not suitable for referral to the National Treatment Purchase Fund or referral to a private hospital due to the complex surgery needs.

We cannot just leave such people in excruciating pain and do nothing about it. Judging from what is being presented here, one would hardly think we have a system that is almost the worst in Europe. Every time we have personnel from the HSE before us, in committee and otherwise, they paint this picture that everything is happening and things will get better and better, yet we see that things are getting worse all the time. Reference was made earlier to shifting the deckchairs around on the Titanic, and that is certainly my view of the matter as well.

I really must take up the issue of nursing. I spoke to a number of nurses who live in Birmingham over the weekend and asked them why they do not come back to work within the system here. They are not a protected species and they do not need to be minded. The nurses I know certainly do not. What they want is a safe working environment. They say the Irish health system is too high-risk. They wonder what will happen if they go into a high-risk situation. They will be trying to do the work of three or four people. They wonder what will happen if they make mistakes and who will have their backs if they make mistakes and lose their licences. That is what they are trying to weigh up, rather than some of the things Ms Cowan mentioned, which may be concerns of a lesser degree. What our nurses deserve is to be provided with a safe working environment. There is a real crisis within nursing and recruitment. The nurses also say the recruitment process is just too complex and that there are too many blockages along the way. Can the HSE simplify that process? If people have the qualifications and experience to do the job, they should be put into that setting and let work in their own country because people have a right to do that.

I think Mr. Gloster said €500 million is to be spent on district hospital beds. Will he tell me how many beds this will equate to and perhaps where they will be? How many step-down beds did he say there are?

Mr. Bernard Gloster

There are 7,002 public beds for older people outside the acute system in community nursing units, 1,982 of which are short stay. The short-stay beds are predominantly used for different types of step-down care. People might go for rehabilitation after a hip fracture, or people might convalesce. There is a variety of uses. We also buy short-stay beds in the private nursing home sector for transition.

What I am trying to get at is the figures that were there when many beds were purposefully closed down. We always refer to our own cases. Half of the 20 beds in Belmullet District Hospital were closed down due to the wisdom of someone within the HSE and the Fianna Fáil Government at the time, even though we stated it would be a major mistake. Now there are people in Mayo University Hospital whose wish is to be cared for within the district hospital setting. What are the major hold-ups here? If €500 million is available, what are the blockages that need to be unblocked? Perhaps the witnesses might explain that for us.

Regarding the missed appointments, one of the biggest problems people have is where services are moved - say, to Galway Hospital. I am all for a centre of excellence but also that the other services be provided on the ground. Obviously, the HSE needs the integrated appointments system as well. People do not have the transport, so the public transport is not there to match up with their appointment times. If someone is living on €188 or €200 per week, to get a private operator or individual to bring him or her from, say, Erris to Galway is just way above and beyond his or her means, and this needs to be looked into as well. We had Bus Éireann and the National Transport Authority before us last week, and this is one of the questions we asked, yet they close down routes all the time that connect to the hospitals and the transport connectivity is not there. I think the HSE has a role in this. Actually, they cited that the HSE's response in terms of having a proper integrated transport system was dismal and certainly not consistent.

If we are to solve the problem within the HSE long term, we need to look at the education system. We have a whole cohort of young people doing their leaving certificate this year. They must go through the health professions admission test, HPAT. Obviously, there must be standards, but for people choosing to go down the medical route who are 18 and 19 years of age, that passage needs to be made easier for them. It is not about lowering standards but about the fact that young people who would make excellent doctors and who have a real sense of social justice, equality and fairness are not just driven and motivated by money. What communications do the witnesses have with the Department of Education and Skills in having a real look at the long-term recruitment and long-term education that is needed to give us the numbers of consultants, doctors and so on that we need within the health service?

When will we see a proper, purpose-built hospital at Merlin Park? The former Taoiseach cited several years ago that the regional hospital in Galway was not fit for purpose.

Mr. Bernard Gloster

I will start with Deputy O'Reilly's question on the Rosalie unit. It is in the west, which is not my area.

If Mr. Gloster could send me a reply in writing, there is no difficulty-----

Mr. Bernard Gloster

I can give the Deputy an answer. I am very familiar with the Rosalie unit because three years ago I spent nine months there covering as the chief officer, and it was quite a hot topic then. Essentially, the Rosalie unit had developed into a quasi-type of later life psychiatry or mental health facility. Given their advancing years, many of the residents who utilised the unit at the time were identified as quite possibly being within the remit of nursing home care. This led to a lot of discourse that the unit was maybe going to close and so on. During the time that I was involved I gave an indication that while I did not believe the evidence would support the unit's retention or continued use for psychiatry of later life, it quite possibly might have a role in the context of older persons' services and care generally. To be fair, I do not want to commit my colleague to something he cannot do, or to undermine his position. When the Deputy raised this point I sent him a text and he has assured me that no decision has been made yet on the unit. I believe there is quite a bit of narrative around it because I am aware that the Minister for Communications, Climate Action and Environment, Deputy Denis Naughten, and Deputy Michael Fitzmaurice have both spoken on the issue. Obviously, there is some local narrative and discourse around the matter, but my colleague, Mr. Tony Canavan, who is the HSE's chief officer in that area, has said to me that no decision has been made yet.

Perhaps Mr. Gloster could ask Mr. Canavan to confirm this in writing.

Mr. Bernard Gloster

I have it listed for him to follow this up with Deputy O'Reilly in writing. Although there is no decision yet, in fairness to the Deputy, to the question and to public anxiety about it, I am sure that Mr. Canavan will also wish to bring clarity to the matter. I will certainly do that.

Senator O'Donnell spoke of St. Camillus Community Hospital in Limerick. I can confirm the situation there because I went there two weeks ago. I met the design team and I have seen the plans. They are very exciting plans. The history of St. Camillus Community Hospital is in the city and we are continuing to use that site. It is proposed to build 75 beds on the site. They are replacements for the existing long-stay beds. I believe there was some confusion that they may be additional beds. They are replacement beds because of the regulations, which are inspected by HIQA. In terms of progress, I am told by the estates department that the pre-planning discussion will happen over the summer and a formal planning application will be made by the end of the summer. It will probably run on for longer than an average planning application because there is quite a lot involved and because of the nature of the site. It is hoped to put a spade in the ground in 2018, and to have the project completed well before the regulation deadline of end of 2021. The unit will be built in two phases; 50 beds over two floors and then a 25 bed section on a single floor.

Will the 50 bed section be open prior to the 25 bed section being completed?

Mr. Bernard Gloster

That is what I would hope but ultimately it will be down to what the contractors can and cannot do, and to the limitations of the site. There is some moving to be done on site. The only aspect after the planning that will dictate the start date will be the cash profile in the capital plan next year. The money is approved within the 2021 programme, but as the members are aware the cash is profiled each year.

Senator Conway-Walsh asked about the €500 million. This investment programme in public, elderly residential care units is not for additional capacity but for replacement capacity. It replaces, predominantly, the old nightingale wards in the older institutional system to provide facilities for older people who are in long-term care in a space that is compliant with regulations and consistent with modern day best practice. It is a replacement programme.

Could we end up with fewer beds?

Mr. Bernard Gloster

The intention is not to end up with fewer beds. On the margins we could lose two or three beds in places, or we could gain. The difficulty with that programme is that it was announced by the then outgoing Government in February 2016. We are experiencing some challenges as we progress through the programme now because of increasing costs in construction since that announcement. This will have to wash through, but we are in very close negotiations and discussions on this with the Department.

Reference was made to closures of some beds, and while I do not know specifically about the Belmullet facility I am aware that in my own facilities in the mid-west two things happened that essentially saw some reduction in the numbers of beds in public units. The first issue was that up to 2011 we were continuing to count the very old historical number of beds. Even though the beds were physically there they had not been used for quite some time. We recalibrated the system to give a more accurate count of open beds from 2011 on. Where units lost beds it was because the site itself was being refurbished. The regulations and regulatory requirements from HIQA are very high in the built environment and the amended regulations to allow us to continue up to 2021 only came about in 2016. Before 2016, therefore, there were some regulatory pressures that led to some bed closures. When our maintenance people go in to rebuild wards some capacity could be lost in the existing sites.

The other reason that bed closures could be experienced in community nursing units is not dissimilar to bed closures in acute hospitals, which is the workforce issue. In different parts of the State we are very challenged in terms of recruiting the workforce we need for those facilities.

Was any of it in order to save money?

Mr. Bernard Gloster

I am certainly not aware of the detail for bed closures in the Belmullet unit.

It was across the board.

Mr. Bernard Gloster

In my own area of the mid-west I have more than 500 public beds and I have not closed any of them due to money.

It is a pity Mr. Gloster was not in Mayo. I must apologise as I have been called for a vote in the Seanad Chamber. I would really appreciate if Mr. Gloster could give the answers to the other questions, and I will read the transcript as it is an important vote.

Mr. Bernard Gloster

The final piece of that query was on the transport issue. Again, I am not sure of the specifics but I am aware that in the north west and the south west my colleagues are very much engaged with rural bus and community bus system and at finding very different and creative ways to assist people, be it in coming for outpatient appointments or in the overall objective of supporting people to continue to live at home and in their own communities, which is what we would all desire. I am not aware of any specific criticism of the HSE around engagement on the transport issue. I take the bona fides of the Senator's comment.

I need the new primary care centres and matching all that up addressed. I also need the spinal unit in Galway and the resource issue there addressed.

Mr. Liam Woods

Ms Cowan will address the issue of the 96 bed block and I will address the other queries.

Ms Colette Cowan

I acknowledge Senator O'Donnell, who walked the campus and looked at the various sites and new hospitals for the 96 bed acute block and the modular build. The HSE conducted its own capacity analysis prior to the national capacity plan, which showed that we needed 150 acute beds on the site to deal with the emergency acute activity that was coming in through the new emergency department. The 96 bed and 60 bed blocks were very timely in that plan. We have advertised for a tender to design the 96 bed blocks. We have funding to do that but we have no other funding in the capital plan yet. The 96 bed project is in the capital plan to be funded from 2020 onwards. It will be a three-year build.

The modular build is a 60 bed block, on which a lot of work is under way. The proposal has gone to Government for discussion for funding with all of the other plans for the State under modular builds. We have a timescale for it and we could realistically get the block up within a 12-month period. We have the site identified and the planning process under way. Boring and testing was done in the area last week and we plan to be shovel ready pending approval to proceed.

Senator Conway-Walsh referred to comments that were made about nursing being a protected species.

I do not believe I said on the record that the profession was a protected species, nor would I ever. I am merely giving feedback from the staff themselves, and from the industrial relations representatives. It is important that this be taken on board, notwithstanding that staffing issues, stress and the turnover of staff at board level is difficult for staff as well. I understand that and take that point.

The point she was making was that nurses felt they were working in an unsafe environment, and that they were under too much pressure given the number of patients they had to look after, the ratio of nurses to patients and the acute illness of the patients. They felt that they were exposed and vulnerable in situations like that.

Ms Colette Cowan

Yes, I think we are on the same page on that. The staff work in very high-octane environments and it is very stressful. I was saying that we have to support these staff if we want to keep them working in the country. Staffing is part of that, and the task force for staffing indicates that. We consistently work on that day in, day out, to try to get staffing levels right.

Ms Cowan made reference to urgent care units and mentioned that a delegation had gone to England to examine them. Perhaps she can expand on the benefit of urgent care units and what they are all about.

The second issue concerns outpatient and inpatient waiting lists. The theatre in Ennis is under-utilised, perhaps to 50% of its capacity. There is huge difficulty with outpatient facilities. There was a plan to move off-site which did not receive planning permission. Perhaps Ms Cowan might address those issues. The outpatient facilities in Ennis are inhibiting consultants from coming out to supply outpatient services there and to move away from the pressurised regional hospitals. Perhaps she might elaborate on urgent care facilities and using the facilities in Ennis to their maximum potential.

Ms Colette Cowan

Urgent care centres was a concept raised at the GP forum with the chief clinical director for UHL. We engaged with our colleague, Mr. Bernard Gloster, the chief officer, and his team to discuss how we could support patients that just need access to diagnostics. These patients would come into an urgent care centre model on the campus rather than going into the busy emergency department. They would be seen there in a unit run by GPs. This model is used in the UK. The GPs could then refer into the emergency department if the patient required anything other than the diagnostics.

A team of people went to the UK, including an emergency medical consultant, and they are now working on a proposal for what this scheme might look like. This will be something that we could test in the Irish system which would take away some of the pressure of patients who may be waiting for long periods for care requiring only a quick turnaround. We can share that paper with the committee once it has been written up. The team is in the middle of working on it at the moment.

Would the urgent care centres sit between casualty and the out-of-hours service, in a sense?

Ms Colette Cowan


Mr. Liam Woods

A couple of other questions were raised by the Senator. We are creating clinical linkage between the spinal unit in Galway and the Mater Misericordiae University Hospital, recognising the point that was raised by him. He asked if there are options internationally. The cross-border directive scheme is there, but for complex spinal surgery that would be quite difficult to operate. A connection with the Mater is being created however. I will provide the Senator with a report of that before the end of the week on that and send copies to the committee.

We have spoken about nurses and transport. There was a reference to long-term workforce planning with regard to doctors and nurses. Work has been done with the education system to address the need for doctors, and as the committee will be aware, there has been some uplift there in previous years. We have recently appointed a head of workforce planning within the HSE. As Mr. Bolger said earlier, the requirement to engage in workforce planning now on the basis that additional capacity is coming into the system is clearly strongly indicated. This will be a key focus for us in the coming period.

There was a question about when there will be a proposal for Merlin Park University Hospital. The Saolta University Health Care Group is putting proposals relating to Merlin Park to the HSE. That is one of the dialogues that is taking place on capacity. There are some proposals with us in that regard. The group is also looking at the full Merlin Park site and what the future of the two locations is. There are currently proposals to put a facility in Merlin Park.

On questions of recruitment and retention, part of the answer is often that we are increasing training places. The issue about increasing training places is that we will lose our graduates if the hospital system is not a magnet system that attracts people to come and work in it, because they will choose to go abroad rather than work in the dysfunctional system that we have. While we need to educate nurses, doctors and other therapists, we also need to create an environment that attracts them, as opposed to repels them.

Mr. Liam Woods

The notion of being an employer of choice for clinical staff in what is a vibrant international market, as the Chairman will be aware, is key to that. Some recent discussions with clinical colleagues about the gap between the post-2012 and pre-2012 consultants could be an issue. Other contractual matters probably need to be considered as well. Overall, there is a question of planning for the numbers we need and then there is an issue about having attractive employment. The overall strategy of shifting to care in the community and allowing hospitals to focus on what they need to focus on will help that attractiveness, as will capital infrastructure. The integrated plan for health should create that environment.

Finally, Ms Cowan was going to speak about Ennis Hospital.

Ms Colette Cowan

We were disappointed that planning permission for the move of the outpatient clinic was turned down, because it is a core need for the service. We have gone back to the table to revamp it and reapply for planning to try to get it over the line. It is of exceptional importance. The current outpatient clinic is small, and we cannot get consultants to move there.

With regard to the theatres, we are focusing on the model 2 hospitals as part of our new strategy document around transforming. The ophthalmology centre in Nenagh Hospital is one example. We have worked with Ennis Hospital on developing the ear, nose and throat, ENT, service. A new consultant will be commencing in the autumn who will operate and develop the ENT service in Ennis. This will address the waiting list problem facing ENT services in the area. That will be the first step for Ennis Hospital. We have some work to do regarding the bowel screening programme there as well. Ennis Hospital is the only hospital in our group that provides a bowel screening service.

I thank the witnesses on behalf of the committee. This is the first group of witnesses who have emptied the committee room. I do not know whether that is positive or negative. I thank Ms Colette Cowan, Mr. Liam Woods and Mr. Bernard Gloster, speaking on behalf of the HSE, for their expert opinions. I also thank Ms Susan Scally, Mr. Paul Bolger and Ms Linda O'Rourke, who contributed on behalf of the Department.

The joint committee adjourned at 12.55 p.m. until 9 a.m. on Wednesday, 11 July 2018.