National Children's Hospital: Discussion

The purpose of the meeting is to receive an update on the national paediatric hospital project, including the new children's hospital at St. James's Hospital and the development of urgent care centres at Connolly and Tallaght hospitals. From the National Paediatric Hospital Development Board, NPHDB, I welcome Mr. Fred Barry, chairman, who is joined by Dr. Emma Curtis, medical director. From Children's Health Ireland I welcome Professor James Browne, chairperson, and Ms Eilísh Hardiman, chief executive. From the Department of Health I welcome Ms Tracey Conroy, assistant secretary, acute care division, and Mr. Colm Desmond, assistant secretary, finance and evaluation division. From the HSE I welcome Mr. Dean Sullivan, deputy director general for strategy, and Mr. Jim Curran, head of estates.

By virtue of section 17(2)(l) of the Defamation Act 2009, witnesses are protected by absolute privilege in respect of their evidence to the committee. However, if they are directed by it to cease giving evidence on a particular matter and continue to so do, they are entitled thereafter 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 and asked to respect the parliamentary practice to the effect that, where possible, they should not criticise or make charges against any person or entity by name or in such a way as to make him, her or it identifiable. Any opening statement made to the committee by witnesses may be published on its website after the 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, either by name or in such a way as to make him or her identifiable.

I invite Mr. Barry to make his opening statement.

Mr. Fred Barry

I thank the joint committee for inviting us to update it on the progress made in the work being carried out at the new children’s hospital. I am joined by Dr. Emma Curtis, medical director, at the National Paediatric Hospital Development Board.

The National Paediatric Hospital Development Board, NPHDB, was appointed in August 2013 to design, build and equip a new national children’s hospital. A planning application was lodged in August 2015 and An Bord Pleánala granted planning permission in April 2016 for the new national children’s hospital, the paediatric outpatients and urgent care centres at Connolly and Tallaght hospitals and related developments, including the Children’s Research and Innovation Centre, CRIC, and a family accommodation unit adjacent to the new national children’s hospital.

I will start with developments related to the development board. My last appearance in front of the committee was preliminary to my appointment as the new chairman of the board. The Minister for Health subsequently confirmed my appointment. Two board members have since resigned, having given great service for six years. The appointment of new members is within the remit of the Minister for Health and we are working together to fill the positions. There have also been resignations by executive personnel, including the project director. An open competition is under way to find a new chief officer. An interim chief officer and an interim project director have been appointed in the meantime.

On progress, the paediatric outpatients and urgent care centre at Connolly Hospital is the most advanced element of the project. Construction work is substantially complete and the building was handed over to Children’s Health Ireland in May. Services will commence in the new building once the usual commissioning activities are completed. That will be a very significant milestone in the delivery of suitable treatment centres for children.

Good progress is also being made at the new paediatric outpatients and urgent care centre at Tallaght Hospital. The decant works are complete and the new crèche, changing facilities and offices are open. Construction of the foundations for the paediatric outpatients and urgent care centre building started earlier this year and the new building has reached first floor level. The new national children’s hospital on the St. James’s Hospital site is by far the biggest element of the project.

The committee will be very aware that the construction costs of these works, as finally agreed with the main contractor BAM, are considerably higher than the previously estimated costs. Notwithstanding the difficulties in reaching agreement with BAM, the view of the development board was that it would be better to proceed with BAM rather than stop the project and retender for the main construction work. We could have retendered the contract, but it would have added years of delay. Between tendering costs, inflation, increased owner costs and mobilisation costs, the likelihood was that retendering would ultimately result in higher rather than lower project costs. Accordingly, the board recommended to the relevant stakeholders that construction proceed on the basis agreed with the main contractor, BAM. At the end of last year the Government authorised the board to proceed with the main construction works.

Another significant development is that it has been decided to procure employer-supplied health technology equipment through traditional procurement means, rather than a managed equipment service. This decision is timely in that it allows for competitive tendering, procurement and delivery of the equipment in line with the overall programme.

The construction focus for the last year or so has been on heavy civil works in excavating the site, pile driving and so on. The building frame is under construction. The frame can be seen above ground level in places and as it rises, it will give a real sense of the scale of the works. The mechanical and electrical installation work has started in the basement. The next construction milestone will be completion of the new access road loop around the site perimeter, thus allowing the excavation of the strip of road running east-west through the building site. It will be visible later this year. Drone footage from the site taken at the end of May can be viewed online at http://www.newchildrenshospital.ie/campus-vision/drone-footage-of-nch-site-may-2019/ .

I thank Mr. Barry and invite Ms Hardiman to make her opening statement.

Ms Eilísh Hardiman

I thank the joint committee for inviting Children’s Health Ireland to attend to update it on the new national children’s hospital. I am joined by Professor Jim Browne, chairman of the board of Children’s Health Ireland.

I welcome the opportunity to provide the committee with an update on the new national children’s hospital project as requested in its invitation. As Children’s Health Ireland is the client of the development board for the project, my update to the committee is in accordance with this remit.

Children’s Health Ireland commenced on 1 January 2019 as the entity that governs and delivers acute paediatric services at Crumlin, Temple Street and Tallaght hospitals and from July at Connolly Hospital in Blanchardstown. The commencement was facilitated with the support of the boards and management of Our Lady’s Children’s Hospital, Crumlin and Temple Street Children’s University Hospital, both of which dissolved this month. I take the opportunity to thank the two former boards and the existing board at Tallaght University Hospital, as well as the previous Children’s Hospital Group Board, for their stewardship of acute paediatric services for many decades and, in some cases, centuries. I also acknowledge the previous Children’s Hospital Group Board in helping to get Children’s Health Ireland commenced. I point out that all board member positions are voluntary and involve the greatest of dedication and effort.

In the delivery of the physical buildings Children’s Health Ireland continues to work closely with the development board on matters related to the build, design and equipping of the new facilities. A series of management and working groups engage on a monthly basis to progress all matters related to ensuring the paediatric outpatients and urgent care centres at Connolly and Tallaght hospital and the new national children’s hospitals meet the clinical and operational needs of children, their families and staff. I take the opportunity to recognise the commitment, work and support of Mr. John Pollock, the former project director of the development board. Within weeks, we will be delivering a service at the paediatric outpatients and urgent care centre at Children’s Health Ireland at Connolly Hospital. It will be followed next year by the paediatric outpatients and urgent care centre at Children’s Health Ireland at Tallaght Hospital. The new facilities, together with the opening of the new national children’s hospital in 2023, will transform how acute paediatric healthcare is delivered to the sickest children in Ireland and local secondary care services are delivered in the greater Dublin area in delivering better healthcare outcomes, as well as ensuring better experiences for children, their families and staff.

Children’s Health Ireland at Connolly Hospital in Blanchardstown was handed over by the development board to Children’s Health Ireland for clinical commissioning in May. Equipment installation is near completion and operational. We hope it will be done next week. Clinical commissioning is under way in time for opening on 31 July, initially on a phased basis.

I remind the committee that 25% of the population are children under 18 years of age. The majority are healthy, which is good, but one quarter of three year olds are obese, while 16% of children have a chronic disease, such as diabetes, allergies and asthma. This figure is increasing and 2% are acutely ill or have very complex care needs.

There is an over-reliance on hospital based inpatient care, with many services accommodated in facilities in Dublin that are no longer fit for purpose. The new children’s hospital will provide national paediatric tertiary services which account for about one quarter of what we do, as well as secondary paediatric care services for children in the greater Dublin area There are 442 beds and 3,388 whole-time staff equivalents delivering services annually to 25,000 inpatients, 28,700 day cases, more than 145,000 outpatients and 120,000 emergency department attendees at the three children’s hospitals.

All national paediatric services are within the remit of Children’s Health Ireland, some with an all-island remit, for example, the all-island congenital heart disease network. The plan for children’s healthcare is outlined in the integrated programme for child health which includes acute paediatrics, social, community, primary care and child and adolescent mental health services. This cross-divisional programme, rightly, reflects a population-focused, integrated and interdisciplinary approach to children’s healthcare and identifies the resources required to best support parents, guardians, families, children and young people in achieving healthier outcomes.

From the perspective of Children's Health Ireland, we have been focusing on our integration programme. The programme centres on valuing and aligning the different cultures of the three hospitals, integrating ICT systems, standardising clinical and operational protocols and staff recruitment and training. Significant work is under way across Children's Health Ireland and I will update the committee on some of these aspects. We have implemented a single patient administration system. Part of Children’s Health Ireland’s path to integrating ICT systems is a new patient administration system. It was implemented and went live in mid-April at Crumlin and Temple Street children's hospitals. It was done without any disruption to services. It will allow Children’s Health Ireland healthcare professionals working in both hospitals and Connolly Hospital, Blanchardstown, when it opens to view shared patient details, including inpatient and outpatient history, referrals and waiting list details, transfers and chart tracking. This means that patients will have a single Children’s Health Ireland unique identifier across Crumlin, Temple Street and Connolly hospitals. It is a tangible and valuable result of the early part of our integration work to support shared and common outpatient waiting lists, starting with general paediatrics.

Turning to staffing, the majority of recruitment for the paediatric outpatient and urgent care centre at Connolly Hospital is well advanced, with most doctors, nurses, health and social care professionals and administrative staff recruited and start dates in the forthcoming weeks and months. We will start to treat patients from 31 July. Children’s Health Ireland at Connolly Hospital will provide a range of services, including urgent care, with a short stay observation unit. Children will be observed and treated for up to eight hours before being discharged. A very small number will require admission to one of our hospitals. The facility will also have outpatient care services, including general paediatrics and orthopaedic fracture clinics. Other specialties will follow. At Connolly Hospital Children’s Health Ireland will create additional capacity for general paediatrics, which is a welcome development in addressing waiting lists. It will also contribute to significant reductions in waiting times and make the situation better for children and their families.

Children’s Health Ireland at Connolly Hospital represents a significant transformation of services for families and children. It will facilitate a new model of care in paediatric services in north County Dublin and its environs, something it does not have. It will deliver the right care, at the right time, in the right facility and as close to the child’s home as possible, as outlined in Sláintecare. I welcome the opportunity to invite and bring members of the committee to the centre ahead of its opening in order that they can see at first-hand this new state-of-the-art facility and the impact it will have in the delivery of care and services.

Children’s Health Ireland is in a period of transition, not just for our staff who transitioned to the new entity in 2019 but in how acute paediatric services are delivered in Ireland. We believe the changes we are making and the impact they will have can be used as an exemplar for the transformation of services across the system. The changes we are making will deliver better, safer and more sustainable healthcare for children, young people and their families.

I thank members of the committee for their attention. I am happy to take questions.

I thank Ms Hardiman.

I welcome the delegates and thank them for their updates. I will start with Ms Hardiman and Children's Health Ireland. I thank her for the information she has given. I would like to get her steer on capacity. We are all acutely aware of some of the waiting times experienced by sick children in gaining access to diagnostics, consultant assessments and surgery, where necessary. Ms Hardiman has stated that across the three children's hospitals there are 442 beds. When the reconfiguration is complete, when the three children's hospitals are shut down and we have the new national children's hospital, with the satellite centres, what will be the total number of beds?

Ms Eilísh Hardiman

The total number of beds accounted for will be 473. In addition, there will be 24 short stay beds in the emergency department and the urgent care centres. As these patients are currently being admitted to the hospitals, we do not count them. Therefore, the increase in capacity will be 31 new beds, as well as the 24 short stay beds. That is the new model of care.

The 31 beds will be inpatient acute beds.

Ms Eilísh Hardiman

For inpatients and day cases. The biggest changes-----

There will be an extra 31 inpatient beds.

Ms Eilísh Hardiman

Yes.

Turning to the issue of staff, there will be a large complement in the new hospital. Ms Hardiman mentioned a figure of 3,388. Will she break down that number and say whether those staff will be clinical, administrative and management staff, etc.? How many clinicians are included in the figure of 3,388?

Ms Eilísh Hardiman

I have some of the details with me and can look for the answers. I can say, however, that the vast majority are clinicians.

Is that across the country or the greater Dublin area?

Ms Eilísh Hardiman

No, 3,388 is the number of staff associated with three children's hospitals in Children's Health Ireland. We have a plan to increase the number to 3,700 in the new national children's hospital. There has been phased implementation of the plan over a couple of years. We have outlined a supply and demand capacity plan. It applies particularly to nursing because nurses make up the largest section of our workforce.

There is an increase of 312 which is quite an increase.

Ms Eilísh Hardiman

It is an increase of 10%.

How much of a reduction is foreseen in the number of administrative and management staff owing to the reconfiguration?

Ms Eilísh Hardiman

One of the things we identified in moving to a digital hospital was that we would be able to transform some of the transactional processes. That requires the implementation of some of the national IT programmes, particularly in the areas of finance and logistics. We have started that process. For example, we do not have store rooms at Crumlin hospital. We introduced-----

No, I understand that, which is why I am asking about how much of a reduction is foreseen.

Ms Eilísh Hardiman

I can check in the documents I have with me. We have identified that the ICT programmes we will be introducing will allow for the removal of some transactional processes which we can replace with what we call higher value added services, particularly client and patient-facing services.

That is great. Will Ms Hardiman provide us with the figures? It would be very helpful to know what they are.

Ms Eilísh Hardiman

I will.

While Ms Hardiman is looking them up, I will ask Mr. Barry some questions. Ms Hardiman might take the time to look up the answers to two questions.

Ms Eilísh Hardiman

That is fine.

As we move to the figure of 3,700 staff, it is good to see that capacity is projected to increase. I am interested in hearing the answers to two questions. What is the projected increase in the number of clinical staff? I presume - Ms Hardiman might clarify the position - there will be a commensurate reduction in the number of administrative and management staff as we move from having three children's hospitals to one. How is all of this playing out in the move to a figure of 3,700 staff?

Turning to Mr. Barry, the last time we met he had just been appointed. In his opening statement he mentioned that two other members of the board had resigned. Is he in a position to share with us their names?

Mr. Fred Barry

Yes, I am. They are John Martin and Marguerite Sayers.

I thank Mr. Barry for that.

He also mentioned that additional executive personnel had resigned. Could he elaborate on that? How many people, was it voluntary or did Mr Barry, as the new chairman, suggest that some people needed to leave?

Mr. Fred Barry

The departures were all voluntary. It is not that such a large number of people have left, because the numbers are quite modest, but the project director and the construction director left, together with another project manager within the team. These are quite senior departures.

I refer to the scale of the overspend, and the detail we now know about the various management failures and so forth that led to this substantial overspend. Mr. Barry's sense previously was that the team was probably missing some skills. What additional skills has he brought into the team to ensure such overspends do not happen again?

Mr. Fred Barry

The first major step was to recognise that we had asked our project director to also act as chief officer. In my view, and that of the board now, that was too much to place on one individual. We have separated the positions. We have an interim chief officer with a competition under way for a permanent chief officer. We have a separate project director position. This is quite an important strengthening at the top level of the organisation.

Mr. Barry mentioned the managed equipment service. Clinicians I have spoken to are very worried about the fact that this has been dropped. Their point is that around the world it is best practice to have managed equipment services. For example, in our children's hospitals in Dublin at the moment, some of the most important diagnostic machines such as MRI machines were meant to be decommissioned years ago. The magnets, for example, are way beyond their use. The current position is that when - and I am told is "when" rather than "if" - these machines go, there will be no replacement for them. This is a high-risk way of running a health system. The solution to this in other countries, which was meant to be used in the children's hospital, is a managed equipment contract. Our children would be diagnosed by our clinicians using the most up-to-date equipment, which is refreshed and renewed so that the best possible technology and medical care can be advanced. I appreciate that there may be a cost saving in moving back to the old way of working. Is it not the case that this introduces a significant medical risk and that we will end up in the worst conceivable position because we have paid so much for a fancy building that may be beautiful but due to its design is expensive, and as a result, the medical services provided in the building will be reduced?

Mr. Fred Barry

I will pass this over to my colleague but the medical equipment that will be provided through direct purchase will be the equipment that is required. There will be no reduction in the specification of the equipment that is going in to hospital following this decision. It should not be thought that this is being done to save money upfront. If anything, it will increase the expenditure upfront.

The situation in hospitals with equipment becoming redundant and needing to be replaced is replicated throughout industry everywhere. Whether equipment is replaced down the road is a matter of whether the funding is made available to do so.

I think that-----

Mr. Fred Barry

It is not predicated by a decision that is made at this stage.

-----is exactly the point. The experience of our clinicians in the Irish healthcare system is that the ongoing investment is not made. For example, fancy equipment is bought and not maintained. The way of dealing with this and, therefore, securing a higher quality healthcare service, was to move to the managed equipment service whereby that investment is locked into the contract.

Mr. Fred Barry

Yes, I understand that.

Before I return to Ms Hardiman, one of the areas that I questioned Mr. Barry on previously is cost savings. This significant overrun has serious implications for the healthcare system and other sectors. Moving away from a better way of ensuring that the diagnostics equipment is up to speed is one of these. Medical care in the building is being sacrificed because of the overrun.

On the previous occasion Mr. Barry was before the committee he suggested that the best way to manage the risks and costs was to look at minimising further additional overspends. He was new to the job but when a member of the public, who is ultimately paying for this hospital, looks at the hospital, they will see a beautiful glass doughnut, curved in every conceivable way. None of us live in houses that are curved glass doughnuts and no private sector company constructs its building as a beautiful curved glass doughnuts because it is not a good way to maximise the space available and because glass and curves and so on are the most expensive way to construct buildings.

Has Mr. Barry had time to consider that the design and approach to this building is incredibly expensive? The architecture involved means that massive capital expenditure is needed, which other buildings do not require. There are opportunities to make changes that could drive down the costs to ensure, for example, that appropriate funding goes into the medical services and equipment.

Mr. Fred Barry

Fortunately, or unfortunately, the project is so advanced that to do something like changing the facade, revisit the materials, or even the architectural style, would effectively mean stopping the project and construction works for a couple of years and starting again and would involve going through the whole planning process. The facade the Deputy mentioned, for example, is on order by the main contractor and is being fabricated at the moment. We are beyond the point where examination and change of that sort can bring any reduction in costs.

That does not deny the possibility to make some changes that will reduce costs. Those are being made at the moment. The engineers and architects are going through the design with a fine toothcomb and where small changes can be made that do not affect functionality and that would not put us in an infringement of the planning conditions, they are being made. I may have said previously - I am unsure if it was earlier at this meeting - that the savings that will come out of this while significant in personal terms, they will not be significant in the context of the overall cost of the project. We are too far down the road to do anything like that.

I do not blame the architects, who work to a brief but given Mr Barry's considerable experience in major construction projects, is it the case that this design using curves and so on is essentially a very expensive design for the State to be engaged in?

Mr. Fred Barry

First, I have not looked backwards. I have been asked many times what I think of PwC's view of what has happened to date. My focus has been on what is going on today and on the organisation going forward and I have been very busy with that. I have not done the sort of review the Deputy is thinking of. As I travel around the world, I see that public buildings, generally, tend to be a little bit more than just purely functional and perhaps there may be a touch of that in this building as well. Whether that is right or wrong is for future generations to decide, which is the way I look at it.

It is for taxpayers today. I thank Mr. Barry.

I would like to go back to Ms Hardiman but I am happy to stop and come back in the next round.

We will give the Deputy the opportunity to finish his questions with Ms Hardiman.

Can Ms Hardiman go through the figures, please?

Ms Eilísh Hardiman

I am just doing so and totting them up here. The vast majority of the increases are down to clinical staff. We are looking at our medical staff, who are our consultant and non-consultant hospital doctors, with an increase of 124 over the next four years. I can report that, as of this year, we have 18 new non-consultant hospital doctors, NCHDs, and 17 new consultants recruited, which is good. We have phased those over the next four years. There are 250 additional nurses. We are cognisant that we do not remain static. We have the turnover in the children's hospitals of approximately 10%. We have a plan to phase this up, taking the current churn rate into account, as well as looking for new posts. Some of these posts are nurse specialists and advanced nurse practitioners, so it is not just about replacing these staff members with new staff nurses.

An increase of 200 is needed in the number of health and social care professionals. These include physiotherapists, occupational therapists and psychologists, in particular, because services for children need significant support.

Regarding the investment in Connolly Hospital Blanchardstown, most of the new staff are in those types of services because that is where the deficits in general paediatrics lie.

As to non-clinical - technical services and such supports - and administrative staff, the vision is one of a digital hospital. A digital hospital does not require a medical records department. Our largest change relates to how the three children's hospitals have approximately 140 people involved in processing paper. We will be converting those roles from administrative-type work into more patient and client-centred roles. That represents a reduction of approximately 140 staff, who will change their roles from currently-----

It is not a reduction, it is a transition. My fear was that Ms Hardiman might say something like what she has just said. When three hospitals are combined into one, there are significant opportunities to rationalise.

Ms Eilísh Hardiman

I have not answered that part yet.

Ms Eilísh Hardiman

There is a corporate integration project. We are examining all of our corporate functions, for example, finance, HR, ICT, quality and safety. We have a plan to merge existing roles so that we do not have three of everything and instead move to having just one of some types of post. We are moving from smaller organisations to a larger one, so we will still need some posts to take on broader remits, but we are looking at streamlining. That is one of the reasons we sought to be commenced four years out. We wanted to work through a process over the next four years of merging those corporate functions into single functions and considering how to streamline.

What is the number?

Ms Eilísh Hardiman

We have not come up with a number. We know what our facts are and we have a plan to identify over this year and next the roles that will be merged. We are looking at streamlining and not replacing posts - we are starting that process at the moment - and getting other individuals to take up broader remits across CHI as opposed to just in their own hospitals. I can revert to the Deputy with further details.

If Ms Hardiman would not mind.

Ms Eilísh Hardiman

It would be no problem.

It worries me because CHI is able to give very useful and exact information on doctors, nurses and healthcare professionals when they are being hired and there is good news, but when we ask harder questions like where services will be rationalised, we suddenly hear two things. First, CHI has no numbers. Second, where technology is making entire areas redundant, CHI will find other jobs for people to do. This has nothing to do with the people involved in CHI. Rather, it is the kind of thing that has gone on in the healthcare system for a long time. It ends up being a ratio of many administrators to not enough clinicians.

Ms Eilísh Hardiman

I assure the Deputy that the vast majority of the services in the children's hospital are clinical-based. That is without a doubt. Since we are co-locating on the campus with St. James's Hospital, we are also looking at this from a campus perspective. We are looking at shared services with St. James's, which will be important. For example, there will only be one distribution centre for the whole of the campus. We take a broader view on this than just CHI. We are considering with St. James's how to can combine all of the support services into one distribution hub. That is our plan. It is intricate and requires negotiation.

Ms Eilísh Hardiman

It also requires careful planning. We have started with the non-valued adding elements, for example, the warehouses on our campus. We have started moving the central distribution services at Crumlin to Temple Street. The services at St. James's will move together so that, when we move to the campus, we do not have warehouses, which do not add value, at a location where we need most of our focus to be on clinical services as opposed to support services. We have a plan to optimise services, but we must work with the HSE on its plans to modernise the whole of the health system in how the latter supports transactional processes and provides back-of-house supports.

I thank Ms Hardiman.

We will now move to the Fine Gael committee members, starting with Deputy Durkan.

I welcome our guests and thank them for the information provided. Mr. Barry mentioned that the cost of the children's hospital will be higher than previously estimated. My colleague was innovative in his generation of actual expenditure as opposed to estimated expenditure. What expenditure are we talking about? Have we overspent on the works to date at the two outreach and acute care hospitals in Tallaght and Blanchardstown and at the site of the new children's hospital? To what extent have we overspent? The word "overspend" keeps arising, which is damaging to the morale of the project, for want of a better description.

Mr. Fred Barry

I thank the Deputy for the opportunity to clarify what I said. The increase to which I referred was the historical increase that brought us to the Government approval of last December. There has been no overrun or overspend since that time. The current works are within the budget approved by the Government last year.

All of the works at all the sites are within budget so far.

Mr. Fred Barry

It is a single budget, but yes.

The use of the word "overspend" was wrong, then.

Mr. Fred Barry

I was referring to the fact that, some years ago-----

The word used should have been "under-projection" or "underestimate".

Mr. Fred Barry

Yes. There was an underestimate some years ago.

How did that develop into what is now commonly referred to as an outrageous overspend? When members of the general public wake up in the morning and read their newspapers, they think that this is appalling, but there is no overspend. All of the works involved so far are within budget. Is that true?

Mr. Fred Barry

It is. The original difficulty arose from an underestimate of what it would and, indeed, needed to cost to build the hospital as currently configured. It took some time for the realisation to dawn that that estimate had been too low.

My colleague was also inspirational on this. He mentioned that clinicians had expressed concerns about procurement. I can understand that, having been involved in the initial stages of a hospital development programme previously. Clinicians usually want the best, and they are entitled to that and should get it, but I am unsure as to whether my colleague was suggesting that there should be increased expenditure to comply with their wishes or whether the quality and status of the services to be provided would likely be of a lesser value as a result of what the clinicians expressed concerns about.

Mr. Fred Barry

To confirm, the specification for the equipment in question has been agreed with CHI and the clinical personnel involved. Whether we procure that equipment through direct purchase or a managed service is a contractual matter and has no impact on the quality of the equipment. The equipment will be provided as agreed and as required.

I am impressed with the response. I am grateful to have had an opportunity to reassure my colleague, who had deep-rooted concerns that the project would come asunder. Obviously, that will not be the case. Adequate provision has been made for ongoing procurement, where necessary, to the standard and quality required.

Mr. Fred Barry

Correct.

My colleague is saying "No", but that is just a stage whisper. He has a habit of doing that from time to time. Since overspend had become a major issue for public confidence in the system, it was important that we clarified the position once and for all. We now know that there is no overspend. It took all this time to bring out that kernel of information, but at least we have it now.

Ms Hardiman referred to chronic diseases among children. How best should we manage them from now on? Obesity and diabetes have been mentioned. A master plan to deal with this situation before it becomes an emergency is necessary. Will Ms Hardiman provide some clarification on this matter?

Ms Eilísh Hardiman

Certainly. I will start and my colleague, Dr. Curtis, might wish to chip in. It is important to note that there is a national model of paediatric healthcare. It sets out the grand scheme plan for 25% of the citizens of Ireland. It is an integrated plan, which means that it takes into account community and acute services.

We have to work in an integrated way, which I am aware the committee supports, and as has been outlined in Sláintecare. In that plan we have identified the priority issues for the next five years that help to address the challenges facing children's healthcare. This involves us working collaboratively with our colleagues in the community - GPs, public health nurses and others - to look at implementing Healthy Ireland and other plans that have a significant element focusing on children. The Government's First 5 programme is a very important plan that identifies getting a child started in the right direction around their health and healthcare outcomes and has significant benefits to the healthcare system and to the health and wealth of a country into the future. There is much planning and integration work. There is great collaboration among the paediatric community and the acute system, which work together on the priorities. We know that everything cannot be invested in during the first year and collectively we have identified the priority areas where we need to focus. We work with some of the national leads with regard to the plans to roll this out.

From our perspective, this year we have identified the regional units in Cork, Limerick and Galway in particular and they have received almost €5 million in investment to build services there. We are working in such a way that the new children's hospital is about a network of services rather than just one bricks and mortar building. We work collaboratively with our colleagues in these services to ensure as many of the services as possible are delivered locally. Some of our clinicians will do outreach clinics in the regional hospitals in specific areas that we have all agreed.

It is a ten year plan and currently we are looking at every year over the next five years for the children's hospital to see how we can invest to add to the existing resources in children's healthcare and to work in a more integrated way with our colleagues, between community, mental health and the acute services especially. We are looking at how to change the delivery of services to get a better outcome.

I am glad to report, and Dr. Curtis will concur, that obesity has started to plateau. There are some positive signs around that. Unfortunately, chronic diseases are still on the increase but I am glad we are getting our second allergist starting, along with a dermatologist and a rheumatologist, which is important. These are areas in which we have new investments this year in Children's Health Ireland that will transform how we address some of those chronic diseases. The plan is not to get down on the numbers of super specialties - we definitely have a need and requirement for some of those - but we plan to build a very strong bedrock and foundation of general paediatrics and to support them with tertiary specialty services. We are glad to say that there has been an increase in general paediatricians with six joining us on the whole team at Children's Health Ireland. Already they are bringing in expertise around adolescent care and transition care and we also have a general paediatrician with a special interest in dermatology.

We are interested in doing things a bit differently whereby the GPs do not have to wait to refer to the specialist who might have a long waiting list. Our general paediatricians are taking on board those referrals on a single waiting list that is jointly shared across Children's Health Ireland and it goes to whoever has the next available clinic. It is about more efficient use of our existing services. We are working with our colleagues to triage to see what could go to the specialist and so better use their time, and to see what can and should be managed with our general paediatricians. In using them and engaging much more closely with our GPs in the community we aim to manage those chronic diseases in that way. It is about supporting them to work a bit differently.

All of the elements mentioned in Sláintecare are the new ways of working that we are embedding into the paediatric outpatient and urgent care centre at Connolly Hospital, for example, with clinical triage of referrals. Our general paediatricians are doing a triage clinic where they clinically triage the referrals and then phone the GP, which is very important. They have managed to divert some 30% of the referrals by engaging with the GP and supporting them to care for the child, as opposed to the child having to come in for a referral. We are also bringing in general nurse specialists in general paediatrics who can deal with some of the chronic elements in paediatrics such as constipation, some of the rashes and so on. These nurses can work with the families as opposed to the child having to see a consultant. All of these new ways of working are how we are trying to transform the services. The new facilities at Connolly Hospital Blanchardstown allow for that. We have not had paediatrics in north county Dublin and its environs previously. I am glad to report that the GPs and our community colleagues in CHO 9 in that area are looking at this and working collaboratively to try to use this as a new opportunity to transform, not do the same old same old, and to implement new ways of working, especially around managing chronic disease as much as possible in the community.

Perhaps Dr. Curtis would like to add to that.

Dr. Emma Curtis

I thank Ms Hardiman. It is probably best to look at chronic disease management in two different categories. To a certain extent there is an increasing number of children with chronic and complex disease because we have got so much better at managing those conditions. Conditions might previously have led to the child's demise in early years but that no longer happens. This is due to great progress in the quality of care delivered and in medical science. There is an increase in chronic disease because children are living now with chronic disease. The emphasis now is not only on continued survival but also on improving the quality of care. This is a community and a hospital function because those children are all over Ireland and they need the support in the community such as physiotherapy, speech and language therapy and occupational therapy. That is where the national model of care comes in. It is making sure that children receive the specialist medical care they need and the community clinical care they need in order to enhance quality of life.

Another interesting part is that with the advances in understanding in genetics we can see that conditions such as diabetes, rheumatoid disorders and many of the epilepsies appear to be genetically determined. We are now understanding where the chronic conditions of a large cohort of children come from. This gives us a lever in improving treatment. These conditions are inherent to the person and therefore are not related to lifestyle or anything like that. There is a medical component. I believe that we now understand why there is an increase in the number of children with chronic and complex conditions: it is because care has improved. We do, however, have to continue to improve it. We really have to make sure we improve quality of life. Living with poor quality of life is not a huge improvement.

Obesity is a mixture - while there is a clinical medical component there is also a huge multi-agency, community and multidisciplinary aspect to obesity. Within the HSE, for example, the role of the national programmes has made a huge difference. The paediatric national programme gave us an understanding of paediatric services around the State that we really never had before. It has enabled Children's Hospital Ireland to have a national co-ordinator for this national network. The other piece that is of value from the clinical programme perspective is that it brings all of those programmes in the HSE together into a super group looking at important public health issues. Childhood obesity and well-being is one of those issues. It will involve education, facilities for sport and recreation and basic nutritional advice for every mother of a young child. It is a huge programme but it is encouraging to see that it is more of an issue now and people understand that it needs to be addressed.

We will continue to see a growth in complex and chronic health conditions, and hopefully through a multi-agency involvement we might begin to address a more complicated issue such as obesity, which is a health issue because of its consequences but the origins of which are much more complicated. That requires everybody to be involved.

I thank Dr. Curtis. I am coming to the end of my questions. In deference to all of the speakers yet to come I do not propose to go on as long as the last speaker.

The points raised are very impressive and correct. The agencies and bodies providing the service are fully alert to the full requirements, the extent of the demand and the likely demand. How is it identified and how does it come to the attention of children's medical services that there is a requirement in the first instance? Is it the initial checks at birth or is it immediately after birth?

To what extent do issues arise during school medical examinations, which I have a particular interest in, or otherwise? How does Dr. Curtis become aware of them?

Dr. Emma Curtis

Increasingly, many of the serious chronic conditions are identified before birth in the maternity hospital so there is an awareness before a child is born. This is all documented. Services maintain databases. Where I work we have a database. For example, I run a developmental and neurodisability clinic so I understand the need that is presenting to me, and we feed that back into the system. There is a disability register and a cancer register. There are registers that understand the need and the data and reports from the hospitals provide information. Data collection is incredibly important. The school piece is still very important. There is a very good child health surveillance programme which is delivered in the community. Within schools there is an emphasis on ensuring that dental, hearing and vision issues are picked up in children because they would impact on their education if they were missed. Those services exist and they are very important. They are outside hospital and are managed through the HSE.

The point that would come to my attention, and I hope I know the answer, is that hopefully all these services will be immediately and readily available to all children in all parts of the country simultaneously. In other words, we will not have a system whereby somebody in Kerry, Donegal or Wexford has to wait longer to be able to avail of the high quality of services that are and will be available. Dr. Curtis is satisfied that that is the case.

Dr. Emma Curtis

Specifically on the new children's hospital, one of the intentions is that with the development of what we are calling a foundation stone of general paediatric care, which replicates the general paediatric care available in all the regional hospitals, access to specialist care - the cardiologists and rheumatologists - is the same for everybody throughout the country. Everybody gets the same foundation level of secondary care wherever they live. If one lives in Dublin, one does not go straight to a specialist. One goes to a secondary general paediatrician who is highly competent and will deal with the vast majority of children he or she sees and then everybody across the country has equal access to the specialist care. Our aim is equity in access for children throughout Ireland.

I know there are other questions the Chairman can follow up on later. My colleague is gone missing but I have a final question relating to construction. There seems to be a preference for right angles and squares as opposed to oval. I am not an expert on this area but I have some knowledge of it. There is no difference whatsoever in the cost for a graduated curve. It is the right angle curve that creates the expense. It is incorrect to presume that the design is wrong because it has a graduated curve. In fact, right angle curves inside or outside the building are appallingly frustrating from a builder's point of view. All builders will tell one that straight away, even if they are only building a house. However, I am willing to give further information on that as required, Chairman.

The Deputy is referring to the Pythagoras theory.

I call Senator Colm Burke.

I thank the witnesses for their presentations. I will refer initially to the national children's hospital and the current progress of the project. The last time the Chairman and myself went out to visit the site I think there were 450 people working on-site at the time. It was explained to us that when it comes to a certain stage, the numbers working on the site will have to increase substantially as regards fit-out and all the necessary specialists who need to go in from electricians to plumbers and so on. My understanding is that in any major project a time chart is made out on which there are targets to be met by certain dates. What is the position in terms of meeting those targets? Are we ahead or behind in terms of those targets for reaching a certain scale by the end of each month?

My second question relates to accessing people to do the work. Due to the scale of this project and because it is competing with a huge number of other large commercial projects in Dublin city as regards availability of people to do the work, where are we with making sure that we have the people to carry out the work as the project progresses? Is there any aspect of the project about which concerns have arisen regarding shortage of supply for any part, whether it is in regard to labour skills, materials or the timescale for accessing the site, because with heavy traffic in that area it is not always possible to deliver to the site when it is needed? Mr. Barry might give us some idea of the challenges on that. Will we meet our targets and are there concerns of which we need to be aware?

Mr. Fred Barry

As the Senator knows and can see by driving by the site, a great deal of progress has been made on the main hospital construction already. The frame of the building is beginning to rise above ground level so it can be seen from the outside. Some of the work is behind the original programme. Some of it is not. There probably is not a single reason for that. It is a very big job and even for a very large international contractor such as BAM, getting up and running efficiently on the scale required is always difficult and can take a little longer than anticipated. Sub-contracts have to be finalised and even though everybody knew the contract would be awarded and so on, the further negotiations with sub-contractors sometimes take a bit longer than might be the case. Design details have to be agreed in support of the construction. The construction industry is very busy and resourcing skilled tradesmen and construction management staff as well is difficult because they are hard to come by at the moment. Those are all the challenges.

The site itself is very congested. Access onto the site from the outside is very difficult. It is a busy part of town. There is a lot of traffic. That is difficult. We are building everywhere within the site. Everybody knew this going into the project and everybody planned for it but very often the reality when it is actually encountered can be a bit more difficult than had been anticipated.

External factors come into play also. For example, there was high windage for a period earlier in the year and the tower cranes were out of action. Factors like that play a part.

There are three years of construction to go. BAM, which is the main contractor, and the principal sub-contractors, Mercury Engineering and the Jones Group, are very large, experienced companies and with the time in front of them I would say they have many opportunities to mitigate any delays to date.

There are delays in some aspects of the project.

Mr. Fred Barry

In some aspects of it, yes.

Are there delays that are causing concern to Mr. Barry at this stage?

Mr. Fred Barry

They are getting our attention. I would not like to be alarmist about it. It is quite early in that phase of the construction but we and the builders are in constant discussion about how to mitigate this and what is to be done about it.

Are there challenges in regard to availability of materials or whatever?

Mr. Fred Barry

I suppose skilled labour is a bigger challenge than actual materials. The Senator has been on the site and he has probably heard all the different accents and languages on the site.

Mr. Fred Barry

The labour on the site is coming from all around the world. In the last boom we had, a good deal of the labour came from Poland and some of the Baltic states. Those states are doing very well at the moment. Their economies are strong and there is not the same availability from those states so more of the labour is coming from some of the other east European countries.

I want to move on to the Connolly Hospital project.

Has the cost stayed within budget from day one?

Mr. Fred Barry

I am not sure what the budget for this specific element was from day one but the satellites are within the overall figure. There is the €1.43 billion authorised by the Government to cover all of the works and those hospitals are part and parcel of that.

That is completed now and the project has reached fit-out stage. Will the project be within target?

Mr. Fred Barry

We are still within the €1.43 billion.

When will the project open?

Mr. Fred Barry

It will be open in a matter of-----

Ms Eilísh Hardiman

Weeks.

Mr. Fred Barry

Weeks, yes.

There has been talk that the hospital would be opened on a gradual basis. Please outline what is involved.

Ms Eilísh Hardiman

The facilities are outpatients, which everybody understands is a Monday to Friday, 9 a.m. to 6 p.m. facility. That actually is opening and we have all of the staff ready to proceed with it, as with the orthopaedic fracture clinics because they already take place in Temple Street. We do not have an increased number of fractures or we do not anticipate more children breaking legs but what we will do is depressurise Temple Street by moving them out of very cramped facilities in Temple Street into the new facilities at Connolly Hospital in Blanchardstown.

In terms of the urgent care, we are doing that in staged phases. It is a new building. People are getting used to the venue, which we are testing as much as possible. Summer time is a quiet period for urgent care. Like everywhere else, winter is when things get very busy. Some staff will come in over the next weeks and months. We are doing this on a staged basis and will be going out and communicating the hours of opening. We will open them on an increasing, phased basis over the next few months.

Will staff transfer from Temple Street?

Ms Eilísh Hardiman

No. To be clear, this is about one entity and staff joining the services such as the emergency department services and general paediatrics. We have increased the number of staff in those services and then the staff will rotate or are allocated on rosters out to the services in Connolly Hospital. We want to assure the public that the staff will be from Children's Health Ireland not different staff. It is also to ensure that if patients need to come back later into the hospitals that people understand them and they come back in under the same clinician. It is about new ways of working and trying to give very unified and standardised services across Dublin starting with Connolly Hospital and then doing the same in Tallaght next year.

Another aspect of the project is that three hospitals will come together. Has CHI consulted the existing hospitals about having one common system or is that already in place?

Ms Eilísh Hardiman

That is part of our integration. Again, we acknowledge that commencement was a big milestone for us in our services because it means we are moving to single functions of ICT. We have identified within the existing hospitals that there are four fundamental basic IT systems. We need to become a single incidence of that ICT system across all of our sites with the patient administration system being the biggest and most important. It went live in April after 28 million patient records from Crumlin and Temple Street - all of our history - were transferred to the new system. That was a phenomenally successful project that took a lot of time and effort without any impact on services; it was a very successful transition with only a handful or .001% of the records having to be amended or adjusted.

Next, we are moving to have a single system in our emergency departments. That is really important because people go to different emergency departments. Particularly from a child protection perspective, having the same information on the one system, across our emergency departments, is a key quality and safety operational requirement for us in children's healthcare. We are also looking at electronic documentation management and that means scanning documents. We are on a digital journey over the next four years to have a digital health system. We are looking at and have identified the existing systems that need to become single incidences, and have a planned approach to do so. We want to implement them in Connolly Hospital so that its staff can see the records and check whether a child has been to one of the other hospitals. We are also working on the electronic healthcare record, which is the new system that will be put into the hospital.

Does that mean that if a child attends two different hospitals in Dublin then one hospital, at present, is unable to access the file in the other hospital?

Ms Eilísh Hardiman

Yes. The new system that we will have will be better than what we have at the moment. We noticed that children have files in the three children's hospitals so one ends up ringing a colleague to get information or get it transferred. The new system will be better for the professionals who deliver healthcare. It means they can look up the record of what has happened in the other hospital. They can just see it, which is very important. As much as possible, we are putting the information on the SIM system so everybody else can see the information.

Let us say a child from Cork attends the paediatric unit in Cork University Hospital, CUH. Can the consultant in CUH access the records using SIM? Likewise, will the person in Connolly Hospital or wherever be able to access the records in CUH for the child?

Ms Eilísh Hardiman

Yes. That is the future. That is the national electronic health records, EHR, project for the HSE. We are not implementing that within CHI. What we are doing within CHI is making sure that our staff can see our patients within CHI. That is just internal to us in the interim or immediate issues. Part of the national plan is to have an integrated care record nationally.

We are trying to have one major children's hospital that will serve the entire country. I know it will deal with ordinary issues concerning children from the greater Dublin area. Is this not the appropriate time to make sure that entire system is digitised and covers all of the children in the country?

Ms Eilísh Hardiman

Yes.

I do not want a situation where all of the Dublin hospitals work together, because it will then be one hospital, but hospitals in Cork, Galway or Limerick will be unable to have the same access. I am concerned that this matter will be left behind.

Ms Eilísh Hardiman

That is all part of the national plan to digitise the healthcare records within the HSE and have a connected system. Obviously there is a timeline issue for the new children's hospital so we have to progress our digital journey to get ready for that. We are working very closely with our colleagues in the information office in the HSE on ensuring that we are aligned on the national plan because we are cognisant that is a larger plan that is bigger than us.

Regarding paediatric units throughout the country, has the HSE outlined to CHI how to co-ordinate this?

Ms Eilísh Hardiman

That is one of the assessments that is being undertaken at the moment around the implementation of the electronic healthcare record - how would these work, and how can systems talk to each other, particularly to send information, thus ensuring clinicians in Cork, quite rightly, can access and read the data on their child patient when he or she is in Dublin? That has all been identified as one of the outcomes that is required of digitising the health system.

How is information fed back to general practitioners in terms of computerisation? Are we working with general practitioners to ensure they receive relevant information as well?

Ms Eilísh Hardiman

I thank the Senator for jogging my memory because central referrals is the other project that I was trying to remember that we are trying to standardise within Children's Health Ireland. Yes, there would be an electronic transfer of referrals and a notification would be sent back to the GPs on where their referral is within the system. We are moving more towards the digital transfer of data and information back to GPs.

Will that all be in place by the time the hospital opens in four years time?

Ms Eilísh Hardiman

Yes, we are moving on that project. We have started central referrals.

With the implementation of the patient administration system, we set up a central referrals office for general paediatrics. Referrals come in digitally and whichever general paediatrician has the shortest waiting list is chosen. We manage it as a team of doctors and nurses in order to make it more efficient.

We are now competing on a world market for the recruitment of specialists in paediatric care. I am sure there are many people whom we would love to recruit but who have decided not to move back. What are the reasons people do not want to come back? Is there any one specific area? Developing a new children's hospital must be very attractive for someone who is just about to qualify as a consultant because a huge range of state-of-the-art facilities will be available. People find it quite attractive to work in childcare in Canada or Australia. What is being said to Ms Hardiman about this?

Ms Eilísh Hardiman

I agree that we are in a global market, particularly in regard to some of the paediatric specialties and the reasons people do not come back are multifactorial. We are looking at plans for key worker accommodation because there is a challenge for workers to get affordable housing in Dublin. We are working with Dublin City Council to ensure we have planning policies and options in this area and we are keen to have a sustainable approach to hospitals, which will mean that people will be able to walk or cycle to work rather than having to drive miles to get there. A huge number of talented people have left our system but want to come back. It is great for people to go away but we need to attract them back in and coming back to new and different ways of doing things is attractive for them as they want to be part of making a difference. We need to progress with the transitioning of our clinical services to contemporary ways of working. Digitising our system is one of the ways of doing that as the people to whom I refer work in digital systems internationally and have great ideas. The restoration of pay parity is an issue for us as it is a factor that has been identified.

People want to make a difference to children's lives and staff are very excited about this project. When they go to Connolly Hospital and see how they can lead the way in doing things differently, it is a huge motivational factor. It is hard to keep the motivation when all they see in the media is a focus on costs. We do not trivialise costs but we have an opportunity to attract and retain highly talented, world-class people.

Does Ms Hardiman think the media have negativised the project too much?

Ms Eilísh Hardiman

No. We have assessed the staff and they have been worried about the project and that it will not go ahead. They have given very much to the design and have set their dreams on moving into it so that they can deliver something that is better. They are delighted that it is proceeding and they are happy to see the work being done when we send the drone footage around every month. The motivation and enthusiasm of staff who are developing the new services are palpable. They are coming up with challenging ideas. Commissioning new services is not easy to do but the staff are bringing solutions to the challenges so I am confident that, along with further investment, we will be able to deliver it.

In the preamble to the recommendations in the PwC report, it states that the guaranteed maximum price, established through the two-stage tender process, does not provide a contractual ceiling on costs and significant residual risks remain to further cost escalation. The report was tasked with looking at the cost escalation and the reasons for it, and to identify solutions. Can Mr. Barry take us through his view of the PwC report in the context of increased governance of the project through the National Paediatric Hospital Development Board? What measures has the board taken to control cost escalation relating to design and quantity surveyor costs? There seems to be an increased risk of cost escalation above the guaranteed maximum price.

Mr. Fred Barry

In chapter 6 of the PwC report it is stated that there are significant residual risks that are not included in the guaranteed maximum price. It is very likely that some of those risks will materialise. The most significant of them, relating to general construction industry inflation which is running at higher levels than are included in the contract, are quite outside our control. The additional amount, if there is to be one, will be determined by a formula based on various construction cost indices as they emerge over the next few years. Other areas are more within our collective control, such as design changes which might be introduced. The hospital was designed when it went for planning approval a couple of years ago and it has developed since but it will be another four years or so before the hospital opens. There may also be changes in medical practice too, or in technology which may need to be introduced in the project at this stage. They may lead to increased costs or a view may be taken that it is better to defer changes until after the hospital is completed. That will be a matter of judgment as we go forward. Children's Health Ireland, CHI, and ourselves will work hand in glove on those decisions.

On the question of governance, we are restructuring the committees of the development board to focus on challenges for the next few years. They have heretofore focused on planning and design, as was right, but our primary focus is now on dispute resolution on the construction and commissioning, integration and IT and we need to work very closely with the children's hospital in transitioning from what is purely a construction job to an operating facility.

When the National Paediatric Hospital Development Board was here at the end of January, its representatives identified a number of risks to the guaranteed maximum price. One was construction inflation, which was pitched at 4%.

If construction inflation were to increase to 7%, it would add €47 million to the cost of the project. If it increased to 10%, €96 million would be added and if it rose to 14%, it would add €166 million. They also identified new design elements, as Mr. Barry stated, which have not been incorporated so far. It was a rolling design in the context of the two-stage process. The PwC report identifies this rolling design as having increased the risks relating to costs. There are also factors outside the control of the board, such as changes in VAT-----

Mr. Fred Barry

Yes, changes in VAT or statutory changes.

Regulatory changes.

Mr. Fred Barry

Yes.

In addition, at the end of January the National Paediatric Hospital Development Board was going to conduct another scenario analysis in order to identify costs that were as yet unidentifiable. Has that analysis been completed and has the board identified other costs? If the project is not completed in 2022 as planned, each month by which it is extended will add a considerable cost, most likely a number of millions per month.

Mr. Fred Barry

Indeed, yes.

On the maximum guaranteed price, there are at least five factors that could lead to a significant escalation in cost.

Mr. Fred Barry

The guaranteed maximum is guaranteed for what is encapsulated within the contract with BAM and its various subcontractors. As the Chair has articulated, as PwC brought out and as I am sure the board advised the Government at the time, there are a lot of factors not included.

So the cost of €1.433 billion is most likely to be exceeded.

Mr. Fred Barry

My crystal ball and the Chairman's are no different as to what will happen in the context of inflation in the construction sector. Of all the factors involved, construction inflation is the one that has significant potential costs associated with it.

Has the board introduced into the process the recommendation in the PwC report to the effect that there should be an independent body sitting between the National Paediatric Hospital Development Board and the design team and quantity surveyor companies to oversee that what they are billing for in respect of the project is absolutely correct?

Mr. Fred Barry

The recommendation relating to an independent check was to do with the tender documentation when the project was being tendered. We have strengthened our own team with regards to cost management and those areas in order to be able to better supervise what is being done by the design team and the quantity surveyors on the job.

Have additional bills been submitted by the design team for amounts above what was expected or what was within the maximum price?

Mr. Fred Barry

Not by the design team. A considerable number of claims have been submitted by the main contractor, BAM, for additional moneys. It has also made requests for extensions. The contractor has even claimed that the instruction under which it is operating is invalid. We anticipate that we will be receiving claims of this sort pretty well continually from now until the end of the project.

Is that acceptable?

Mr. Fred Barry

It cannot be stopped in that the contractor is entitled to submit claims in respect of anything it thinks appropriate. There is a process under the contract for dealing with these. The claims are finally determined by the employer's representative, who has to determine in a binding manner whether the claims have any validity and, if they do, to what extent and what the implications are. Only one of these claims so far has gone through that process and the determination was that it was unfounded and there were no additional moneys due. However, it is the first of what will be a long sequence of such claims from now until the end of the project.

Is that the norm with projects like this or has the two-stage procurement process led to this capacity to continually submit additional claims?

Mr. Fred Barry

The two-stage process would normally have led to a diminution in the number of claims being received at this stage. With the two-stage process, when the second stage is complete, normally a lot of the issues that might otherwise give rise to claims and contention have been worked out and are captured within the guaranteed maximum price. However, there will always be arguments over costs and times. It is in the nature of the industry. Certainly, the main contractor, BAM, is probably a little more active in this regard than many other contractors.

I apologise for having to step out of the meeting; it was unavoidable. My first questions relate to media reports that there would be a separate entrance for the private section of the hospital. I am interested to know where that came from because clearly it came from someone looking at the plans. In the same vein, as soon as this was spoken about there was a raft of people rushing in to explain that the money for any private medicine would be recouped. I have asked the Minister and I am asking our guests now if that is worked out in any structured way. Is there a calculation for what the private facility is going to cost? If we do not know how much it is going to cost, we cannot know how much we are going to recoup. We cannot say with any confidence that we are going to recoup the money that will be spent on any private section of the hospital without knowing how much it is going to cost. If our guests know how much it is going to cost, I am interested in hearing what they have to say. I am also interested in the structured arrangements that will be put in place to ensure that the money is returned to the Exchequer. Clearly, notwithstanding the attempts by some on the committee to reframe this as something other than a massive overspend or underestimation - whichever way we put it, ultimately it is going to cost significantly more - the idea that contrary to the spirit and the letter of Sláintecare we are now going to be stacking private care into a public hospital is very disturbing for many people. Perhaps someone might outline how that is going to work.

Ms Eilísh Hardiman

I am glad to clarify that because there has been some misinterpretation of information that has been shared in respect of the private clinics. When we say that there is an entrance, there is an entrance to all of the outpatient clinics. It is an entrance off the concourse; it is not an external entrance to the private clinic. As the Deputy will appreciate, there is high footfall from the point of view of outpatients in that area. We have a large concourse and each of the outpatient areas has an entrance off that concourse. That was just written into the brief of how one gets into the concourse. It might have been misinterpreted as if it was a special entrance outside. It is no different. The facilities there are no different from the public facilities for the outpatient clinics in the area. There are 119 rooms in the outpatient area and a suite of nine for private clinics.

CHI is aware that the policy position is that there are clinics and private health medicine in public hospitals. We are familiar with the de Buitléir report and Sláintecare, and if there is a change in the policy position, CHI will implement any such changes and is willing to do that. Contractually, as an employer we have a legal obligation to the effect that our clinicians are entitled to see patients privately on our site. We have three private clinics in the existing hospital so it is about following through on that.

Would that be an increase in capacity? The three clinics that exist at the moment-----

Ms Eilísh Hardiman

It is less, I would say.

Will there be private facilities within the urgent care centres as well?

Ms Eilísh Hardiman

No.

This is just for the main hospital.

Ms Eilísh Hardiman

Correct.

There is just the question on price, then.

Ms Eilísh Hardiman

As I said, if there is a policy change, we are willing to implement it because we can use that for public patients. How we operate this is that clinicians who want to avail of it provide an operational fee that covers the running costs and the fees. We have not worked those out yet but that is the model that we are proposing.

That is the model we are proposing. As part of our merger and integration, we are looking at the three clinics at the moment and how we move forward to a model whereby if clinicians want to avail of this facility, they will pay a fee for services and a simple operational method of doing it. That is our plan to implement that.

Ms Hardiman has not quantified the cost for me.

Ms Eilísh Hardiman

We are doing that.

Will that be publicised?

Ms Eilísh Hardiman

We would be willing to share that.

That would be important.

One of the main criticisms, and something the committee struggled with, was the structure of various committees, who reported to whom and who were on what committee. The structure was, to put it kindly, very convoluted. Have attempts been made to streamline the structure? It was very frustrating for committee members trying to get information when we never seemed to be talking to the people who were on the right committee or in the right room. The PwC report also referred to this. Have the structures been flattened out or streamlined in any way?

Mr. Fred Barry

Speaking first for the development board, the structures are quite complicated - I agree completely.

Convoluted was what I said, not complicated. Convoluted has a slightly different meaning. It was very difficult to penetrate, if I may put it that way.

Mr. Fred Barry

Okay. For us at the moment, while the structures above us as far as I know have not changed, although there may be change planned there I do not know. The structures above us are not really getting in the way of us doing what we have to do on the construction side. We needed some key decisions, such as how the equipment would be procured and we have been given those decisions. From the perspective of the development board, we have a clear road ahead of us. If changes are made to the oversight, then of course we will be working with the changed arrangements, but there is not anything in there that is getting in the way of us doing our job at the moment.

Ms Eilísh Hardiman

For us, it has got a little bit simpler. We were dealing with three boards and our administrative board. With the formation of the new board, I think the chairman, Dr. Browne, would say decision making is just getting a little bit cleaner and simpler which is helpful. We would acknowledge that the project is now very much moving into commissioning and handover, and all those elements. We are looking at how we can work with the development board on the decision making to make it fast. I would like to assure the committee that with Children's Health Ireland and the National Paediatric Hospital Development Board, at executive level we have very clear robust ways of working and we work very closely together. The boards would also work that. Anything above us we would have-----

Dr. James Browne

I would agree. The legislation has provided for great clarity around the existing hospitals. Bringing together the existing hospitals has been a major achievement. That the hospitals in Crumlin and Temple Street effectively shut down their governing authorities and passed authority to us was a major step forward without any baggage in terms of any ethical issues or whatever. That was done very well. Great credit is due to the people involved - to the boards of those hospitals and indeed to the religious orders and the Archbishop of Dublin who did a fabulous job in having that transformation take place under the radar but very efficiently.

There is necessary complexity in a project like this because we have a role as a board in terms of managing existing facilities that we now control, acting as client for the new hospital, and also preparing for a new facility and preparing our services. That provides tremendous challenges and is obviously complex, but I think our board is up for that.

The other complexity arises from the fact that the hospital is funded publicly. Therefore, the control of the budget does not lie with my board or the National Paediatric Hospital Development Board. That is unusual. We recognise that is necessary in the context of public investment.

There is also necessary complexity associated with standardisation. We all agree on the need for a national electronic health record across the service. On the other hand, we have to progress it with each hospital in the context of a national standard. That provides complexity.

It would be very difficult to progress a digital hospital in the context of a non-digitised health service.

Dr. James Browne

I agree, but we are the sharp end of the wedge in terms of getting that project started. On the other hand we cannot simply go off on our own and create our own record. We must have cognisance of the national picture. That creates complexity but it is necessary complexity.

I would not wait for the rest of the HSE to catch up.

Dr. James Browne

I would not say that. It is important that we have a-----

I would probably be more inclined to forge ahead with it, but I take the point.

Dr. James Browne

I think the system is working well. That is what I am coming down to in the end. There is much greater clarity than there was.

I suspect Dr. Browne's predecessors also thought their system was working well, but unfortunately it was not in all cases. The hope is that the hospital will be built and the additional capacity provided.

I wish to ask about the urgent care centre in Connolly Hospital. I apologise if this question was asked already. When I asked the Minister this question, he was unable to give me an answer. Will it be open from 8 a.m. until midnight, seven days a week?

Ms Eilísh Hardiman

I handled that earlier.

I can look back over the record.

I am concerned that staff would be taken from the existing hospitals to staff the urgent care centre. In radiology, for example, we are already 40% short in paediatric radiologists. We need to add that 40% in to maintain the basic standard and then we need more for any additional services. Obviously at this stage the planning is done. Will the personnel be ready to go? Obviously at this stage they will have given notice in respect of wherever they are working.

Ms Eilísh Hardiman

The Deputy is touching on a challenge we have recognised. We started way back last year trying to plan to implement this. We do not want to take experienced personnel from one area resulting in a vacancy with associated risk. We have worked very closely with the management in the children's hospitals, with their direction, to risk-assess the staged approach of opening. We have identified the staff who have gone - well done if they have got promotions. If they have come from one particular area, we have looked at a staged release for them with their agreement. We have managed to go and at the same time do backfill-----

I do not understand what that means.

Ms Eilísh Hardiman

If three nurses from one ward want to go out there, it is too much for three nurses to go all together. It would cause concern over maintaining services in a ward in, for example, Temple Street or Crumlin. We have worked to have those staff going out one month or six weeks apart. We have identified backfills who have come in and started very quickly so that there is not a drop in the numbers in the ward. We have worked very closely with nursing to identify the areas from which they are coming and whether there is a risk concerned with them moving and whether we have a backfill identified very quickly.

The wider problem is one of understaffing across the hospitals.

Ms Eilísh Hardiman

I will come to that. I started with nurses because the biggest numbers relate to nurses and so that was one of our biggest challenges.

The Deputy is right. For example in imaging, radiology, we have sought 5.65 posts in imaging. Of those, 3.65 have accepted. We have ended up with two vacancies that we have not been able to fill yet. However, we are working with the imaging staff to try to address this because we have a challenge with imaging as the Deputy has identified. The demands for the services far outstrip the capacity we have. We are taking this in the round. It is not just about Connolly Hospital which has moderate requirements for imaging: it is plain film imaging. We are looking at all our imaging, working with our radiology consultants and working the HSE through NTPF and other ways of insourcing and looking at other elements in the public system to address a capacity challenge we have at the moment.

We have identified proleptic appointments and putting in a pipeline of staff. We have increased our specialist registrars in imaging so that we have a future pipeline of clinicians coming out in this area. It is a national and international challenge. We are working with the various areas and we have identified better ways of using our existing resources to prepare capacity plans in conjunction with the staff involved.

If Ms Hardiman has identified better ways of working within existing resources she must acknowledge that the existing resources are not sufficient.

Ms Eilísh Hardiman

We do.

It is only very recently that the INMO has started to count trolley waiting times for children's hospitals. That was a new departure and an area it never went into previously, primarily because it was not much of a feature. It was starting to become a feature more and more. That the INMO counts waiting times now is a clear indication that there are issues regarding staffing. One can talk about backfilling as staff progressively move out but if one is only backfilling to the current level, one is still going to be understaffed in the original hospitals before people start to move. There is genuine concern among staff that the push to open the urgent care facility will leave already hard-pressed staff in the main hospitals under even greater pressure as personnel move out. While we are told the plan is to backfill rapidly, if the staff are there to backfill, why are they not there to fill the roster and ensure staffing levels are maintained at the required level? There is no group or category of workers in the hospital outside, possibly, of administration where people are operating with a full staff complement.

Ms Eilísh Hardiman

I concur completely. In fact, we have a staffing plan that has identified increased staffing, which needs to be funded every year through the Estimates process, as an investment in paediatrics. We have based that on evidence from comparable international services. Nobody disagrees with us on whether we have identified deficits. Within Children's Health Ireland, we have identified where our priority areas for investment are. We know we cannot do it all in one year. We have clearly worked across all three hospitals with clinical directors, nurses, managers and the head of the health and social care professionals and identified and prioritised our areas for investment. I am happy to say we have had the largest investment in paediatrics in 2018 with an additional 173 posts coming into Children's Health Ireland. The vast majority of those are clinical posts and we are working hard there. However, we are cognisant of the need for further investment and will identify that as part of that annual investment process. All of that has been identified in our future workforce plans.

We have a challenge in that there is only so much capacity within the existing hospitals. We are in a very challenging area at the moment. If one walks around Temple Street Hospital, one will see that we cannot squeeze anything else in. That is why people welcome the investment in the new facilities. They are not seen as being in competition. We are seeing it as taking some of the pressure out of Temple Street in particular so that we can concentrate on tertiary, high-end services within the hospitals and get general paediatrics, orthopaedics and other services out to Connolly Hospital, which will help greatly. We are looking at strategic alliances through the National Treatment Purchase Fund and others over the next few years as we will have to increase our workforce. We cannot leave it all to 2023 to do a sudden leap.

We have an evidence base with our waiting list whereby there is a requirement for further investment. With the HSE and the commissioning team around children's health, we have mapped out what we think we need, including identifying the pipeline and whether we can realistically fill these posts. Some of that means we have set up a whole workforce planning group with the HSE. We have established specific sub-committees on nursing because of the quantum of the numbers involved. We have identified a clear action plan for the supply and demand in nursing. We have worked up something with our colleagues in the doctor training unit on the future, in particular for specialist registrars and having a pipeline there. We have sought to identify colleagues who have left the country and would return if they saw the investment taking place. We are making some progress although it is slow and takes time. There are niche areas in which it is particularly challenging to fill posts. We want to work also with health and social care professionals. While they are not among the cohorts with the highest numbers, there are still a lot of them. There is, therefore, a need to ensure we have a pipeline and, when they come to us, that they have somewhere to work. It is complex but while the board continues to engage with colleagues on the build project, we have very much moved from the building to issues around staffing and ICT. Those are our major areas of focus to try to deliver a good service when we get the building.

I appreciate that the following was covered while I was out of the meeting. Are there enough paediatric emergency consultants to open from 8 a.m. until midnight, seven days a week, in Connolly.

Ms Eilísh Hardiman

Not at the moment. That is why I was saying we have adopted a staged approach and are working on paediatrics.

What does "staged approach" mean? Does it mean a 9 a.m. to 5 p.m. service?

Ms Eilísh Hardiman

It means fewer hours. We have not concluded on that yet and are still working with paediatrics. Some of our clinicians are on maternity leave and returning. We have to build all that in.

When are they returning?

Ms Eilísh Hardiman

Well-----

I apologise. They would be identifiable.

Ms Eilísh Hardiman

Yes. We have a plan.

I withdraw that. It is definitely not going to be 8 a.m. to midnight.

Ms Eilísh Hardiman

No. It will be a phased approach which is sensible in a new facility.

I do not necessarily agree that it is sensible. The children in my constituency will be some of the main users of this facility and what we were promised was an 8 a.m. to midnight service from 31 July. That is not going to be the case. Ms Hardiman is saying it is most likely to be a 9 a.m. to 5 p.m. service and that Children's Health Ireland is still working on that.

Ms Eilísh Hardiman

We are still working on that and we will communicate on it. It is done in a way that is safe and progressive and we will see how we can increase the provision. We have talked to our colleagues internationally who have done this. They have not gone with a big bang on the first day. In fact, they have built up their services over a period of time. Our intention is to do the same and we have some resources coming back that will help us in that regard. We are happy to communicate the plan when it is concluded.

When the whole project is complete, the satellite centres in Connolly and Tallaght will be ambulatory centres. There will be no overnight beds.

Ms Eilísh Hardiman

Correct.

If someone needs admission, he or she will be transferred to St. James's Hospital.

Ms Eilísh Hardiman

Yes.

Eventually, the opening hours will be 8 a.m. to midnight.

Ms Eilísh Hardiman

Yes, with the last patient being admitted at 10 p.m. To be clear, we have done a great deal of healthcare planning on attendances at our existing hospitals to see when children come, how long they stay and the reasons for their visits. This is based very much on the evidence and on the advice of the clinicians working on planning.

I welcome the witnesses and thank them for giving up their time to attend. I thank them also for the information provided so far. A great deal of what I had planned to ask has already been asked. That is the disadvantage of being the final speaker. I ask for the clarification of a few matters. Does staged opening refer to time only and not to services?

Ms Eilísh Hardiman

Yes.

Is Ms Hardiman as positive as she can be that 31 July is D-Day?

Ms Eilísh Hardiman

That is the date we have.

I would have thought that the plans we have heard about would be in place from 31 July. It is a bit disappointing that is not the case. I presume it is difficult to manage a phased process like that. I find it hard to understand why the facility cannot just open on 31 July as planned.

Ms Eilísh Hardiman

We have been very fortunate in being able to attract seven new emergency medicine consultants back into our services. It is a good achievement. However, some people have taken maternity leave, which is something that simply happens in a system. We have paediatric emergency department consultants who are very committed to the project. However, we have some locum posts which are harder to fill than permanent posts. We feel we can fill permanent posts because people will return for those. However, we have a challenge with locum positions. We had some people doing locum work who have now got permanent posts and it is good to see that progression. We want to do this in a way that is safe for both the existing hospitals and for the new facility. August is one of our quietest months as many people have been away. That will give us some time. We have opened facilities on a staged basis previously while we have done all the pre-testing and so on. We want this to be a success. While it would be preferable to have every post filled, the reality is that staffing is a challenge in the health service. It is no different for us. We have made great inroads through continuous work with staff. They will come up with a process and a staged approach because everybody wants to make this work for the children.

I remember reading some time ago that Children's Health Ireland had filled ten out of 13 consultant positions. Is that still the case?

Ms Eilísh Hardiman

That is correct. A recruitment campaign has been advanced in respect of those positions and we have a shortlist of candidates.

So it will hopefully only be a matter of time before all 13 positions are filled.

Ms Eilísh Hardiman

Yes, we hope there will be appointments from that campaign.

I am glad that the issue of the private paediatric practice has been clarified. I welcome that.

On the children's hospital and physical access to it, when the committee discussed the location of the facility, there was a great deal of emphasis on the road and the infrastructure. I accept that this is probably outside of the National Paediatric Hospital Development Board's brief but are there plans to make it easier for people to access the hospital?

Mr. Fred Barry

As the Deputy stated, the physical infrastructure outside the hospital is outside the brief of the development board. Elsewhere, the National Transport Authority, NTA, is working on initiatives such as BusConnects and other programmes to try to improve transport in the city. I assure the Deputy that the development board and the NTA will be working closely on the plans in the-----

Does the NTA keep the development board posted after its meetings?

Mr. Fred Barry

The Deputy may not be aware that I am also involved the NTA so I can assure everybody-----

Mr. Barry wears two hats.

Mr. Fred Barry

-----that there will be close co-ordination between the development board and the NTA. There already is close co-operation.

That is good because it is important for that matter to be resolved.

Ms Eilísh Hardiman

I might be able to add to that. CHI and St. James's Hospital have a sustainability and mobility manager on campus. He is leading on a sustainable future and working to ensure that the campus is taken into account when any of the policy issues are being dealt with. We are also using digital measures to establish a facility whereby if an appointment is made, people will be able to use Google to guide and help them so that parents and families will not be stressing about the fastest way of getting to the hospital. That includes the 675 car parking spaces, which is three times more than what we have in the existing children's hospital. I re-emphasise that we have taken access and, in particular, parking seriously. Temple Street Children's University Hospital is, with the exception of the Mater Hospital, the facility that is closest to the centre of the city. Parents are able to get there but when they do, they cannot get parking. Therefore, we really put an emphasis on the parking requirements. At the same time, the campus has some of the best public transport links for those who do not need to come by car. That is not the children and the families but it is some of our staff and visitors and our students in particular.

Dr. Emma Curtis

As a result of the fact that this is a new build, it meets all of the wider requirements relating to accessibility. Many of our children have disabilities and some might require assisted ambulation, etc. Therefore, the design of the hospital is such that the first floor of the car park feeds directly into the outpatient department. The entryway is underground, so it is dry and secure and of sufficient width to accommodate children getting into buggies or wheelchairs. There is direct ambulatory access from that car park into the outpatient department.

I very much welcome that. That is good. Is there a plan to develop a charter for the new hospital?

Ms Eilísh Hardiman

There is a patient charter by which we abide. We have already developed our values, vision and mission for CHI. We did it on the basis of all the good work that the three children's hospitals have been doing in the course of their respective histories. We ascribed to the United Nations Convention on the Rights of the Child and we also have the European charter for children's hospitals. All of these are clearly driving the values, vision and mission of our entity.

Does Deputy O'Connell want to come in?

We will return to our second round of speakers. I call Deputy Donnelly.

I thank our guests for their ongoing energy. Being here can be gruelling and I imagine it is a lot more difficult on their side of the room than it is over here. Before I proceed to put further questions to our guests, I want to thank Deputy Durkan in his absence. He made some quite extraordinary statements earlier which, from what I can see, fit very neatly with Orwellian doublespeak. He seems to have recast a €650 million budget going to €1.7 billion as not being an overspend. According to Deputy Durkan, there has been no overspend or overrun, there was simply an underestimation. That is extraordinary. It is a bit like agreeing a price of €200,000 for a house with a builder who comes back 18 months later and states that more pipes and wiring are needed and that the new cost will be €600,000 but that the good news is that this is not an overspend or an overrun, it was just caused by an underestimation. On a serious point, the Deputy's recategorisation of the amount of taxpayer's money that is being used is an insult to everyone who uses the healthcare system and to those who pay taxes. The idea that we would dismiss an increase from €650 million to €1.7 billion and counting - because it seems like it will go a lot higher - as not being an overspend or an overrun is an insulting re-spin in the context of what we all know to have happened.

I would like to go into the issue of private practice with Ms Hardiman. There was a public report to the effect that there would be a private entrance as part of the hospital. I asked the Minister about this and he came back to me in writing just yesterday.

We have dealt with that issue.

I was here for that. I intend to delve further into the issue. The Minister indicated that there would not be a private entrance, but what Ms Hardiman confirmed to Deputy O'Reilly was that there will be a private entrance within the concourse. If I understand the matter correctly, there will be a segregated entrance that will lead to dedicated consulting rooms for private patients. Is that correct?

Ms Eilísh Hardiman

To be clear, all of our outpatient areas are off the concourse and each has an entrance. That is how the outpatient suites are planned out. One of them has nine rooms and that is the private clinic. There is an entrance to it and it is the same for all the rest of them. They are designed like modules in order that we can have flexibility. It is not the case that, for example, in the middle of an outpatient suite one room would be private. There are nine rooms that are off the concourse like everywhere else.

So it is not the case that a consultant working in the hospital would only be engaged in public practice. He or she can rent one of the public rooms and do private work there.

Ms Eilísh Hardiman

That is correct.

There will be a separate entrance to physically discrete suites for private patients.

Ms Eilísh Hardiman

All of the-----

The answer is either "Yes" or "No." Will there be a separate entrance to the private suites?

Ms Eilísh Hardiman

My response is that all of the outpatient suites have their own entrance. It is no different to the public suites that we have off the concourse. It is built in exactly the same way.

To be clear, Ms Hardiman is confirming that there will be a separate entrance to private suites for private patients.

Ms Eilísh Hardiman

That is correct.

We are all aware that there are huge waiting lists for children in the context of getting access to diagnostics and treatment. However, those lists do not apply if a child's parents can afford to pay for the treatment. Are we potentially looking at a situation where there may be two children with the same condition who need to see the same consultant and where one child whose parents cannot afford to pay and who may have to wait two years to see him or her will go through one door while the other child whose parents can pay will go through the private door and be seen within two days?

Ms Eilísh Hardiman

That is the system. That is what Sláintecare has identified and that is what the de Buitléir report was asked to consider.

We are physically building that into the new children's hospital.

Ms Eilísh Hardiman

We have a legal remit and a policy remit but, as I have stated, if the policy changes, this is not a problem. We can implement the new policy. In paediatrics, the vast majority of our clinicians operate in the public system. It is a much smaller element of private healthcare in paediatrics than is the case with adult healthcare.

I take Ms Hardiman's point that it is a policy decision.

Ms Eilísh Hardiman

It is less than 10% of our facilities.

I have a question about access to diagnostics. In the case of Temple Street hospital, for instance, a child who needs an MRI scan, in conjunction with a general anaesthetic, will be put on a 27-month waiting list. At more than two years, it is the longest wait time anywhere in the developed world. When the new hospital is operational and assuming there will still be these waiting lists, will it be possible for parents to pay to have quicker access to diagnostics using the same machine other children are waiting more than two years to access?

Ms Eilísh Hardiman

Our intention is to have the waiting list issues addressed before we move into the national children's hospital. We do not want to design how it will operate based on-----

I understand that, but let us assume there will be waiting lists in the future.

Ms Eilísh Hardiman

We intend to deal with that issue. One does not design a new hospital to function and operate according to a system that is not functioning and operating to the best of its ability. We have identified as a priority replacing the very old MRI machines in both Crumlin and Temple Street hospitals. The HSE is working with us to meet that objective and management understands how helpful it would be to us. In addition, we are looking at changing working hours and how we can increase throughput.

I understand the caveats, but I am asking a direct question. Will private patients have access to diagnostics through publicly purchased diagnostic machines such as MRI scanners?

Ms Eilísh Hardiman

With his question the Deputy has identified that the inequality in the system is related to access to outpatients services. Once a person has a referral to use a facility within the hospital, whether as a day case, an inpatient or otherwise, he or she is put on the list and prioritised according to clinical need. The inequality in access lies in an outpatient's opportunity to get to see a consultant earlier than he or she would via the public system. However, once such a patient is referred on, he or she is put on the list, as everybody else is, based on clinical need.

I am not sure people listening to this conversation will know what the answer to my question is based on what Ms Hardiman said. I am not saying she is trying to avoid answering it.

Ms Eilísh Hardiman

I am not.

It is a simple question and I ask Ms Hardiman to give a clear answer. We have publicly purchased MRI machines in hospitals. In many cases there is more than a two-year wait just for children to be given an appointment for a scan. Is it the case that parents will be able to pay for their children, as private patients, to access these machines more quickly than they would if their parents were not paying?

Ms Eilísh Hardiman

No. They will pay to get an earlier outpatients appointment and if they require access to anything else, including machines, laboratory tests, inpatient services and operating theatres, they will be put on an internal waiting list.

There is no differentiation between patients in that regard?

Ms Eilísh Hardiman

Such patients will be positioned according to clinical need and still have to pay.

Under the current system, a private patient gets to see a consultant much more quickly. In a situation where a public patient and a private patient see a clinician on the same day, are both sent for an MRI scan and found to have the same level of medical need, will there be any difference in time of access as between the public and the private patient?

Ms Eilísh Hardiman

No. What we find is that people use private MRI facilities to have the procedures done as opposed to using the hospital system-----

They will go outside the hospital and then come back again.

Ms Eilísh Hardiman

-----because there is such a huge waiting list.

They will not be using the public machines?

Ms Eilísh Hardiman

They will not be fast-tracked in using the public machines.

Moving on to recruitment, there has been a great deal of talk that the urgent care facility at Connolly Hospital in Blanchardstown will operate for significantly fewer hours than we thought. I understand part of the reason for this is that there must be six whole-time equivalent urgent care paediatric consultants and t hat, between the jigs and the reels and the fact that we are dealing with a recruitment and retention crisis, it is only 1.5 or two. We know that available doctors are like hens' teeth both here and around the world, one of the main issues in this country being the pay disparity for new entrants. In Ms Hardiman's experience of trying to hire doctors - we wish her the very best of luck and want to help with it - can she identify one or two changes that could be made, as well as getting rid of the pay disparity, to help us to retain the doctors we have, move from locums to permanent staff, which is what is needed in order to have a sustainable model, and make it easier to attract some of our paediatric consultants who are working around the world to come back and work here?

Ms Eilísh Hardiman

I spoke a bit about this earlier when the Deputy was out of the room, but I have no problem repeating it. There are multiple factors that would help us both in recruiting and retaining staff. Restoration of pay parity is one such factor, as the Deputy mentioned. Helping staff to find affordable accommodation in Dublin is one of the priority issues we have identified. To that end, we would like to work with Dublin City Council and others. We are working on policies on affordable housing to ensure our staff have a sustainable commute to and from work, as opposed to having to drive many miles.

Another issue we have identified is that digitisation of the system would help because people are coming from a system that is digitised and want to work in that way. They are coming to us with lots of ideas on how to connect with patients, patients' families and other clinicians. It is not just about new electronic healthcare worker records but also using apps and so on and looking at new ways of doing things. The most important aspect is that when staff come back and talk to us about this, it is clear they really want to make a difference. They are here because they want to care for children and make a difference. The new buildings and new ways of working attract them and they are up for the change and willing to be rostered until midnight if it makes services better for children. We must find ways to support them as much as possible in that regard.

We have seven new emergency department consultants, but some of them are on maternity leave. That is just the reality of the challenge we face, that there are often temporary reasons we do not have every position filled. We have two people in promotional posts. We seem to be able to fill the permanent posts, but the challenge lies in filling locum positions. These are some of the issues we are looking to address, especially accommodation, pay and, in addition, ensuring the team we are putting in place is an interdisciplinary one. Our staff want to work in new roles and with new people. The general paediatricians, for example, are being assigned clinical nurse specialists which they never had before. That type of change is making a great difference to how they deliver their services. In general, we are concerned not just to keep doing the same old thing but, instead, to use digitisation, new roles and other things that deliver better value to patients.

I have a question about Holles Street hospital. One of the big sells in having a new national children's hospital was that there would be trilocation of paediatric, maternity and adult services, but there has been no movement on the relocation of Holles Street hospital. The planning and development phase has not started and we found out at the committee recently that there was no money budgeted to begin the work this year. Does Ms Hardiman have any insight into why there has been no progress on something that was trumpeted as being a critical feature of the new healthcare campus, offering benefits for both children and mothers?

The information we received was on the Coombe hospital rather than Holles Street hospital.

I thank the Chairman. I meant to refer to the Coombe hospital.

Ms Eilísh Hardiman

Trilocation is still an objective and the medical boards have discussed it with the master of the Coombe hospital. St. James's Hospital is important in that regard because we want to have those synergies in the delivery of maternity and paediatric services. The three chairmen are meeting to see how they can progress this from the boards' perspective. There are some planning elements that could happen which are not resource intensive but which need to be done in the context of the clinical model.

I apologise for interrupting, but I asked a different question from the one Ms Hardiman is answering. Her response is the same one we have been hearing every year for the past five years. We are told that people are meeting, that terribly important work is being done and that everyone is talking to each other, but we have been hearing that for years. My question is whether Ms Hardiman has any insight into why pretty much nothing has actually happened in those years.

We are in the process of building the children's hospital but the budget to begin the planning phase for the maternity hospital has not even been allocated. Has Ms Hardiman any insight into why that is happening?

Ms Eilísh Hardiman

No, I will have to defer to my colleagues in the HSE and the Department.

Ms Tracey Conroy

From a policy perspective, the decision to locate the children's hospital on the St. James's campus and the subsequent decision on the co-location were made by the Government a number of years ago. The maternity hospital is part of the strategic investment priority and the national development plan, but its construction will not commence until the new children's hospital is completed. The Minister has been clear about his commitment to the project in previous appearances before the committee and elsewhere, including in the Dáil. As Ms Hardiman noted, that commitment is shared by the chief executive of St. James's Hospital and the master of the Coombe. The site for the proposed maternity hospital, as identified in the site master plan for the campus at St. James's Hospital, is a core element of the maternity strategy, and construction cannot commence until the children's hospital is completed. In maternity policy terms, the focus has been on the national maternity hospital, about which we have had detailed discussions. My colleague might speak about the moneys available in the capital plan for the national maternity hospital.

We are pursuing a policy of tri-location and relocation of the existing maternity hospitals, starting with the National Maternity Hospital and moving on to the Rotunda and the Coombe. That work will be ongoing over the coming years such that we will be in a position to move as expeditiously as possible to commence the works once the children's hospital has been completed.

Self-evidently, however, Ms Conroy's final point is not true, because if it were, the planning and development phase would have started. The Department may say that for engineering or capital reasons or whatever, the two hospitals will not be built at the same time. I have no technical view on that. Nevertheless, that is not the current situation. We are in the middle of building the children's hospital, but the basic, preliminary design and planning work for the maternity hospital has not even started. By definition, we are not moving as expeditiously as we could to be in a position to start building the maternity hospital as soon as possible. That is exactly what we should be doing but we are not, and my question is why. Why have we not even started the planning and development phase, which can take years? God knows, Ms Hardiman was involved in the hospital on two different sites over many years and it all related to planning and development.

Mr. Colm Desmond

It is in line with the priorities set out in the national development plan for a broad range of large projects. A number of projects relating to the maternity hospital are identified in the plan. It is clear it is a question of proceeding as the available capital programme allows, on a multi-annual basis, to determine what we can achieve. The current priority has been preparatory work on the move of the maternity hospital to the St. Vincent's site. Funding has been set aside in the capital plan for the preparatory work, while pre-preparatory work on the site is under way. Work on proposals for the development of maternity services is ongoing.

The other projects, such as the Coombe and others, are slightly further along. A decision was made that the maternity hospital would be developed in conjunction with the development of the children's hospital, which would be completed first. We are working within that timeframe on the development of maternity services generally.

I return to the conversation between Mr. Barry and the Chairman. Mr. Barry stated it is highly like that some of the additional overspends, or further estimations, in Deputy Durkan's words, will come to pass. Does he have a sense of the likely figure?

Dr. Curtis is the clinical director for the project. Is there anything else that we in the Oireachtas should or could do to help her and the clinical teams to get ready for the transition and to provide the best possible services in the short and longer terms?

Mr. Fred Barry

On how much more than the €1.43 billion we are likely to spend, I do not have a good sense of where the figure will land. Years of construction and inflationary pressures remain, and there are various other pressures too. I would be misleading the committee if I estimated figures.

Does Mr. Barry have a sense of whether it will be in the tens or hundreds of millions of euro?

Mr. Fred Barry

It will certainly be at least tens of millions of euro. The largest figures in any speculation I have seen about the matter have been the calculation included in the PricewaterhouseCoopers, PwC, report on inflation. If inflation is high enough, it will be at that sort of level.

Tens of millions of euro.

Mr. Fred Barry

It will be more if inflation is high enough. A table in the PwC report sets out potential overspends ranging from €44 million to €140 million or €150 million due to inflation alone. Those are the largest figures I have seen about any of the risks.

It could be hundreds of millions of euro but we do not yet know.

Mr. Fred Barry

It is too soon to say.

Dr. Emma Curtis

It is such a broad remit but-----

I thought we would finish on a nice question. What can we do to help?

Dr. Emma Curtis

It is such a large and wonderful project, yet its development has felt attritional, difficult and challenged. That is entirely reasonable because of the difficulties the project has faced over the time. One of the consequences has been that for the staff in the three children's hospitals, and paediatric services, children and families who will avail of it nationwide, there has been doubt and confusion about whether it will ever happen. It is seen as a poisoned chalice. We have done good work on planning and design and we have great staff. In paediatrics, almost all our staff have been trained outside the country or else trained by the best people here. Obviously, it is not the building that makes for excellent care but an inadequate building can make excellent care more difficult to deliver, whereas a good environment and resources can enhance the ability to deliver excellent care. I would like a positive perception of the project to emerge but that is not how people see it. I know the design inside out, I work closely with the CHI and, therefore, I am familiar with its work on integration.

The hospital will be excellent. It will be a very good place for children who have illnesses and conditions and who need medical input, which is a shame because, ideally, childhood is not marred by such problems. In some way, it is important that it is seen for what it is, namely, a fantastic investment, long overdue, in the health and well-being of children and young people. That is not the responsibility solely of the Oireachtas but we are all part of ensuring that the hospital is seen in that way rather than as something terribly negative, which is sometimes how it feels.

Ms Hardiman outlined the difficulties in staffing and the genuine challenges in merging three hospitals, doing everything together and commissioning three new buildings. I welcome any support, input or wisdom from the Oireachtas to the Department, which is a significant supporter of the project, while the HSE is intricately involved in the project. We are not in this on our own. All the bodies in attendance at the meeting are involved. Any support the Oireachtas can give in guiding and supporting us in the challenging job we have to do is welcome. The hospital will be a fantastic benefit to children and young people.

It has the potential, through its network and through working with primary care and community, not just the hospital, to really enhance the health of future children and young people in Ireland for decades and into the next century.

I thank Dr. Curtis. I call Deputy Louise O'Reilly.

My questions again relate to staffing. Perhaps we can refrain from mentioning there is a global shortage as we all know that. What we specifically want to know is what is being done here. With regard to nursing recruitment, I presume if there is to be an expansion of service, we are going to need more qualified nurses than we have now. Given the likely timeline, those nurses are either doing their leaving certificate now or are just finished their first year in nursing. In terms of how they are to be phased in, can Children's Health Ireland give us an idea of the numbers and whether it has sourced these nurses? I met some of the student nurses. A recent survey from the INMO indicates those nurses have no intention of waiting here and working within the health service, and they have every intention of emigrating. From my previous work, I know that cohort of workers very well. Traditionally, they would go away for a year and come back, but they are not coming back. Is there a specific plan in place? Is there any incentivisation? Is anything being done with the universities? Have any of the nurses given anything like a commitment that they are going to stay? Without the staff, we just have a massively expensive building in which no services can be delivered. It is the aspiration of the Oireachtas Members to work with the people in this room because we all want to see the hospital built. However, it becomes increasingly difficult to imagine it is going to be staffed, given the absolute crisis in staffing that exists within the health service at the moment.

Ms Eilísh Hardiman

To reiterate, workforce and ICT are the two areas we are focusing on in terms of trying to ensure we are able to leverage this capital investment. It is of assurance to us that we have oversubscribing among students coming out of the leaving certificate who want to undertake nursing, which is helpful. Paediatric nursing has the highest points in the whole of the nursing system, sometimes very high points, yet we are oversubscribed. What we have managed to do is demonstrate that we have increased the undergraduate places for paediatric nursing by ten places, which is good, so we have ten more every year cumulatively going through since two years ago. Increasing that again is part of the plan we are talking about in regard to the supply and demand of nursing.

We have also assessed and discussed this with the nurses who graduate. The vast majority, up to 90%, are offered a contract and they accept it on graduation, and we will be doing that again. We have to work very creatively, within a system that is currently very strong on headcount and budget, to try to address that. We have 90 graduates coming out from September to December of next year and we know we need them because we are in expansion mode. It is a question of how to do that and that is a challenge we are trying to work through at the moment.

From evaluating our existing nurses, we know that postgraduate nurses - those that are qualified in general nursing and then do a postgraduate course in, for example, paediatrics - stay longer with us and those courses do not take as long. In our plan for supply, we are looking at how we can increase the number on postgraduate courses. That requires funding and investment because those nurses are not full-time on pay but are 0.5, which means somebody else has to pay for the other 0.5. That is part of the plan we have identified to see how we can increase the numbers.

With regard to accommodation, we have exit interviews when people are leaving the services. Some of them have had to travel long distances and it just becomes too hard to continue doing that from a long-term perspective. Key worker accommodation is something we want.

I agree the cost of accommodation is an absolute challenge. Does Children's Health Ireland have a numbered target?

Ms Eilísh Hardiman

We do.

Perhaps it could be outlined by year to explain how it is going to be phased in and how many will be expected. If Children's Health Ireland has a plan for a young man or young woman who is doing the leaving certificate now, and it hopes he or she will, in four years' time, walk through the doors, how many of those has Children's Health Ireland identified, how many will it need and how many will come from existing resources?

Ms Eilísh Hardiman

We want to increase this by another ten places in the undergraduate programme, so that is ten every year, and we then want to add to the postgraduate programme. There are only so many coming in every year and the real leverage is in the postgraduate area because we are taking from all of the nurses who graduate in adult services. That is what we have identified. We are then looking at the mix between healthcare assistants and nurses and how we can contemporise that. That is something we are looking at with the unions involved. We have sat down and we are doing this in a very collaborative way. It is not behind anyone's back and is done on the basis that we can do things differently. That is one of the things we are doing to ensure we do not have high-dependency nursing.

We are also quite willing to look at new ways of working, for example, physician assistants have been introduced in some of the public system and the private system. To us, that is using nursing resources better. We have identified there are elements of paediatric nursing where one does not need to be a paediatric specialist, such as in theatres. We are looking at all of those elements. That is all in what we call the supply and demand of nursing that we have mapped out. We have a process with the HSE to identify the needs because some of these will need to go into the Department of Education and Skills and other areas to effect those changes.

My point is that this should be done now.

Ms Eilísh Hardiman

We have it done.

Children's Health Ireland has targeted an additional ten places. We have already established there are not enough staff to open the urgent care centre from 8 a.m. to midnight, as was promised.

Ms Eilísh Hardiman

That is not nursing staff. It is a small number of consultant staff, which we are confident-----

The net effect for people in my constituency is the same. They are not going to have the access that was promised.

Ms Eilísh Hardiman

I appreciate that.

It was promised for 8 a.m. to midnight. The issue was not around building or the cost of building but around the staffing. That is a fact. It does not matter what grade, group or category of worker it is, there will not be enough workers to open it from 8 a.m. to midnight. That will be very disappointing news for people in Fingal who were promised they would have it.

To put that to one side, I do not for one moment dispute the fact those present are working hard and making their best efforts and in no way is this intended to be critical of any one person. However, how are we to be convinced Children's Health Ireland will have the staff for the hospital when it does not have the staff for the first small part of the service? I understand Ms Hardiman is saying it would be better to phase it in. We were not told it was going to be phased in. We were told it was going to be 8 a.m. to midnight and that was the best. Now, since that cannot be done, the best is something else and people are told they will have to wait. How can we be convinced about the staffing plan? I am not convinced there will be sufficient staff because there are not sufficient staff in the health service as it is.

There does not seem to be a targeted plan. For those young adults who are doing their leaving certificate now, has Children's Health Ireland identified those numbers, where they are going to fit and how it will cope with retirements and the inevitable maternity leave and turnover and churn of staff?

Ms Eilísh Hardiman

I can absolutely and categorically say we have done what we are calling a supply and demand, which is workforce planning, as to what the requirements are for nursing, medics and health and social care professionals. We have set up a group with the HSE, because the issues are broader than Children's Health Ireland, to effect that. That group has been established and is meeting. We have a work plan mapped out in regard to how to progress with that. Nursing has been a bit ahead of the others because it is a bigger number and a bigger challenge, and the other is with regard to doctors in training. We have identified what the requirements are. Within Children's Health Ireland, we are then looking at how we get the clinical placements and we are all doing all of that planning. The directors of nursing are working actively on that.

We are also doing what we are calling "healthcare in a box". This is an initiative to educate the primary schools because it is not at leaving certificate that students make this decision about where they want to go. We have gone out to many of the primary schools in Dublin 8 to inform them about what it is like to work in a hospital.

I do not know if the Deputy has seen what was done with STEM, when they ran "Engineering-in-a-Box". That was done by our colleagues from the development board. We have replicated that. Doctors, nurses and health and social care professionals have gone into schools. Yesterday, the Canal Way Educate Together kids came back into our offices and we awarded them some nice certificates relating to their understanding of where their future roles could be. We agree that we have a broader remit than just looking at what is coming out of the universities. We believe that we have to work with primary schools and the education system. What we have pulled together, with the development board, is a community benefits group that includes the education boards and authorities in Dublin 12 and Dublin 8, Tusla, the Garda, the HSE and Dublin City Council, working with us to see how we can leverage this investment in an area that is socially deprived so that the whole area would benefit from that. The hospital will provide significant opportunities for employment. The development board has been very successful in generating employment in areas where there has not been employment in the past. We have built-in contracts for that. We want them to build and see where the future roles are so that people coming from the local community-----

I am from that area. I was born in St. James's Hospital. All of my family live around there and there are plenty of teachers in my family, so I am well aware of what is happening with that. If the supply and demand and workforce planning model used to staff the hospital is the same as that used to staff the urgent care centre, the witnesses will forgive me for being a little sceptical, because the urgent care centre will not be staffed the way that we were informed. I welcome that work on the initiatives in the schools, which is very good.

Are the separate entrance and private healthcare facility that are being built a direct result of the contract signed between consultants and Mary Harney? Is that the requirement? The witnesses alluded to consultants having the facility for private rooms.

Ms Eilísh Hardiman

I think it is from the 2008 contract, from whoever it was.

That was Mary Harney and the Fianna Fáil-led Government at the time. That is grand. I just wanted to double-check that.

There are many magnet hospitals around the world, such as the Mayo Clinic, John Hopkins, Great Ormond Street and Toronto children's hospital. I presume that the national children's hospital will promote itself as a magnet hospital where, instead of having to go and look for people, it will receive unsolicited applications to work in a state-of-the-art hospital.

Ms Eilísh Hardiman

Absolutely. We are finding that we are being asked to support and give advice and guidance globally on our plans. Our colleagues internationally are very impressed that it is a national model of care. We are looking at it as a network. We are focusing on providing care as locally as possible. We are consolidating into one hospital. It is helpful that we are tri-locating. Internationally people would like to do it that way and they are envious. In their planning for paediatric healthcare, they are coming to seek our advice and guidance, which is not an area we intend to engage in too much, but we have a plan and it will be hard work and challenging. When we implement it, we will be as good as anywhere in the world.

Ms Tracey Conroy

There has, necessarily, been significant focus on this capital project over recent years, following the planning failure at the Mater Hospital site. Ms Hardiman and Dr. Curtis have spoken about the national paediatric model of care, which will radically transform paediatric healthcare in the country, and using the wonderful capital project as a lever to drive that reform. The opportunity to be part of that model of care and to drive better outcomes and experiences for patients in this country will attract the kind of excellence and consultants from abroad. That is part of what we would like to better articulate and communicate in this forum and elsewhere, and to use other opportunities, as Dr. Curtis spoke about so fluently, to talk about the wonderful opportunity that this hospital and this model of care presents.

Regarding the private element of the hospital, is it just nine rooms?

Ms Eilísh Hardiman

Nine rooms. There are no inpatient rooms.

I imagine it is a bit like a hangar at an airport with wings leading off it, so that parts can be added on. Ms Hardiman mentioned being flexible. Is there an entrance to each of these?

Ms Eilísh Hardiman

Each suite of outpatient rooms is off the concourse. They are built that way to be flexible. We do not know what the specialty requirements will be in 20 years. One can flex the services up and down for the suites. One happens to be where the private outpatient-----

How many suites are there?

Ms Eilísh Hardiman

There are 119 rooms in total.

There are nine rooms in this suite.

Ms Eilísh Hardiman

Yes.

How many suites are there? I am trying to establish what proportion this is.

Ms Eilísh Hardiman

There are approximately ten suites. I can come back with the specifics.

Does each suite have nine rooms?

Ms Eilísh Hardiman

Yes. They tend to be in clusters. Some of them are designed a bit differently because of the requirements. For example, cochlear implants have substantial requirements and other matters have unique requirements. The hospital has to be flexible as a building so we have managed them in that way.

There is no suite with 50 rooms and another with five rooms.

Ms Eilísh Hardiman

No.

Will this be rented out?

Ms Eilísh Hardiman

Yes.

With regard to Deputy O'Reilly's question about the contract, my understanding was that there were not many people in paediatrics on a dual contract. Perhaps I am wrong. What proportion of paediatric consultants are on a public-private contract?

Ms Eilísh Hardiman

We do not have many.

It seems to include ophthalmics and such.

Ms Eilísh Hardiman

Private healthcare is not a big feature in paediatrics.

Why is this being facilitated? In my experience, there is very little private input into children's care. Sometimes, insurance companies claim fees for neonates going into intensive care and anaesthetic fees. My understanding is that there is not much list jumping when it comes to children. Why was it ever considered to put in suites which comprise approximately 10% of the building for something which is not significant?.

Ms Eilísh Hardiman

We are contractually obliged as an employer, under the consultants' contract, to ensure they are able to see children as private patients in the facilities on the campus.

This is a hangover from co-location-----

Ms Eilísh Hardiman

It is the 2008 consultants' contract.

Ms Tracey Conroy

It is part of the national contract for consultants, negotiated in 2008.

Who services the suites when, for example, cleaners are in? Are they totally paid for and do consultants then rent them and pay a fee?

Ms Eilísh Hardiman

We will work that out because we currently have those facilities in our children's hospitals. A fee will be paid for utilising them, which will cover all of the operational costs.

Will the consultants provide the service individually or will there be an external private company? For example, if there are nine rooms in a suite and ten doctors, whom the hospital wants to use, is it through company or the consultants individually that arrangements will be made? I do not want there to be potential for a private company to control the leasing. Ms Hardiman will know that in private hospitals, doctors pay a substantial amount to own a suite. I want to make sure that is not a possibility.

Ms Eilísh Hardiman

The current model is that consultants pay a fee to utilise it and run it themselves. We do not have external companies running them in existing hospitals. We are reviewing that and mapping out what it will be.

Our intention is that the operating model will involve paying a fee for use. It will be the individual consultant-----

That is fine. Does Great Ormond Street Hospital have a private facility?

Ms Eilísh Hardiman

It does.

It is not abnormal internationally to have it like this.

Ms Eilísh Hardiman

No.

If the policy changes, this can revert back into-----

Ms Eilísh Hardiman

Correct. Absolutely.

No one is going to have a hold on a piece of the hospital.

Ms Eilísh Hardiman

No. As I have said, the hospital is designed to be flexible. There is no differencing factor. The hospital is designed with single rooms throughout. Parents can stay in the rooms. Meals can be delivered to rooms. It is designed to the standard that the public system should have.

I know. I have attended many meetings at which this project has been discussed. Most of the issues have been exhausted. It is important to reiterate Dr. Curtis's point about the positive role of those who are delivering the hospital. I have made this point on many occasions. Perhaps the Chairman and the other members of the committee are aware of the state of Temple Street Hospital and Crumlin hospital. The witnesses are definitely aware of it. When I was in the car park of Crumlin hospital nine years ago, I saw cranes lifting prefabricated theatres into the hospital. I thought it was a waste of money because a new hospital was being built. I am sure children are being served as well as possible in these prefabricated units, which have been in existence for nine years. They represent an example of the facilities being given to our children. I acknowledge that the negativity around this must be very difficult. Dr. Curtis mentioned that a very good job has been done with planning and designing. Our job as public representatives is to try to get value for money. I never had a problem with the location when I studied it. I have never had a problem with providing the best care for our children. This is long overdue. I am a big supporter of trilocation and would like a planning master plan to be delivered for the site. I understand that the money is not there in the national development plan. I understand the cascade of priority when it comes to the national maternity hospital being first on the list. Many people who are looking at this project as it unfolds are losing the will to support it at times. Many people support it because of the trilocation model and as the best provider of healthcare. To my mind, the public anger has been about the money element. It is just so much money. That is where our job comes in. We have to take money from elsewhere to pay for it. It will be a fantastic hospital. None of this criticism is personal. We put ourselves in the public eye and take what we are given most of the time, much of which is deserved. Many of the witnesses have received undue public criticism, but that is just the way it goes. I will support them in any way I can as they continue their challenging job of delivering the new hospital. Many of us would sleep easier at night if we could see a maternity hospital happening in the near future, perhaps if we have a few pounds to spend on another hospital in the next plan. I thank the witnesses for their work and for their time this morning.

I will give Deputy Durkan the final word.

I apologise to my colleague whom I lampooned when he was unavoidably absent. Likewise, I apologise for my absence during his outburst.

I think the Deputy should carry on.

I assure the committee that on the next occasion, I will give full time and attention to the necessary response.

I gave some leeway to the Deputy and his colleague. The next time they should have their conversation outside the committee room.

No, these things happened in the committee room. Whatever happens in this room is accountable in here. The Chairman should not worry about that.

I thank the Deputy. On behalf of the joint committee, I thank the witnesses for coming. I am reminded by the clerk to the committee that we have been invited to visit Connolly Hospital. We will be very happy to take up that invitation.

Ms Eilísh Hardiman

I thank the Chairman.

We hope to go there on 3 July or 10 July.

Ms Eilísh Hardiman

Excellent. Thank you so much.

We will have to pick an evening. It will probably be a Wednesday afternoon.

Ms Eilísh Hardiman

Perfect. We will be happy to accommodate the members of the committee.

We will give sufficient notice. I thank Mr. Barry and Dr. Curtis of the NPHDB, Ms Hardiman and Dr. Browne of Children's Health Ireland and Ms Conroy and Mr. Desmond of the Department of Health. I also thank Mr. Sullivan and Mr. Curran of the HSE even though they did not get an opportunity to make a contribution. When this meeting resumes in private session at 12.30 p.m., we will hear from the Department about the legislation underpinning the tribunal on cervical smears.

Sitting suspended at 12.15 p.m. and resumed in private session at 12.30 p.m.
The joint committee adjourned at 12.50 p.m. until 9 a.m. on Wednesday, 19 June 2019.