Sláintecare Implementation Strategy: Discussion

In our second session of the morning we will get an update from the Sláintecare implementation office on progress with the Sláintecare programme. I welcome Ms Laura Magahy, executive director of the Sláintecare programme implementation office, Mr. Colm Ó Conaill of the Department of Health, Mr. Dean Sullivan, chief strategic and planning officer with the HSE, Ms Ciara Mellett, Sláintecare programme implementation office and Dr. Gráinne Healy, chairwoman of the Sláintecare citizen and staff engagement and empowerment steering group.

I draw the attention of witnesses to the fact that 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 the committee to cease giving evidence on a particular matter and they continue to so do, they are entitled thereafter only to a 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 they are asked to respect the parliamentary practice to the effect that, where possible, they should not criticise or make charges against any person, persons or entity by name or in such a way as to make him, her or it identifiable. I also advise the witnesses that any opening statements they have made to the committee may be published on the committee's website after this meeting.

Members are reminded of the long-standing parliamentary practice to the effect that they should not comment on, criticise or make charges against a person outside the House or an official either by name or in such a way as to make him or her identifiable. I invite Ms Magahy to make her opening statement, which I believe is in the form of a PowerPoint presentation.

Ms Laura Magahy

I thank the Chair and the committee for this opportunity to meet them. I will provide an update by way of the opening statement and then we will take questions. We are one year into implementation. I first met the committee a year ago when the office was being set up. I wish to update the committee on what we are doing in terms of the action plan and where that is at. Then I will step back a little, say what we have done and analyse the implementation to date in terms of what are the foundational steps we have taken, what key enablers we have been able to put in place, what the next steps will be and what the dependencies are on that.

The slide shows where we were last year. We very much value the ongoing opportunity to update the committee on a quarterly basis and to get its input. The effort we are making in the Sláintecare implementation office is based on an all-party Oireachtas approach and we cannot do it without the continuing support of the committee, which we welcome.

The implementation advisory council has also met four times so far during the year. That is under the chairmanship of Dr. Tom Keane. We have very good input and advice from the council. We very much appreciate its work. The implementation office was set up in quarter 1 of this year, in January. We published our action plan, which has taken a very programmatic approach to translating the vision of the all-party Oireachtas committee into the first year of its implementation. We are embarking now on the action plan for 2020 to 2022.

In terms of governance we also have the high-level delivery board, comprising the Secretaries Generals of the Departments of the Taoiseach, Public Expenditure and Reform and Health, plus the chief executive of the HSE and me. The board discusses issues of cross-departmental importance to Sláintecare.

I am delighted that Mr. Dean Sullivan is present. Since the advent of the new HSE board, we have put in place oversight taking a joint implementation approach for two key programmes that need to be rolled out in the coming years. We have established a joint implementation approach to that, which feeds through into direct oversight by the Minister. That is the system of governance. It is now well-established and is working well. It gives grounding to a programmatic and systematic implementation.

Our action plan update, as of September, is going to the Government next week. I am pleased to share that we have taken our workstreams approach through the action plan and that we have reported on all of the different elements through the action plan. The summary is that 114 deliverables were due by September and we are 93% on track. As for the eight that are off track; they will be back on track by the end of this year. That is the reason we put them into the orange category.

I acknowledge the work that has been done by colleagues in the Department of Health and the HSE to bring these deliverables to bear. Our office is there to make sure that things happen; we are not doing a lot of the work. Where things go off track, we have an input and we are there to make sure things stay on track. We acknowledge the work that has happened. We are 93% on track and will be there by the end of the year.

I will analyse where we are with the implementation process. I have categorised the process into foundational decisions without which we could not have moved forward. These have all taken place and were deliverables in the action plan. They have all taken place since we came into office. In the past year the decision was made on the six new regional health areas. On the previous occasion I was before the committee I asked if we could please stay with the plan and do it because we knew there was not unanimous agreement on regional health areas but everyone stayed with it. I acknowledge that and thank the committee members and the system for staying with that because it is a foundational piece. That allows us to plan for six integrated regional plans. I will come to that later.

The second foundational decision was to get the new HSE board and CEO in place. That is already putting a discipline around what is happening. We have a very good working relationship with the HSE through the new CEO and with the deputy director general, Mr. Dean Sullivan, who is present. A third foundational piece was the GP contract, again, without which we could not move forward. It was a key enabler especially in the context of chronic disease management and that will be rolled out from next year. Another key enabler is the enhanced nurse contract, which will make sure services can move seamlessly between the hospital and community.

A fifth piece we have been very pleased to see being put in place is through the office of Dr. Colm Henry. He has had a national clinical programmes review and made recommendations on what happens next in regard to them. They are important because if we say we are going to have six regional plans, we need them to be done in a national context. Not every region can go off and design its own way of doing things. It must be done in such a way that we have one national cancer programme, one neurorehabilitation strategy and there are many other strategies that are national and that can be interpreted in a regional way. Putting that foundational piece in place has been extremely good.

We considered the multi-annual commitment to recruiting staff in the community as another important piece that was put in through the budget because it allows us to plan in a multi-annual way. As members are aware, that is unusual because most service plans are done on an annual basis so we are very pleased that we will have visibility into the future for those. We want and need more of that.

In terms of foundational decisions, the dialogue forum has been a critical initiative to strengthen the relationship with voluntary providers. As members are aware, section 38 and 39 organisations are a significant part of the system. Putting the dialogue forum in place following the Catherine Day report is another very important foundational decision. Those are not everything but they are the ones I have picked out for today. There will be more in the action plan that will be released next week.

Next I wish to focus on some of the key enablers that have been put in place. The forum that has been put in place to look at the oversight implementation of the role of public health doctors, in particular in the context of regional planning, is important. If we are to have population-based planning we need an enhanced public health doctor role. The conversations that are happening at the moment through the office of the chief medical officer in the Department and our HSE colleagues with the public health doctors will be concluded by the end of this year. They are a key enabler.

The postgraduate medical education strategy forum, which is being chaired by Mary Doyle, is another really important initiative. This forum is looking at long-term postgraduate medical education and how it will be planned into the future.

We cannot have a shared care record or an electronic health record unless we have an individual health identifier office, which was put in place this year and is being staffed. The individual health identifier numbers have come across from the Department of Employment Affairs and Social Protection. Again, if this had not happened, we would not be able to roll out our shared records so this was a very important key enabler.

I consider e-pharmacy to be extremely important and one of the first and most important pieces of a shared care record. We have put the governance in place through the HSE to roll that out as urgently as possible. Regarding the joint initiative between the Departments of Housing, Planning and Local Government and Health on housing options for our ageing population, an implementation group chaired by Leo Kearns has been set up. If we are to keep people well and keep them in their own homes for as long as possible, looking at alternatives to nursing homes is critical. This group produced a very good strategy which an implementation group is examining to make sure it is rolled out.

Mr. Sullivan and I put an elective hospital oversight group in place. We know that the Government made the decision to have elective hospitals in Galway, Cork and Dublin but we need to address this issue in a national context in order that everybody in the country is covered for elective care. Those groups are working with us. The timeframe for the group's deliberations is 12 weeks and it is progressing very well. A clinical lead for trauma has been appointed. Mr. Sullivan is leading on this project, which involves naming and rolling out trauma centres in Dublin. A decision will be made on that in the next two months.

I have not addressed every issue but I have highlighted areas that are very important and without which we would not be able to move forward. There is a commitment to have a single assessment tool. The preferred bidder is being selected and that will be rolled out from February. Selecting and rolling out the single assessment tool is a key enabler.

I will now discuss the budget allocation for Sláintecare in 2020. The budget contained many initiatives that are what I would call Sláintecare-friendly but these initiatives specifically come into our section. We are very pleased that we have the enhanced community fund, a multi-annual fund to hire up to up to 1,000 therapists, nurses and other front-line staff to care for people in the community, including advisers for people with dementia. This will allow us to treat people in the community closer to their own homes, thereby reducing community waiting lists. I am happy to discuss how this will be rolled out when we come to questions but it is very important. We cannot move people out of hospital unless we have the capacity in the community to do so. The all-party Oireachtas committee's report was very clear on that. The allocation for the fund will rise to €60 million in 2021.

I will describe a few projects covered by the integration fund of €20 million. There has been a huge response from the system in terms of ideas for doing things better and in a different way and scaling good ideas. The €12 million care redesign fund is about providing care at the least form of complexity, in accordance with the clinical care programmes, to people in the right location. Again, this is very good work that we need to scale. It is all about moving people out of hospital to the place of least complexity, as appropriate.

I am happy for Ms Healy to take more questions on citizen and staff engagement but I will touch on a few matters. We have a very good response from the system, particularly from staff. Everybody is now talking about Sláintecare and how they are doing things in the Sláintecare way. They talk about Sláintecare in action and how they can do things in a more integrated and joined up way. It has become very much a language as well as action across the system. We have been very careful to engage with all the different healthcare professionals, such as nurses and doctors, including at conferences, to hear their suggestions about doing things in a different and more joined up way. We have received a very good response and that this is embedded across the system. More work needs to be done but there has been a very good start.

In respect of wider citizen engagement, we have been carrying out joint initiatives with Healthy Ireland. A very interesting Health Reform Alliance event was held last week and other consultation events with citizens have been held. We have also worked with staff around values in action, conferences and briefings. We welcome our engagement with this committee and elected representatives through the quarterly action plan report, committee attendance and other briefings, as needed. We are always open to discussing any aspect of the process with members or their colleagues.

I mentioned the integration fund because it was a highlight during the year when so many interesting projects applied for funding. A total of 477 applications were received, of which 122 projects were successful. They are found all around the country. The little dots in the slide represent the locations around the country. The goal was to promote the engagement and empowerment of citizens in the care of their own health, to scale and share examples of best practice and processes for chronic disease management and care of older people in particular, and to encourage innovations in the shift of care to the community or provide hospital avoidance measures. We received very interesting ideas, some of which involved scaling existing things while others proposed new initiatives.

I will discuss some sample projects. Jigsaw Online is an e-mental health platform. Jigsaw is very engaged and involved in youth mental health and the e-mental health platform the organisation is setting up for young people is a very interesting project. Other examples of projects include one by Epilepsy Ireland and Alone's BConnect project. Alone's project is very innovative. It is talking about linking healthcare, social care and community care using technology and services. Other projects include Beating Breathlessness by the Asthma Society; Croí, West of Ireland Cardiac Foundation's MySláinte community lifestyle programme; and Diabetes care in the mid-west. The latter project was a very interesting one that involved a podiatry-led pathway for timely provision of footwear and orthotics in the community. Basically, it was about preventing amputations through early intervention. It is a critical project. Another project involves rolling out FIT teams in Mullingar, Wexford and west Wicklow. We know the FIT teams have been proven to work in Limerick and other places. These teams go into hospitals, identify people in the emergency department and try to get early interventions so they stop older people in particular from having to be admitted to hospital and wrap the services around them. It is a very good project. There are around 300 staff within the integration fund projects. As we know, the staff are the core of services and health and social care is all about services.

We have work to do on eligibility and entitlement. We are submitting a memorandum to Government on the de Buitléir report, developing a roadmap for universal access and establishing an interdepartmental group on eligibility and entitlement. We would love to discuss with the committee whether there should be a citizens assembly on the issue of eligibility and entitlement.

Regarding access and capacity, I mentioned that two key programmes are being rolled out using a joint integration approach. The left hand side of the slide details the regional integrated care areas, RICA, programme while the right hand side details the capacity-access programme. We know we need to create more capacity in the system. We know we need 2,600 more beds and more staff and that we must shift care from hospitals to the community and focus on prevention. This framework provides an interesting way of approaching how we will do that and names projects to achieve this. Some of the key ones to pull out are healthy living to scale patient empowerment integration fund programmes. An awful lot of programmes in there involve patient empowerment, social inclusion and social prescribing. We need to implement housing options for our ageing population. They are just two initiatives. With regard to enhanced community care, we need to recruit 1,000 new front-line community staff, implement alternative paths for unscheduled care and diagnostics and procure the shared care record.

On hospital productivity, we need to optimise usage of existing hospital beds and decide locations of elective hospitals and procure design teams for them. These are the projects for next year and the year after in the context of the capacity plan. It is very important that they are put in the right sequence and that decisions are made in the right order.

I shall now turn to regional integrated care areas. We had a very good meeting with the chief executive officers of the hospital groups and the community organisations two weeks ago and we asked them if they would be willing, able and up for doing joint planning from the bottom up for each of the six regions. They have come back and have nominated people they would like to be involved. We also want to get patient representatives and representation from the section 38 and section 39 organisations, and from the public health doctors, in order that we can begin in earnest the regional planning for each of those six areas. The approach we are taking is to: look at the population mapping and then to look at population needs; decide capacity planning requirements for each region; look at the enablers that need to be rolled out for the regions; and - critically - looking at the pathways of care per region. In the next two weeks, we will have an interesting opportunity when Carolyn Gullery from Canterbury, which is often quoted as a very successful region, will come over to share her experience with and meet each of the six groups we have set up in order to look at these six integrated regional plans. It will be very interesting and I am excited about that. It is a great opportunity to get our regional planning right.

Deputy Shortall is interested in population profiling and how it is done. Through the health intelligence section of the HSE we have done the population profiling for each of the six regions. The profile is based on age and so on. We can then plan what the services are that each of the regions has. We have done that for each of the regions as a first step.

All of this work we are doing involves a number of dependencies. We are quite clear about the steps we want to take and how we can roll it out, but we need to maintain the momentum that has been put down during this year, to continue the stakeholder buy-in and to ensure that we have the members' support. If we do not have that support, if there is anything we can do better, we would be very open to that. We also need the Government to continue to take key strategic decisions - because there are a number that need to be taken in the next short while - and to resource those decisions. Depending on all of that, we are up for it, we are able and we have all of the structures and governance in place. I thank the committee for its continued support.

I thank Ms Magahy for that comprehensive overview of progress. I shall now open the floor to the members, the first of whom is Deputy Donnelly.

I thank Ms Magahy and her team for all of their work and for the very comprehensive presentation, including all of the facts and figures.

Different people mean different things or hear different things but, essentially, Sláintecare is universal healthcare, which involves three components, namely, access, quality and affordability. One has to be able to get care when one needs it, it has to be high-quality in nature and it has to be at a price that does not cause a person undue financial hardship. Unfortunately, we are moving rapidly in the opposite direction. Access within the public health system is collapsing. We have the worst level of access ever in the history of the State and we have by far the worst access to healthcare anywhere in the developed world. It was getting better quite quickly but over the past five or six years, it has been growing rapidly worse. Over the past three or four years, the decline has accelerated. I fear that we have passed a tipping point whereby some of the negative feedback loops are reinforcing the damage already done. Word has got out within the clinical community globally that Ireland may not be a great place to come and work as a doctor, nurse or midwife for reasons relating to working conditions, etc. These things reinforce themselves.

Ms Magahy has a very good, attractive-looking slide in her presentation that illustrates the different parts of the system. I made a few notes as I went through it. In my area of Wicklow, mental health services pretty much do not exist. I have no doubt that it is the same in many other areas. They are now telling people that they are not even going to bother putting them on a waiting list because the service just does not exist any more. Self-care in the advanced medical sense of having diagnostics and working with GP-led teams to manage one's own care also does not really exists. Dentistry services exist but they are too expensive for most people to access in any meaningful way. For the first time ever, in many instances it now takes several weeks to see a GP. A group of pensioners in Wicklow town recently told me that if they call their GP regarding, for example, respiratory issues that need to be seen to immediately or the person could end up in the accident and emergency department, it can be three weeks before they are seen. GP care has never been as hard to access. That is if one can access it. A new patient cannot actually get a GP pretty much anywhere in Wicklow any longer. Occupational therapy appointments may take four years if one is a really severe case. For a child to get access to speech and language appointments, it can be three, four or five years before he or she is seen. In fact, they are beginning to send out letters now saying that it will be at least two years and that a time cannot be given because there is no money, resources or therapists. This is the reality faced by children, mums and dads.

If one gets to a hospital, to St. Vincent's, for example, there could be a wait of a few days on a trolley. A person would be lucky to get a bed. People are terrified of having to go into accident and emergency departments. Diagnostics have reached the point where people are just trying to borrow money to pay for private appointments because they are being told it could be six months, a year or two years before they can get the scans their doctors think they need. If a person gets a scan and is referred for specialist care, it might be another year or two before he or she gets to see that doctor. If that doctor says that an operation is required it could be another year or two years before that is done. This is the reality. Social workers in Wicklow have so few resources they are working out of their cars.

The Deputy needs to ask a question.

I am coming to it. Bear with me. We need to call this out. I am not blaming Ms Magahy or her team for any of this, but there is a lot of talk about plans, governance, oversight, budgets and pilot projects. The reality, however, is sick children, sick adults and sick pensioners who can no longer access healthcare in the State. The only thing that really matters is when are they going to see a difference? When will it be possible for a child with special needs to get help? When will it be possible for an elderly person to be able to access his or her doctor when he or she needs to do so? When are things going to actually improve for men, women and children who need healthcare?

Ms. Laura Magahy

I acknowledge what Deputy Donnelly is saying and absolutely recognise the need to provide resources, particularly the community. I will come back to access in hospitals shortly. This is why it was so important that the thousand therapists are being funded. Prioritising the allocation of them to address community waiting lists, staffing of primary care centres and keeping people out of hospital is critical. This is what we will be working through with Dean over the next couple of weeks. The Deputy is absolutely right that Sláintecare is all about moving care to the place of least complexity, trying to prevent things happening in the first place and resourcing of the community. Our one mantra in the programme and implementation office was always "Let us resource the community properly and do it in an organised way". Patients will see the benefits of that next year. Will everybody see the benefits immediately? Probably not. Will there be a start? Yes, there will. That is the priority from our perspective.

The integration fund also has a large number of projects that address issues the Deputy has raised around mental health and older people. Many of these are not simply pilots, many of them are scaling initiatives that have already been working properly but which needed resourcing and scaling.

Our goal is to get immediate, short-term improvements. That is what will be put in place through next year.

Ms Magahy hopes people will begin to see a meaningful difference by next year.

Ms Laura Magahy

Absolutely, and we-----

On the same issue, Ms Magahy has obviously been looking in depth at our system.

Ms Laura Magahy


One of the things on which I cannot really get an answer is that when the amount of money being spent on healthcare is going up so quickly - it has gone from approximately €13 billion to €18 billion under the current Minister for Health alone, an unprecedented increase in healthcare spending - there is at the exact same time an unprecedented collapse in access to healthcare, which obviously should not be happening. Having done all this work, analysis and stakeholder engagement, has Ms Magahy come up with any reasons things have got so bad when funding has gone up by so much?

Ms Laura Magahy

I will say two things in response. First is our rising elderly demographic. We are getting older and living longer, which is putting additional pressures on the system. The older people are, the greater their demand on the health services. That is a fact.

That is a steady-state issue, though. What we are seeing is access collapsing over a relatively short period, whereas the demographics have been tipping along for some time. What has happened for access to collapse at the same time? The extra €5 billion that has gone into the system in the past four years comfortably covers demographics, so the funding is more than in place to deal with the demographics. Does Ms Magahy have a sense of what else is happening that we are seeing such a collapse?

Ms Laura Magahy

I do not think we are getting the turnaround time within our hospital system. That is another thing we have identified. We know that a large number of beds in hospitals - probably 1,600 beds at present - are suboptimised. That is a large amount of capacity in the system that needs to be looked at. As I said, Mr. Sullivan and I are jointly looking at capacity and immediate access to see what we can do about this. Half of this is due to hospitals not being used optimally and approximately half is due to people who should be in different locations. Deputy Donnelly mentioned respiratory illness. We are outliers in terms of chronic obstructive pulmonary disease, COPD, occupancy in hospitals. We need to put services around those people in the community. That is part of what the integration fund is about, and the enhanced nurse contract will also help us to do that. In alluding to all these key enablers in our presentation, we were trying to say those things will make a difference. The GP contract and chronic disease management will make a difference, but going back to Deputy Donnelly's main point, we are not using optimally what we have. That is my view, having looked at the figures. We need to do more jointly with the HSE. Does Mr. Sullivan wish to come in on that?

Ms Laura Magahy

Sorry, Deputy. I might ask Mr. Sullivan to come in.

May I ask one more question before that? I can come back in later if the Chairman so wishes.

We will get Mr. Sullivan in first. The Deputy has one more question. Then we will move on.

Mr. Dean Sullivan

To pick up briefly on a question Deputy Donnelly asked and Ms Magahy's response, waiting times are unacceptable. I am not sure I would describe access as having collapsed. The lists were unacceptable a year ago, and they are still unacceptable now. It is a key priority for the HSE, the Department and the Minister to tackle those waiting times, not just for themselves but because of what they mean for individuals waiting for care and the concern and waste the issue causes in the system in terms of patients cycling through it, going back to their GPs, tipping up to emergency departments and so on. Tackling this is an absolute priority of the organisation I am in and Ms Magahy. We need to recognise, though, that the work to which Ms Magahy alluded, the PA Consulting capacity planning work commissioned by the Department just over a year ago, has flagged up material capacity shortfalls in the system. Efforts are being made to address those. That is the reality. That work also recognises, as Ms Magahy said, that there are opportunities to use more effectively the capacity we have.

I will make a final point, which is again consistent with the Government's commitment around all this. Ms Magahy referred to the €12 million care redesign fund. That will be targeted at, among other things, the access issue and delivery of care in a different way and in different settings of lower complexity. There is also an uplift in funding for the NTPF this year within the letter of determination from €75 million to €100 million. That funding will be very helpful in trying to tackle precisely the problem Deputy Donnelly talked about. I am confident we will begin to see a change during 2020. I think there are opportunities, especially on the scheduled care side of the house, where a lot of the waits to which the Deputy alluded are, to begin to make progress on that and to start to build confidence in all our stakeholders. I think the unscheduled care will be more challenging. The reality is that there is a demographic pressure there. Admissions to hospital will continue to rise every year. Capacity is tight. We will make progress there but I do not think we will be as quick as with the progress on the scheduled care side of the house. I hope, if we are back here in six to nine months, that we will begin to see that tanker starting to turn, but we can revisit the issue then.

Does Deputy Donnelly have a further short question?

I missed some of Ms Magahy's presentation but, in my defence, I was getting the flu shot. I had read it anyway.

Ms Magahy referred to the 1,600 suboptimised beds. I find it a bit hard to reconcile that with the fact that we have bed occupancy rates approaching 100%. When Ms Magahy says "suboptimised", is she talking about delayed discharges?

Ms Laura Magahy

Not only.

I ask Ms Magahy to elaborate for us if she can.

Ms Laura Magahy

I am happy to supply the Deputy with the analysis after the meeting, but the bottom line is that, standing back, equalising across different beds across the system and taking the best-performing hospitals, we must consider average length of stay, people coming in when they should not, perhaps the night before an operation, and people in beds because they are waiting for radiology treatments - people not being in the right place. We have analysis and detail on that so we need to stop doing that. To do so, we need to be able to provide those services somewhere else, so it is not as simple as saying, "Stop doing that", because we need to provide alternatives. We are in the process of doing so. Some of this is accounted for by delayed discharges, and again the-----

For what proportion do delayed discharges account?

Ms Laura Magahy

From the analysis, roughly half.

That is very interesting. The budget provided for approximately two fifths of the home help hours needed. That will help, obviously - any additional home help hours will help - but it will not clear that list.

Ms Laura Magahy

Part of this is trying to stop people coming into a hospital when they should not be in the hospital. Nobody wants to be in hospital if they do not need to be there, and we need to start providing alternative pathways. We need to look at other professions and what they can do. We need to look at what pharmacists could do. We need to provide alternative treatment paths and not have everybody coming into the emergency departments. That is part of it. Then, as we said, there are very good initiatives happening but we need to scale them. People are coming into emergency departments and being met by FIT teams, brought to other locations and treated in a better and much more humane way. Things are happening in pockets around the system but we must scale them, standardise them and roll them out.

Mr. Dean Sullivan

That is a never-ending journey. There are 11,000 hospital beds, as Ms Magahy's slides showed. One of the key planks of the capacity and access process is to improve the efficiency with which we use beds, but we will never get to the end of that journey. The opportunities Ms Magahy has flagged up are there and we need to tackle them. There are other opportunities, however, from discharge once a patient is declared medically fit all the way through to, as Ms Magahy said, patients being admitted on the day of surgery, ideally, or on the day before. Good progress is being made on that, but again there is further work to be done.

I do not want to get in a row with Mr. Sullivan. He can say good progress has been made, and that was a great PowerPoint presentation, but in real life it does not appear that way to people. Ms Magahy said we might begin to see an appreciable difference next year, but the Sláintecare report is already two or three years old and there has not been any difference. In fact, the trolley wait figure for today is 551, and that figure hardly ever goes below 500. What I am trying to tease out is where we will see an appreciable difference.

Mr. Dean Sullivan

That was the point I making. The unscheduled care is a more complex problem with hard capacity issues in there in terms of patients who, no matter how many community alternatives we have, will require admission to hospital. That is flagged up in the PA review, which states that even today we are 1,000 beds light of what we would need to tackle the occupancy issue the Deputy was talking about. That is why we have to continue to apply pressure on the unscheduled care side of things and control. I think it will be a slower improvement but on the scheduled care side-----

I am 100% with Mr. Sullivan. When they were closing hospital beds, I opposed it. I know there is a need for additional beds and additional capacity.

Mr. Dean Sullivan

-----we can see improvements more quickly. I would be hopeful in that regard. It is essential that we do.

Does Mr.Sullivan have a view on the de Buitléir report? We discussed it this morning. I refer specifically to the fact that the national children's hospital will have a private facility, and that the new maternity hospital has planned on having a private facility. Is there a little bit of a contradiction there in terms of Government policy?

Ms Laura Magahy

I would not take the two in the same breath. I absolutely have a view on de Buitléir in that it is part of what the original Oireachtas committee agreed to do. The report is very logical and while it looks at doing things over a longer timeframe than was originally envisaged, it does so in a cautious way and suggests doing it in an iterative way. A memo is being prepared for the consideration of Government on the de Buitléir report.

Does Ms Magahy not think there is an inherent contradiction in the fact that we are sitting here talking about public medicine and the need to remove private healthcare from the public system while at the same time the Government-sponsored hospital is going to have a private facility in it? Ms Magahy is the head of the Sláintecare implementation office and I would have thought she would have a view on that.

Ms Laura Magahy

My view is to implement whatever Government decides. Government will be given a memo on de Buitléir and if Government decides to implement it, we will make sure it is implemented. It is a foundational piece of Sláintecare and was very much part of what the original objectives were about - the separation of private from public is part of what was originally mooted but it is a Government decision to make. It is critical that it is made because if we are going to be building elective hospitals, we need a decision. That is all I would say.

I think it is critical as well. If Ms Magahy's view is to implement Government policy that is fine but I think there is an inherent contradiction in what the Government is saying. There is no purpose in us going down that road any further. Ms Magahy referred to a multi-annual commitment to recruiting staff into the community. I know it is the 1,000 therapy posts. Kids in my constituency wait 33 months to see a therapist. That list is only getting longer and the parents are only getting more desperate. We know that. In terms of physical bodies, what does that mean? It seems to me that we have heard the 1,000 posts announced and reannounced in a number of different formats. Where are they going to be? When are they going to be recruited? Are they in college now? What grades are they? When are they going to start?

Ms Laura Magahy

Up to 1,000 front-line staff is what the budget permits. That is €10 million next year rising to €60 million. They will be in place by the end of next year. We are committed to doing it in a way that links it with services. We could say we will put however many physiotherapists in however many locations and hope for the best but that is not what we are doing. We want it to be linked to services for children, for people either on community waiting lists or to move people from hospital into the community. It will be done linked with services. Mr. Sullivan will be working through the service plan and will be identifying those positions.

Mr. Dean Sullivan

We had a letter of determination from the Department a couple of weeks ago and we are working through that as part of the service planning process. As Ms Magahy says, the key thing for us will not just be putting bodies on the ground but understanding what the impact of those bodies is going to be.

That is the exact question I am asking. What grade, group or category of workers are they going to be?

Mr. Dean Sullivan

All of that detail is to be worked through.

The HSE is hoping these 1,000 people are going to be in posts by the end of next year.

Mr. Dean Sullivan


Do the witnesses know how many people were recruited from the beginning of this year until now?

Mr. Dean Sullivan

Not sitting here now, but I am assured that a number of the order that we are seeking to recruit; the staff are out there on panels and so on if we can find the funding, which obviously we have now through the Government's allocation this year.

Currently, the staff are on their panels and they are just waiting on the position.

Mr. Dean Sullivan

It is my understanding that a large number of staff are panelled.

Does Mr. Sullivan have sight, obviously not of the names, but of the numbers on the panels?

Mr. Dean Sullivan

I do not have them with me today.

Could he get them for us?

Mr. Dean Sullivan


These are therapy grades as well as public health nurses, presumably.

Mr. Dean Sullivan

A range of different types of staff, yes.

Does that include public health nurses?

Mr. Dean Sullivan

My understanding is that for all of the staff we are seeking to recruit, they are either panelled or available through other processes during the next year.

I would be very interested in hearing that because I am not convinced there is a cohort of public health nurses panelled and waiting to come in to work.

Mr. Dean Sullivan

I will give the Deputy a note.

It would be helpful if Mr. Sullivan could share that with us.

Mr. Dean Sullivan

Certainly. For clarity, I will get the Deputy a note on that with all the detail.

I know Mr. Sullivan does not have the figures with him. I am not trying to bounce him into saying something. I am just saying I will be making this face if there is a group of public health nurses panelled and ready to come in.

Mr. Dean Sullivan

Or if not panelled, they can be certainly in post before the end of next year through another process.

Mr. Sullivan might talk to his colleagues in the acute sector because they have desperate trouble recruiting nurses.

Over the past four years, my understanding is that an extra 16,000 people have been recruited and are now working in the HSE. That is compared to December 2014. While there has been a 24% increase in administration and management staff, there has been only a 3.7% increase in the number of public health nurses. Can we be given a figure as to the increase in public health nurses that is going to happen over the next 12 months? Although my colleague has given the impression that the whole health service has collapsed, the number of outpatient appointments has not decreased. The number of day care procedures has not decreased. The number of operations happening per week, per month and per annum have not decreased. The witnesses would probably agree with that. If anything, the numbers in all areas have increased. In case people get the concept that there are 118,000 people in the HSE sitting around doing nothing all day, that is not the position. They are all working very hard. However, I want to raise the issue of access to diagnostics by GPs. As regards people having to be referred in to accident and emergency departments to get access to diagnostics, what proactive work has been done? We want to keep care in the community and away from the hospital. What has been done to make diagnostic services available to GPs in a faster timescale than currently is available?

I have raised the issue of dieticians consistently over the last three or four years and nothing has been done on it. We have a system whereby if a nursing home patient requires advice or consultation with a dietician, he or she has to be taken in to the hospital. What are we doing to have dieticians call to nursing homes once every month or two to reduce the overall cost of this? If a patient has to be taken into a hospital to see a dietician, the likelihood is that two staff from the community hospital or whatever have to travel with them. There is a significant cost and time factor. It is a very simple issue where work can be done in the community rather than in a hospital. I would like to hear answers on the three issues I have raised.

Ms Laura Magahy

I will take the question on access to diagnostics. It is a really important piece.

A group that was set up under the national clinical programme for radiology is actively examining that. It is looking at working across traditional boundaries and promoting advanced practice radiographers. By 2022, we will have 70% more radiographers. They are in training at present. It is very important that they are in the pipeline, as it were, and will be ready to do it. A new workforce model is being developed to meet GP and patient needs, as well as new models of education and training. I am happy to supply details of that. It is the work of the HSE's national clinical programme for radiology. It has mapped all the different radiology infrastructure throughout the country. Again, that work was one of the deliverables in the action plan and it has been done. The issue is to get it up and running.

Mr. Dean Sullivan

I will comment more generally about diagnostics and take up the point the Senator was making about the slightly convoluted process around dietetics. The most important thing, to refer back to Deputy Donnelly's point, is that people have timely access to diagnostics. That is more important than whether it is through a GP or whether the diagnostics are delivered close to the patient's home. The first thing we must do is ensure that the capacity in the system in Ireland is sufficient to respond in a timely way to the needs of the population. We must get that in some type of order, and that is some way ahead at present. However, through the same process we were talking about previously we will start to see progress on it during 2020 and beyond. Then we can move to make it ever more accessible for GPs and so forth and, in due course, get to a position where, if it is entirely reasonable for somebody to be referred by the person's GP for a scan of some description, it does not go around the houses and we end up with that service being delivered in a local setting.

On the dietetics issue, we could pick a number of pathways. Some of the eye care pathways are a little like that as well, with people going around the houses to an extent. A number of pathway processes are being reviewed by the clinical programmes with a view to streamlining them and identifying whether there is any added value in the patient going through two or three hoops when care could be delivered more straightforwardly and locally without the various hoops on the way. There are issues to be resolved and assurances given to various clinical staff to understand what that would look like. They are motivated by, among other things, ensuring that patients do not fall between the cracks. That is how these pathways in some cases have developed. However, in the 21st century there is certainly scope, and dietetics is one area, to make the pathway much more straightforward for the patient so he or she does not have to go via a hospital to get physiotherapy, dietetics, diagnostics or whatever else. It should be entirely possible for patients to access those at local level without going anywhere near a hospital or a hospital practitioner.

With regard to dieticians, one of the issues is that they will not deal with community hospitals because their travel expenses from the hospital to the community hospital are not covered. That is a simple issue that can be resolved.

Mr. Dean Sullivan


Why are we not seeing proactive work on that simple issue? There are approximately 24,000 people in nursing homes. If any one of them wishes to get access, the individual must physically go to a hospital. This is a very simple matter. There is a huge cost reduction in having a simple system put in place to accommodate the needs of the dietician who can provide the care where the person is being cared for.

Mr. Dean Sullivan

I fully agree. We will get a note to the Senator on the position on that, if that is acceptable.

The other issue I raised was public health nurses. What is the current position in that regard and what percentage increase will there be over the next 12 months?

Mr. Dean Sullivan

Again, that is part of the discussion on how we commit the €10 million increase and the €60 million in 2021. That will not be available in the immediate week or two but will be worked through in the next couple of months with Ms Magahy and other colleagues in the Department.

My argument is that there was a 24% increase in one area of healthcare, which was administration and management, while in another area, front-line public health nurses, there was a 3.7% increase in the number of people working. That does not appear to be the correct way of developing community care.

Ms Laura Magahy

We can come back to the Senator on that.

I call Deputy Shortall, the chairperson of the Sláintecare committee.

I thank the witnesses for their presentation. It is clear that a great deal of work has been done on the detailed planning for the implementation of Sláintecare and the outworking of many aspects of the recommendations. That is commendable.

The missing piece is the funding required to make these recommendations happen in the short term as opposed to stretching out over future years, so we get beyond the point of pilot projects and individual funds for interesting things. They are not on a sufficient scale to achieve the type of step change that is required and was envisaged in the Sláintecare report. It is regrettable. The opportunity arose in the budget for the Government and those who support it to allocate the necessary funds at a level that would achieve that step change and ensure that citizens would see an appreciable improvement in services. That can only happen if funding is provided on the scale to achieve those major changes and the shifts in where we provide services. It is only when that happens that people will starting seeing a difference and will be able to achieve access.

The main problem for many of our citizens is that access is so poor. An example of that are the issues of eligibility and entitlement, on which the committee was very strong. We need to move beyond the current arrangement where people are eligible to receive services if the services are available but there is no legal entitlement. That is the big difference between healthcare and, for example, social welfare. I can appreciate that the witnesses are in an awkward position and that they must talk about the issue of entitlement potentially being kicked to a citizens' assembly, but the Sláintecare report referred to extending legal entitlement from the start of the implementation of Sláintecare.

There are other big ticket items that must be dealt with and where there has not been much progress. One of those is the consultant contract. Earlier Dr. de Buitléir spoke to the committee about its importance if we are to achieve the ending of private care in public hospitals, which is a key enabler and potentially a game changer in how we provide healthcare services. Will Mr. Sullivan give us any hope that work is being done on a new consultant contract? It was not referred to in the presentation. This is in light of the recommendations in the de Buitléir report, the issues that were raised during the summer regarding the Medical Council, a high level of bullying and unacceptable practices in the hospital doctors arena, the question of specialisation, and the fact that we seem to be concentrating too much on specialisation among hospital doctors at the expense of generalists and getting people out and working more quickly. There are indications that there is much interest in public-only contracts. We must move quickly towards those if we are to achieve significant changes in hospital services. Perhaps Mr. Sullivan will tell us the position with the new consultant contract and when we might see some product from that.

Equally, there is the GP contract. We know there is a major shortage of GPs and we know that many new graduates would willingly stay here if they could afford to do so and if they were not expected to set up their own practice or work as an assistant. There is a programme for Government commitment with regard to the introduction of salaried GPs. Is anything happening on that? There is a new GP contract, but as far as I can see there has been no progress on salaried GPs.

There are other areas on which I have questions.

One of the key recommendations of the Sláintecare report that was not covered in the report before us relates to legislation. If memory serves me, we recommended that legislation be introduced in seven areas. One of the most important is the question of accountability, throughout the system, starting with ministerial accountability for the provision of adequate services. It was recommended to us on the committee that introducing such accountability would be a game changer in respect of the politics of the issue. What is the status of that proposal and of the recommendation on legislating for accountability at clinical and administrative level? The chair of the board, Dr. Tom Keane, was very strong on the need to legislate for clinical accountability. As far as I recall, he stated it was one of the most important steps we could take. Given that our guests have not mentioned legislation, they might comment on that.

On the question of entitlement, is putting it to a citizens' assembly the only recommendation? We expected progress to be made in the area. I get the distinct impression the matter is being kicked into a long process. When is there likely to be some progress in the area?

On the additional 1,000 community staff who were flagged in the budget, I very much welcome the decision in principle but I am anxious to hear the planned timescale. If those who have control of budgetary matters had provided the funding in a more upfront manner, the staff would be recruited upfront, rather than in what has been described as the medium or longer term. To what extent has Ms Magahy's office control over the allocation of those staff posts? What is the basis on which it will allocate those posts? We in the committee were strong about having objective resource allocation systems in place and removing the politics from the allocation of resources. Will Ms Magahy update us in that regard?

Ms Laura Magahy

I thank Deputy Shortall for recognising the work that was done by colleagues in the HSE and throughout the system. It means a great deal, given that she was the Chairman of the committee that produced the original Oireachtas report.

On eligibility and entitlement, there will be a concerted effort immediately. I highlighted a couple of aspects in the presentation, including the memo to Government on the de Buitléir report, which is important. A unit is being established within the Department of Health specifically to examine eligibility and entitlement, and will be resourced to do so. There has not yet been a concerted effort but there was acknowledgement through the Secretary General that it would happen and we are very pleased about that.

The issue of eligibility and entitlement touches on several Departments. As the committee will be aware, if one is eligible to a medical card, one will also be entitled to other benefits. We have agreed at the high-level delivery board that an interdepartmental group will be set up to examine eligibility and entitlement. They are tangible steps that will give emphasis and momentum to that question, which is important. The Minister recently attended the universal healthcare forum in New York and is very committed to universal healthcare. It is important to get the homework done in respect of what universal healthcare means and produce a pathway to what it will cost. The issue of cost explains why we proposed a citizens' assembly. I might ask Dr. Healy to say a few words on the matter and I can return to the other questions thereafter.

Dr. Gráinne Healy

I am sure we are all aware of how effective a tool a citizens' assembly as a structure has been at allowing us to bring citizens into the room, to present them with solid, evidence-based research and to put questions to them. By and large, not just in the case of the assemblies on marriage equality and the eighth amendment, the experience has been that they come up with the correct answers.

The commitment to universal healthcare is strong and has not slipped. Nevertheless, engaging the citizens in a conversation about the path to it would be useful. It is not about not providing it but rather about seeking the informed views on how we would go about providing it, which we would determine by gathering the citizens' opinions. I am a fan of the citizens' assembly as an important, structured way of gathering views. While we are mindful of the House's own work over a period, carried out by many Members of the Oireachtas, the committee and the experts who appeared before it, we have discovered in our engagement that the public has little knowledge or understanding of the matter. The citizens' assembly structure is a way of focusing the desired media attention on such conversations and discussions and of genuinely involving the public.

That is a short summary of why we propose a citizens' assembly. There is a head of steam behind it and we would love for it to be done. It is not a way of kicking the can down the road. In fact, it is the opposite. It is a matter of engaging the citizens on what remains one of the main commitments of the Sláintecare project.

Ms Laura Magahy

On consultants' contracts, we are pleased the discussion has commenced with the Irish Medical Organisation, IMO, while the Irish Hospital Consultants Association, IHCA, has been invited in and will soon appear at a meeting to discuss the matter. I imagine that the issue will play out over the next several months and we will return to the Government for a decision.

The Deputy indicated that it is not just money that keeps people in a job, although it is an important factor. I acknowledge her point. It is also about the atmosphere - not just physical but also cultural - in which they work. If people cannot get access to theatres to perform operations or see people in the correct circumstances, it becomes hard for all healthcare staff to work in such conditions. The elective hospitals initiative we have done, which was intended to streamline unscheduled and scheduled care, will help in that regard. It will help people to have their theatre time and will keep professionals interested and engaged in their work. That is as, if not more, important as money to the professionals to whom we have spoken. Highly skilled people being unable to get into theatres on time is not conducive to retention.

On resource allocation and the additional 1,000 front-line staff, I am mindful a resource allocation model has been applied throughout the system. The ESRI has pointed out there is an unequal distribution of community healthcare workers per head of population throughout the country. While I am mindful of that as a base, we must also examine the services that such community healthcare professionals will put in place, in response to community waiting lists or staffing the primary care centres, as well as the initiatives or services that will move and keep people out of hospital-----

Will that model be ready for the allocation of the 1,000 posts?

Ms Laura Magahy

Yes, as Mr. Sullivan noted. The baseline has been done and we know the extent of the community waiting lists throughout the country. It is now a matter of identifying the priorities and the need, because the allocation will not solve everything.

The additional staff will not be used just to reduce waiting lists.

Ms Laura Magahy

No. I mentioned community waiting lists as a barometer in respect of Deputy O'Reilly's point about people waiting for services in a community.

Can Mr. Sullivan answer the question about the GP contract?

Mr. Dean Sullivan

As the Deputy said, there is a GP contract in place.

There is also-----

Mr. Dean Sullivan

I am not aware of the issue about salary GPs that the Deputy is asking about and whether that was a part of discussions or not. My understanding is that it is not part of the current contract at all but I am happy to come back to the Deputy on that.

It is not a part of the contract but is anything happening on the commitment to introduce that?

Mr. Dean Sullivan

I am not aware of anything but that is not to say that there is nothing happening. I will get back to the Deputy if there is anything happening but I am certainly not aware of it.

I congratulate our guests for embracing the task ahead of them in a positive way, identifying targets in a realistic way and setting about their job in a practical way. They are to be congratulated. It is very easy to sit by and criticise the system and say that somebody should do something. Oscar Wilde said that duty is what we expect of others but not necessarily of ourselves. Our guests have embraced the mission with decisiveness, clarity and a sense of purpose.

Are our guests satisfied with the progress of the action plan in meeting their targets so far? Has the progress been in line with their expectations? Is the progress that has been made on track to achieve the expectations next year and in subsequent years?

What has been the impact on the delivery and co-ordination of activity in the system since the appointment of the new board of the HSE? One of my colleagues will deal with the governance of e-pharmacies and I will leave that.

The enablers that have been put in place seem to be embracing and comprehensive. Other issues will arise as Sláintecare evolves but have any arisen so far?

The postgraduate medical education strategy is an issue that has come up on a number of occasions as requiring urgent attention. Are our guests satisfied that the required attention is being given to the issue as a means of addressing a whole series of issues that may arise down the line?

How is the single assessment mechanism progressing? Is it in line with expectations? Are there any snags? Can it be improved? If not, why not?

I am also concerned about access to hospitals. Senator Colm Burke referred to nursing homes and dietary issues. Dietary issues seem to be important for older people who are long-stay patients in hospitals. The extent to which an appropriate diet is available to such persons seems to be much more important than we, or at least I, first anticipated. This committee will meet some people on that issue in the not so distant future and that will hopefully be of benefit in improving quality of service and quality of life and health for people who are either in care at home or in nursing homes. Sufficient emphasis has not been placed on dietary issues in the past. From what we now see, hear and read, that is an area in which we can contribute greatly, at little cost, to an area that could relieve the burden on many aspects of services in many ways.

Ms Laura Magahy

I thank the Deputy for his comments which I will relay to the team and they will be pleased.

The Deputy has asked several questions and I will try to answer them in sequence. We are on track so far but we have an awful lot to do. We are only in year one. It is only 13 months since I sat before the committee without a team and with no staff. We started pulling it together from scratch and working with colleagues in the HSE and the Department. We have put structures in place now so we have a fair wind behind us and I acknowledge the work of my colleagues in the Department and the HSE as a part of that. We are on track so far but we cannot rest on our laurels.

One of the first things that the director general, Paul Reid, asked about when he started was how the HSE was doing and how the board of the HSE, with its new remit and governance structures, was going to interface with the Sláintecare implementation office. There was a genuine acknowledgement on his part and on mine that we need to work seamlessly together. One cannot have one piece of work in the Department and another in the HSE, trying to do things that are not joined at the hip. I am delighted to have agreed with Mr. Sullivan that we are going to have a joint implementation approach to capacity planning, in particular, and the roll-out of the regional integrated health plan. That took a while to work through but is now in place.

The Deputy also asked about the single assessment tool which is critical because it is the basis of the statutory home care scheme. All older people and, eventually, people with a disability will be assessed through the single assessment tool. Their requirements will be looked at and it will form the basis of the statutory home care scheme. I should have alluded to that as another important eligibility entitlement initiative when I was answering questions from Deputy Shortall.

The tool is being piloted at the moment in a few different areas and they are working through how it is happening in practice and talking with the various people on the ground about glitches and improvements that need to be made if there are any. It will be fully rolled out from February onwards. It is a very good thing that is happening.

I agree that the postgraduate medical education strategy is very important. It is joined up. It is being chaired by Mary Doyle, the former Secretary General of the Department of Education and Skills, who is a capable and knowledgeable person. I have a meeting with that team this afternoon to see how that is going. It is a very important piece of the jigsaw.

The Deputy may not know that HIQA is organising that a survey for patients will go into nursing homes and that will feed in nicely to seeing what the response is to food and we look forward to seeing the results of that. The Deputy is right that diet is a key part of our health and well-being.

Did I miss any of the questions that the Deputy asked?

Was there any question asked by Deputy Durkan that was left unanswered?

I am sure I will come back in again.

I also thank the witnesses for coming before us. I hope this all works out because it is two and a half years since the report of the Select Committee on the Future of Healthcare, chaired by Deputy Shortall and upon which Deputy Durkan and I sat, was published. We are now 25% of the way into a ten-year plan. It is not Ms Magahy's fault because she had nothing to work with initially apart from our report. That committee report was born out of a frustration with the system and situation as it was. We all worked together to try and leave our bias behind and work to the future.

Following on from that, part of the issue I see now is the constant leeching of top-end consultants that this committee spoke about in the previous session and last week. Those consultants are leaving our public sector to join our private sector and we have not yet managed to stop that bleed.

As long as that continues, I fear we cannot deliver this, despite whatever else we do, unless we have the hospital consultants to lead this healthcare provision. We need to focus on the consultants. Some 50% of NCHDs are not in training posts. We have the leaching of the top people but in terms of succession planning, we do not have the bodies coming along in the future that are wedded to the system and part of a structured career path. If all of this worked out, and everybody was up for it, how are we going to guarantee that we have the consultants to lead the delivery of healthcare?

The GP contract and salaried GPs was a critical point of Sláintecare. There has been an emergence in the larger urban areas of GPs who have general medical services, GMS contracts doing many elective and cosmetic surgeries in their clinics and many travel vaccines. I do not class all GPs in this group. These procedures are not jobs that GPs should be doing in a strained health service. I would much prefer to see my child's burst eardrum being seen over somebody getting elective Botox in a surgery. I am quite concerned about the use of GPs' time. This is not a criticism as they have to pay rents, rates and salaries and there is probably more money in elective cosmetic surgeries than in weeping children's ears. I am concerned that if we do not go down the salaried GP route, we will always be competing where the skill sets of the GPs are siphoned off into sectors that are more profitable and have no public health value.

On pharmacists, we spoke about patients earlier and often speak of them as if they are all same type of patient. Any of us who works in the health service, however, knows that there are major complexities in patients. I am reminded of a pharmacist in Galway who took it upon himself to monitor ten complex patients across gender and age groups. This pharmacist together with the local public hospital and GPs, they held the hands of ten people as they went through their complex lives with their complex medical conditions. It was a loose study, but the ten individuals were admitted to hospital 30 times in the year prior to this intervention, an average of three admissions. Following this intervention, there were only four admissions in the next year. My concern is that we look on patients as if they are all the same and we never hold the hand the most vulnerable. We just keep firing money and expensive injections and treatments at them but we do not follow up whether the injection goes into their body or whether they turn up for their appointment. The group of people in Galway proved that when resources are directed at the most vulnerable and complex cases, this can have a significant impact on hospital admissions. Various figures are bandied around, but there is a claim that up to 60% of hospital admissions are due to medication errors. If, as Deputy Donnelly mentioned earlier, three quarters of beds in public hospitals are occupied by people who come in through emergency departments, investment in the more complex patients with great need seems to be the key to try to reduce the bed occupancy rate and waiting lists. How is Sláintecare progressing with the pharmacists? The fundamental basis of Sláintecare was need and not ability to pay, and a move towards the community. It must be ten years since pharmacists started doing the flu vaccine. It started off - with no offence intended towards the Chairman - with the question as to how pharmacists might manage and what if some person died or had an anaphylactic reaction? Some ten years later, is ten years correct?

Yes, I believe it was ten.

I was expecting a child when I believe I may have been in the first tranche of recipients. It was said that pharmacists would not want to give injections to people but we all got over it. How will the role of the pharmacist in the community be expanded to prevent this 60% of admissions that are based on medication errors?

I know I am boring everybody to tears, but some of the things that happen are so common. Someone seeing a consultant in a private hospital, for example, and does not think that he or she needs to tell his or her GP in Clare what is going on with the cardiologist in Dublin. They then go somewhere else to get something else done. They then get a prescription in one pharmacy, and get the other one in the pharmacy beside the private hospital. They go home and are taking three times the medication they should be on. This is common. I get worried when we talk about citizens' assemblies and such matters when we have not focused on why people are turning up in emergency departments. Accidents and emergencies happen. However, if we invested in the prevention of man-made errors, we could free up capacity in our system.

Can the Deputy allow me to have some of those questions to be answered?

There are a number of minutes left.

Ms Laura Magahy

I agree 100% that pharmacists should, and could, do more. As recently as last week, I had a productive conversation with Mr. Daragh Connolly from the Irish Pharmacy Union, IPU, about what it could do. There are good examples relating to minor ailments in Scotland and, therefore, we are working up a scheme to see what we can do. Pharmacists are on nearly every street in the country. They open later than most other healthcare providers and there is a significant opportunity in this regard. I will be very happy to come back to the committee when that is worked out.

It is also the second most-trusted profession, which is important.

Ms Laura Magahy

Which is the first?

I believe it is the veterinary profession.

Ms Laura Magahy

Why are GPs not the first?

We sometime look after animals.

Ms Laura Magahy

I fully recognise the role that pharmacists could play and we are actively exploring that.

On the questions raised by the Deputy on medication errors, we are looking at e-pharmacy as a priority project, and the HSE has agreed the governance for that. The individual health identifiers, IHIs, are now in place, which give the basis for the shared care record. The e-pharmacy project will be the quickest win in value for the patient from a shared record point of view. If we had that and we are looking at a patient portal, the patient would go to the private hospital or to the places the Deputy has mentioned, and their medications would be on their portal, which would be able to show what have had. That is critical to the move between the hospital and the community, and for the patient to move between different care settings. That is an absolute priority. This is firmly on Mr. Sullivan's radar as well. I will be happy to come back to the committee regarding progress on this issue.

I thank Ms Magahy for her reply.

Dietetics has been a concern of mine for years in respect of people in nursing homes. The HSE did a great deal of work on cutting back on elemental feeds and so on. To follow on from Deputy Durkan's commentary, wound management and protein content of food is vital for older people and people with an injury, old or young. I agree with the Deputy Durkan that while hospital meals have improved in recent years, a fundamental part of growing and repairing a patient's body seems to have been neglected. It is unacceptable that older people or people with swallow issues can be handed a carton of Ensure.

Regardless of their age or the complexity of their needs, people receiving care have a very basic right to have a balanced diet made available to them if they are not able to get their own food, which will obviously be the case if they are in a nursing home. Diet has to mesh with medication, doctors and nursing. This issue cannot be left on its own. There is no point in a patient getting wonderful wound care from wound specialists using really expensive pressure sore bandages if he or she is getting no protein. That wound will never heal. This has been ignored or left to the wayside for the years, probably due to the power of the companies making the elemental feeds.

I would like to pick up on something Deputy O'Connell touched on, namely, the shared care record. When representatives of the IMO appeared here last week, they identified the shared care record as one of the critical enablers of reform of the health service because it crosses all clinical disciplines and drives efficiency. A practitioner could log into a shared care record and see what diagnostics have already been carried out and do not have to be duplicated, as well as finding information on a patient's current medication. This is absolutely critical, more so than clinical input and numbers of consultants, nurses and allied professions. It drives efficiency. One of the critical points in the Sláintecare report was the need for a shared care record and a single health identifier in order that people could be tracked through the system. It drives efficiency so well. It would substantially reduce waiting lists because there are many people on several waiting lists seeking service from several different hospitals and disciplines.

The Sláintecare report set aside a figure of €850 million or €875 million for the shared care record. In the current climate it is unlikely that this kind of money will be available in the short or medium term. How is the Sláintecare implementation office approaching the introduction of a shared care record? I see that e-health has been included under "Workstream 1" in the submission. What progress has been made on this? A shared care record also drives integration, another cornerstone of Sláintecare. It offers efficiency, integration and a better quality of care. What stage has that reached?

Ms Laura Magahy

I completely agree with everything the Chairman has said. This issue is absolutely critical. The e-health office is currently involved in a dialogue to see how quickly a shared care record can be put in place. The results of this dialogue, which is currently ongoing with ten companies, will be produced by the end of this year. This will offer a direction and enable us to use what we have. We have had this conversation before. There is already an awful lot of data, including data from the primary care reimbursement service, PCRS, GP data which will hopefully come on stream, patient administration system, PAS, data from the hospital system and data on radiology from the national integrated medical imaging system, NIMIS. There is an awful lot of system data. We now need a platform that can get these data sets to talk to each other. That is different to the electronic health record, which has already been rolled out in some of the maternity hospitals and St. James's Hospital. The shared care record is more urgent and more applicable from the patient's perspective. Good progress is being made but a real focus will be needed next year. The capital plan includes a budget for that. I know that every effort is being made through Mr. Sullivan's good offices to make that happen.

How soon will we see a shared care record?

Ms Laura Magahy

A period of two years is predicted. If we establish a way forward next year by having all the conversations concerning data sets and the general data protection regulation, GDPR, go to tender and put it in place, it should take two years, given a good impetus. That is what I am hoping for.

I thank Ms Magahy. We only have 11 minutes left.

I do not need all of that time. I will be happy to share it with my colleagues.

We can take one question from each member. I will allow one minute to each with one minute for an answer.

I would like to make one very quick observation. Reference has been made to citizen and staff engagement. That excludes people who may not technically be citizens but are working in the health service. Perhaps the language could be altered slightly. I acknowledge exclusion was not intended. Has that had an impact or do the witnesses believe the full breadth and diversity of people who could contribute to this engagement has been encompassed?

Ms Laura Magahy

I do not think we have achieved that yet. Would Dr. Healy like to comment?

Dr. Gráinne Healy

We have looked at the possibility that this could be exclusionary. We have gone back to using the word "citizen" because of the feedback we received. The feedback we received indicated this wording was seen as more inclusive. We did a bit of research on that. Our sense is that we are not there yet. However, we engaged 100 advocacy groups at a seminar last week. These groups included all different kinds of voluntary organisations representing people right across the community. When we examine the regions over the next year, we hope to really drill down in co-operation with those organisations, so that we get right down into the communities to inform the co-design of the system. Whether someone is a citizen or not, we will be very mindful of that-----

I was just struck by that.

Dr. Gráinne Healy

I take the Deputy's point.

I have a further question-----

We will have to move on.

I refer to recruitment and the establishment of the new structures. How many staff members above grade 8 have been employed as part of the new structures?

Ms Laura Magahy

No additional personnel have been recruited.

As such, this is just a change in structures with no new staff to support it.

Ms Laura Magahy

If one thinks about it, we are moving from 14 structures to six.

Has anyone lost their job?

Ms Laura Magahy

We have not done it yet.

Can we get some more information on housing options for the aging population? If the witnesses do not have it just now I can receive it by correspondence. I would also like further elaboration on the postgraduate medical education strategy. It is an important item that has come up several times and we could do with some more information on it.

I wish to refer to the citizens' assembly. I initially baulked at the idea but I am now thinking it through. As we cannot change the system overnight, the witnesses are really talking about letting people decide what their priorities are in relation to universality. For example perhaps chiropody or GP care should become universal. Is the aim of this idea to let the people decide what the priorities are?

Dr. Gráinne Healy

It is not just about priority but that there are several options as to how this might happen. A citizens' assembly would determine what people are looking for in order to get some direction from an informed evidence base. If there are five different ways of reaching universality, what is the public's preference, what would it look like and what would the stepped approach be? That would give us a real sense of priorities. That is the thinking behind this idea.

I did not get a reply to my question on legislation.

Ms Laura Magahy

The question concerned clinical governance in particular. My apologies to the Deputy. Everyone would agree that clinical governance has to be embedded in every single thing that happens. It is not just an add-on or something that comes from the top. It has to be incorporated into every single part of all of the services available across the system. Clinical governance will be part of the design of the regions and the allocation of roles between the Department, the HSE and the regions. It is envisaged that legislation for the regions and everything that means will be brought into place in two years' time. That is the position.

Does that mean legislation will be introduced in two years?

Ms Laura Magahy


That is an unnecessary delay. Our fears about departmental capture are being realised.

Ms Laura Magahy

We will achieve this more quickly if we can.

I have two quick questions. The figure of 2,600 beds comes from the capacity review.

The review describes this figure as an extreme requirement, not the likely requirement. It is the minimum conceivable number. If everything in the world worked exactly right, at the right time and infinite resources were available to do everything else, 2,600 beds would be needed. The review states, however, that up to 7,200 beds would be needed. Experts have informed me that the number is probably somewhere in between those two figures, in other words, between 4,500 and 5,000 extra beds will be needed. Given that, is the independent review group worried that we are planning to fail? If we add 2,600 beds when we probably need twice that number, are we knitting in failure of the system for the next two years?

On costs, has the independent review group been able to discover the cost per bed day or procedure, or both, for the different hospitals?

Ms Laura Magahy

I agree the target of 2,600 beds is almost like a best case scenario. After all the improvements required are taken into consideration, only 2,600 beds are needed, which is still a very large number. However, the timeframe is until 2031 so we have a bit of road to travel, although we know it takes a long time to plan and build infrastructure. We were talking earlier about the suboptimal use of some current beds. The first and most immediate target is to try to get the beds in place. The second target is to try to get the elective hospitals streamlining the scheduled and unscheduled care. Mr. Sullivan and I are working assiduously on naming and getting that capacity in place. The next target is the needs of the regions. That is how we are going about allocating those beds. A hospital improvement programme is also needed in order to maximise the stock we already have.

I get all of that. I am referring specifically to the number of beds needed. The figure of 2,600 applies in a scenario where everything is done correctly, which is not possible, even with the best will in the world. No country in the world can do everything right. Are we not essentially planning to have too few beds? If the minimum conceivable extra number of beds is 2,600 and the experts are saying it is probably several thousand more than that, are we in danger of planning to fail and of almost guaranteeing failure?

Mr. Dean Sullivan

I would need to read the small print of the report again but I was involved in the process at the time and my recollection is that it was not trying to land the answer on a sixpence in the way the Deputy might be implying. It was a set of reasonable assumptions around the impact of public health interventions, the impact of additional staff and resources in the community and the potential to improve how we use the existing bed stock, an issue to which Ms Magahy alluded. After all of that, the figure left was the 2,600 number to which the Deputy referred. Those were the assumptions as opposed to five things all having to break perfectly, in which case only 2,600 beds would be needed. I am happy to proceed on the basis of getting 2,600 beds in place, and implementing the other interventions that are necessary so that only 2,600 beds are needed. We will then see where we are. There are an awful lot of moving parts in health and social care that the Deputy is well aware of. Population needs may change over the next ten years and so on. We will work towards that in good faith. We are constantly looking at it in any event. We have processes in place and we have the model whereby we re-run and test things and so on. I am not aware of anything in the review that is so far out there as to be virtually unachievable. The figure is about right, plus or minus, and we will keep refocusing and reviewing as we go forward.

Ms Laura Magahy

We can say that the impact of moving hospital care to community care is this and that we can provide a range of initiatives for that. The piece that is harder to predict is that if we put money into prevention, at what point does it kick in to save a bed? That is harder to predict because sometimes it might have a ten-year impact if a measure is started now. It is also harder to argue for resources for such a measure but that is where we should be trying to make changes. The Deputy mentioned the importance of diet, prevention, exercise and all the usual things and asked if we were doing enough on prevention and dealing with the obesity crisis. There are probably some brave decisions to be made next year on prevention and the budget for health and well-being. These cut across Departments and probably need to be stepped up. That is a harder piece to prove with regard to beds, if I am being honest.

I have a final comment before we leave-----

On the costs-----

Sorry, I will first ask a question. On critical enablers, I mentioned the shared care record. Another issue is access to diagnostics, which is a serious matter in respect of the optimal use of beds. During the week, 60 patients were waiting for an MRI scan in University Hospital Limerick where there is one scanner for a population of 400,000 people. It is essential not only that there is access to diagnostics from general practice but that there is access to diagnostics within the hospital system. Many patients are waiting for a diagnosis that will allow them to go home, stay in hospital or influence their treatment. If we are talking about the suboptimal use of beds, access to scanning and ultrasound diagnostics in particular is a critical enabler in driving efficiency. I could also mention many other diagnostic tests that are required.

Ms Laura Magahy

We fully agree with the Chairman. The work being done by the radiology programme will bear fruit quite quickly because we have identified where all the equipment is around the country and we can provide it pro rata by population.

Or where it is not.

Ms Laura Magahy

We know now where it is not in place and that also needs to be prioritised. I am well aware of the position in University Hospital Limerick. On costing, we know what the costs of procedures are through activity-based funding or ABF.

We know what we are paying for them. That is different from what they cost. Does the independent review group have any costing data?

Ms Laura Magahy

Yes, we do.

What is the cost per procedure?

Ms Laura Magahy

That is what drives ABF.

Can that information be provided to the Deputy?

Mr. Dean Sullivan

We could probably choke a horse with the amount of costing data we have. We will try to give a sense of things and if the Deputy has any further queries-----

I will do my best. I can deal with large amounts of data. The other matter was the cost per bed night. That is important.

Mr. Dean Sullivan

We have information on that as well.

Is that per hospital?

Ms Laura Magahy

Yes, we have that information for each hospital.

That is not a large amount of data. Can that be provided to the committee urgently?

Mr. Dean Sullivan


That would be great.

Mr. Dean Sullivan

I do not want to oversimplify the position. We know how many bed days there are but the apportionment of cost to those bed days, while not an art, is wandering towards that space. I will speak to my colleagues in finance and try to share the information in a reasonably intelligible format as quickly as we can.

As usual, we have gone to the limit and beyond. We have to consider our staff in the recording box who must work on another committee in ten minutes. I compliment the witnesses and their staff on their engagement, both politically and in the work they are doing on Sláintecare. The Sláintecare report is a critical report and one of the most important reports this Dáil has produced. It will have far-reaching consequences. I thank the witnesses for all the work they are doing on that. On behalf of the committee, I thank Mr. Colm Ó Conaill, Mr. Dean Sullivan, Ms Laura Magahy, Ms Ciara Mellett and Dr. Gráinne Healy for their attendance.

The joint committee adjourned at 1.50 p.m. until 9 a.m. on Wednesday, 6 November 2019.