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Joint Committee on Health debate -
Wednesday, 24 Nov 2021

Issues Facing Acute Hospitals and the Winter Plan: HSE

I welcome the witnesses from the HSE to this morning's meeting. They will provide us with an update on issues facing acute hospitals and the winter plan. I welcome Mr. Paul Reid, chief executive officer, Ms Anne O'Connor, chief operations officer, Dr. Colm Henry, chief clinical officer, Ms Yvonne O'Neill, national director, community operations, and Mr. Liam Woods, national director, acute operations.

Members now have the option of being physically present in the committee room or they may join the meeting remotely from Leinster House or its environs. Members and all in attendance are asked to exercise personal responsibility in protecting themselves and others from the risk of contracting Covid-19. They are strongly advised to practise good hand hygiene and to leave at least one vacant seat between themselves and others in attendance. They should always maintain an appropriate level of social distance during and after the meeting. Masks, preferably of medical grade, should be worn at all times during the meeting except when speaking. I ask for everyone's full co-operation in this regard.

Witnesses are reminded of the long-standing parliamentary practice to the effect that they should not comment on, criticise nor make charges against any person or entity by name or in such a way as to make him, her or it identifiable, or otherwise engage in speech that might be regarded as damaging to the good name of the person or entity. Therefore, if their statements are potentially defamatory in relation to an identifiable person or entity, they will be directed to discontinue their remarks. It is imperative that they comply with any such direction.

Members are reminded of the long-standing parliamentary practice to the effect that they should not comment on, criticise nor 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 apologise for the delay in starting, which was due to some necessary housekeeping work that had to be done.

I invite Mr. Reid to make his opening remarks.

Mr. Paul Reid

I thank members for the invitation to meet the Joint Committee on Health to discuss the issues facing acute hospitals this winter and the HSE winter plan. I am joined by my colleagues, Ms Anne O'Connor, chief operations officer, Dr. Colm Henry, chief clinical officer, Mr. Liam Woods, national director, acute operations, and Ms Yvonne O'Neill, national director, community operations.

As members will be aware from the daily headline figures, we are now firmly in the midst of a fourth surge in Covid-19 infections. The entire health system, both acute hospitals and community, are now under serious pressure. Last Monday week, I briefed the Cabinet sub-committee on Covid-19 on the seriousness of the situation. The Government responded with a number of public health measures. It has also been necessary for the HSE to take immediate measures in response to hospital and ICU pressures, including the short-term prioritisation of unscheduled care, and increasing our surge capacity through providing additional beds, particularly in ICU. I know that the resurgence of the virus, and the response now required, will place even more pressure on staff. I assure the committee that we will do everything we can to support our staff during this difficult period.

The winter season in any year presents additional challenges to all health systems around the world, with presentation related to the combination of seasonal viruses, weather-related trauma and illness, longer periods spent indoors with lower levels of ventilation and seasonal social activity. Pressures associated with winter of 2021-22 are further compounded by the massive increase in Covid-19 infections we are currently experiencing, and the resulting presentations in emergency departments and onward into wards and, critically, intensive care units. Emergency departments continue to operate distinct pathways of care for Covid and non-Covid patients, and this places a huge demand on staffing and space available.

In line with the principles of Sláintecare, the HSE winter preparedness plan identifies a comprehensive set of actions and initiatives aimed at mitigating the pressures on services. As part of this integrated plan, the HSE will focus on avoidance of hospital admittance unless absolutely necessary, patient flow through hospitals, and safe and timely departure of patients from hospital. The plan provides for the appropriate, safe and timely care for patients by ensuring, insofar as possible, the right levels of capacity and resources are in place to meet the expected growth in activity levels. This includes the use of private hospitals to increase capacity in the short term and to support the continuance of urgent unscheduled care while the system is in surge. There will be an enhanced focus on patient experience times, and performance against these targets will be monitored by integrated oversight and reporting teams.

A total of €77 million has been provided by the Government to support these actions and initiatives. This investment builds on previous winter plans and the National Service Plan 2021 in developing and promoting the home first approach, which was supported through additional investment in home support hours in 2021. General practice is also key to the success of this approach.

The HSE continues to work closely with general practice through the chief clinical officer and GP forum, and in collaboration with the Irish Medical Association and the Irish College of General Practitioners, ICGP, in responding to the Covid-19 pandemic, as well as providing core primary healthcare services.

The Covid-19 supports to general practice for assessment and referral for testing remain in place. In terms of our strategic priorities, an important first step in ensuring the sustainability of general practice for the future has been the implementation of the GP agreement of 2019, involving an investment of €210 million over the period from 2019 to 2022, including the roll-out of a new structured programme, chronic disease management, for medical card and GP visit card holders over 18 years which will apply to 431,000 patients when fully implemented in 2023. This will also see the appointment of a GP lead in each of our 96 community healthcare networks to ensure for the first time a structured process of engagement with general practice at local level and to facilitate integration and co-ordination with our acute hospital services.

A further strategic priority for the HSE has been the expansion of the GP workforce. To this end, an important milestone was achieved this year with the successful transfer of the GP training programme to the ICGP. In addition, GP training places have been increased by 27 in 2021, with a further 24 in 2022, bringing the total to 259 next year, with a targeted increase to 350 training places by 2026.

A consequence of the significant rise in hospital attendances through emergency departments has been the necessity to relieve the overall pressure on hospitals by evaluating planned procedures and cancelling less urgent appointments for both day cases and inpatients. The number of cancellations and non-booking of planned surgery has been growing due to the growing incidence of Covid-19 in hospitals.

The Department of Health published a waiting list action plan in October 2021. This plan was developed in collaboration with the HSE and the National Treatment Purchase Fund and it focuses on delivering additional procedures through public and private hospitals by the end of 2021 with a view to reducing waiting lists. The plan sets out targets in terms of numbers of patients waiting at the end of the year. Those targets are 69,822 for inpatient and day cases, 653,524 for outpatients and 33,128 for gastrointestinal scopes. Since the inception of the plan, the number of outpatients waiting has reduced by 12,450. The number waiting for GI scopes has reduced by 1,819. However, progress on the inpatient and day case waiting lists has been significantly affected by the cancellation of electives due to Covid-19 and emergency department pressures, which has resulted in a smaller reduction. A significant focus is being placed on using private hospital capacity to deal with these waiting lists. However, public hospitals are also relying on access to private hospitals to support emergency workload pressures.

The HSE also welcomes the additional funding of €200 million announced by the Government for 2022 to support access to care which will be focused on delivering additional capacity to impact waiting lists. This funding will be targeted at working through these lists as quickly as possible by making the best use of our own capacity, supplemented by making arrangements for a substantial number of procedures to be carried out through the contract arrangements with private hospitals.

I remind members that we have to be out of this committee room by 12.30 p.m. I want to give as much opportunity to everybody as possible. In the first instance, each speaker will have seven or eight minutes.

I thought we had ten minutes.

I do not think we will get through all the speakers if we allocate ten-minute slots. The members may not get answers, if we do that. It might be better-----

We were not told that a private session would eat into our time before we agreed to it. It was understood that-----

It was mentioned. I mentioned that during the private session. I do not want to cut people short but I am putting members on notice.

It is wholly unsatisfactory. We do not have the head of the HSE before the committee as often as we should. It would be unacceptable to have our time reduced.

I want to try to make sure everybody gets an opportunity to speak. It is now 10.05 a.m. If, for instance, we go over the time limit without allowing each member to speak-----

We have almost two and a half hours.

We need to allow for answers. Is the Deputy proposing two and a half minutes each?

We have almost two and a half hours.

We will do a reprise in the second session, if we have to. If there is time to come back in, members will be allowed to do so. We do not get to do anything in the first session. I call Senator Conway, who has seven minutes.

I thank Mr. Reid and his colleagues. I reiterate the committee's thanks for the phenomenal work he and his colleagues are doing. I will break my questioning into three areas, if I can. I will start with the booster vaccination programme. There is a lot of public concern about the booster vaccine. We have seen how successful it is in other countries. There is a lot of concern that it is not necessarily being rolled out as quickly as it should be in Ireland. I want to get an indication from Mr. Reid how many booster vaccine shots he expects to have delivered by the end of this week and how many he expects to be delivered by the end of next week.

I also wish to ask about disability settings, including day care settings, and the vulnerable people in those circumstances. When can they expect their booster shots? I would be interested in an update on that.

We all appreciate that the service is under pressure in its ICUs because there has been a surge in the numbers in hospitals. There were 130 people in ICU yesterday, which is a significant number. What are the HSE's projections, based on the modelling it has done, for the increase in ICU numbers? What numbers does the HSE expect will be in ICUs by the end of this week and next? Is the HSE ready for a surge? Will it be requisitioning further capacity in the private hospitals? I would be interested in an up-to-date position for how the HSE is planning for the thousands of cases a day we are, unfortunately, seeing.

I will also ask about a more localised issue, that is, the situation in University Hospital Limerick. The situation there is wholly unsatisfactory. A 60-bed modular unit was built there in the past couple of years to try to deal with the challenges in the accident and emergency department, yet in excess of 90 people are on trolleys most days. What is the problem in Limerick? Why is that happening? If the investment in the infrastructure has been made, what is the problem in Limerick that does not exist in other parts of the country? It has been going for years. It is not only a result of Covid-19. This was a problem before the pandemic. It has not been addressed. Where are the blockages? What is the problem? Is it a recruitment problem? Where are the difficulties? We need answers at this stage because it has been going on too long.

Mr. Paul Reid

I will address the Senator's questions about boosters and ICUs. I will ask my colleague, Mr. Woods, to address the issue in University Hospital Limerick. To cut to the chase, I will make a few points about booster vaccination. We commenced the booster programme once we got recommendations and advice to that effect from the national immunisation advisory committee, NIAC. That was the immediate trigger for us to commence the programme. At a high level, to give the Senator the figures as of this morning, more than 630,000 vaccines have been administered, of which 560,000 have been delivered through the booster programme and 72,000 have been administered to people who are immunocompromised. We are making good progress across all of the vulnerable groups that have been approved for vaccination to date. The vaccination of the over-80s is substantially complete, although there are more to go through. Vaccination is also substantially complete in long-term care facilities, although we need to revisit some of the long-term care facilities where we have had outbreaks. More than 190,000 of the over-70s have been vaccinated, which is much more than half of that cohort over the past two weeks. In the over-60 group, 43,000 have been vaccinated.

There is a significant difference between the roll-out of the booster programme and the roll-out of the original vaccination programme, in that under the eligibility criteria, five months must have passed from the date of a person's previous vaccination. For example, in the over-60s group we addressing now, only 25,000 met that criterion in the first week we could address them. However, in the second week, more than 120,000 are eligible. There is a difference as the different cohorts are approved and there is an issue around that five-month threshold.

To update the committee on the numbers and progress we are planning for, we are mobilising to accommodate 230,000 people per month, across our vaccination centres, GPs and the pharmacies that are coming on board. The primary route for the vast majority, as we move through the population, will be through the vaccination centres.

GPs have played a phenomenal role throughout the programme and will continue to do so. We will bring more pharmacies on board.

As of today, 130 people are in ICU. The Senator will have seen the modelling from NPHET, going from the pessimistic and optimistic, stating that the number could go to anywhere between 200 and 400 over the next few weeks. We take a lot of confidence from the actions of the public over recent weeks in trying to restrain numbers of contacts and to implement public health measures, which we very much appreciate. We think they are fully acknowledged. We hope to see that mitigate some of the spread.

The Senator asked about surge capacity. I wrote to all the hospitals last week. They were and are scaling up surge capacity. We normally have 300 open and fully resourced beds. We are aiming to surge to a level where we were in January, with about 350 beds. We are working through that process with the hospitals.

I am conscious of time. Will the witnesses address the University of Limerick Hospitals Group?

Mr. Liam Woods

The Senator is right in saying that the issues in Limerick pre-dated Covid. It is important to note that as of 8 p.m. yesterday, there were 47 Covid-positive patients in Limerick, which is causing a significant difference and is eating into the capacity to which the Senator referred, which is a 60-bed block. Further capacity was added. The key challenge in Limerick at the moment is the growth in attendance and admissions. It is very high. Admissions in September 2021 were up by 23%, with an increase of 25% in attendances at the emergency departments. Some of the key measures we are taking, which will be supported by the winter plan and funding that is in place, include support for access to diagnostics for GPs and effective discharge from hospital. Although it will not be for this winter, we are still in dialogue and looking at further capacity requirements in Limerick. We are looking at what is happening with regard to Covid in University Hospital Limerick and the high attendance at the hospital.

Is there a management or human resources issue?

Mr. Liam Woods

There is a constant competition for resources of all types within the system. University Hospital Limerick has been successful in attracting resources over a number of years for its expanding capacity, including its new ICU, new emergency department, the Leben Building, with which the Senator will be familiar, and, more recently, the bed capacity. It is still recruiting both internationally and locally. That is under way.

My first question is for Mr. Reid. It is impossible, in the time we have, to be able to do justice to all of the issues. It is even more difficult with the reduced time, which is obviously not an issue for Mr. Reid. I will speak firstly about what is happening with PCR testing. There have been reports of ten counties where people are unable to register to get a PCR test. It is a time when we are asking people to abide by public health advice. We have a difficulty with this virus. We know what is happening in the hospitals, which I will get to in a moment. People expect much quicker turnaround times for PCR tests. I know there is pressure on the system. There are issues in many counties, including in the south east, where I come from, in Waterford, Wexford, Tipperary and Kilkenny. Where do people in the south east go? They have to travel out of the region if they want to get a PCR test more quickly. It is completely unacceptable. Will Mr. Reid talk to me about why that is the case?

Mr. Paul Reid

I am conscious of the Deputy's time as well as ours. To give context to what is happening, over the past seven days, 210,000 PCR tests have been completed in our laboratories. We scaled up to 100,000 over the course of last year. We had the highest day ever just two days ago, with 26,000 tests in the community. We had a capacity of about 15,000 a day in the community. We surged and scaled it up to 20,000. That is the volume that has come at us. In the past six or seven weeks, more than 1 million PCR tests have been completed. These are phenomenal numbers relative to the population.

To address what we are doing to mitigate the impacts, first, we have redeployed further staff, which is a significant challenge for us because the whole healthcare system is under pressure. We are deploying further National Ambulance Service sites and pop-up centres. We have deployed further staff from the Defence Forces. We have also taken capacity from private testing and resourcing in the three airports and other sites, which have been scaled up to this week. Some of them do 1,000 per day. We are also looking at major automation of the process, which helps to alleviate matters. We are aiming to prioritise clinical assessments, referrals to GPs and symptomatic people.

On the scale of what we are doing, while I do not have this week's figures, last week, 82% of people received a test on the first day. I acknowledge the pressure, demands and the delays people will experience. It is important that people who feel they need a PCR test and are symptomatic restrict their movements, including for at least 48 hours after their symptoms abate. That is not an immediate message for people getting their test. We saw 210,000 tests done last week. Some people will go in the next day, and as the Deputy knows, there may be further delays.

Our time is limited. We have three minutes left. It shows how ridiculous it is that we have the head of the HSE in and cannot do any justice to any of the issues. On that particular issue, I ask Mr. Reid to please focus on the counties and regions where we have a particular problem and to provide the needed resources.

I will move to the hospitals if I can. As Mr. Reid knows, I have been in many hospitals over recent months. I have spoken directly to hospital consultants, managers, nurses, healthcare assistants and people who work across healthcare. Only this week, I met the CEO of the Saolta group. The message is consistent everywhere I go that there is staff burnout, low morale, and a difficult problem in our hospitals. As the Saolta group CEO pointed out to me, there is a deficit of 200 beds across the hospital network. It has been screaming at the HSE to get capital projects over the line. There are issues with rapid modular builds, new hospital beds and single isolation beds. I am told many will not come until next year. The winter plan was produced in November when there are hospitals screaming out for resources, including beds and staff. I acknowledge that additional beds and staff were put in last year, but it still is not enough, and we are leaving hospitals badly exposed in a difficult period.

What more can be done to speed up the capital approval process to make sure we can get these projects over the line? Every hospital I have been in is looking for up to 100 beds and they are being told that the problem is with the process, the speed with which decisions are made, and the difficulty in getting these projects over the line. That is the first question I have about the capital approval process and projects for more beds.

Mr. Paul Reid

I will try to be as short as I can. I acknowledge that staff are exhausted, frustrated and tired. I acknowledge what they have done for the past two years. It is not easy for any of them. The Deputy described bed and resourcing issues. We have increased resourcing through funding for 11,300 since January 2020. A significant proportion of them have been consultants, doctors, nurses, medical and dental professionals, and healthcare assistants across the board. We are continuing to increase resources. There is a worldwide market for these skilled people. I will not go through beds specifically. The Deputy has made a point. The beds we brought in last year represented the biggest number of beds brought in in many years. The capital planning process can be a frustration for us, as can planning issues when we get to execute some of it. That is a frustration across many large hospital sites, including our model 4 hospitals. We are expediting the process as much as we can.

We are particularly aware of the challenges-----

There needs to be more urgency here because, again, the Taoiseach accepted that there are difficulties with the speed with which decisions are made. Hospital managers, consultants and nurses are really frustrated by the speed with which these projects are proceeding. We are now accepting 500 or 600 patients on hospital trolleys per day as normal. It is not normal. We are accepting wholesale cancellation of elective procedures, which has dire consequences for patients and pushes up waiting times, as normal. We are almost accepting 600,000 people waiting for outpatient appointments as normal. None of this is normal. It is not normal because it should not be happening but it is normal because of the lack of capacity in the system. The HSE needs to bring more urgency to it. Mr. Reid says the system needs to be speeded up. With respect, his job is to make sure it is speeded up because I can tell him that what is happening in our hospitals is really difficult and challenging for those working in them.

Mr. Paul Reid

I can assure the Deputy that neither I nor anybody in senior management or throughout the HSE accepts as normal what we have been going through for the past two years and probably longer. We know we do not have the capacity we want to have to give the right healthcare to people in Ireland. The 800 or so beds, and I will not list where they come from, have supported it. We want to bring on more as part of the winter plan but we certainly do not accept as normal any of the issues described by the Deputy and I know we work around the clock to try to make things better for our staff and resources. Many of the things described by the Deputy are equally frustrating for us. We are working and bringing in more beds and resources. We are working in a pandemic, which must be taken into account.

I thank Mr. Reid and his team. A year ago, we had to lock down the hospitals and divide them into Covid and non-Covid care. It mainly became Covid care. I commend the HSE, particularly in the past six or eight months, on how it attempted to normalise hospital work again in so far as it was possible. There are waiting lists and there are issues in Tallaght University Hospital but the HSE has also managed during this time to open the children's satellite hospital at Tallaght. A new primary care centre is almost ready in Ballyboden. These are significant achievements and will have significant impacts on care. To listen to some, you would think nothing was happening and it really angers me. For this to have gone on for a period approaching two years and for the HSE still to manage to carry the weight of that while delivering services is pretty incredible and very deserving of our admiration. Is Mr. Reid in a position to provide a ballpark figure to give us an idea of how many people aged 50 to 60, 40 to 50 and 30 to 40 might have received the booster vaccine by Christmas generally speaking?

Mr. Paul Reid

It is not fair to compare January 2021, when there were over 2,000 people in hospital and 212 people in ICU, and now, when well over 600 people are in hospital and 130 are in ICU, because back then, as the Deputy noted, we were not carrying out all of the other services we are carrying out now. As the whole nation was in complete lockdown, we did not have sporting activities so there were no trauma injuries. The situations are very different.

We are working towards boosters for those groups approved by NIAC. Looking towards December, we can indicatively say that we will have completed boosters for large portions of the vulnerable groups so long-term care facilities and boosters for those aged over 80 and over 70 will be completed. Boosters for those aged over 60 will be significantly completed but I would make the point - and this will be a feature of the booster campaign - that there will be a significant tail into the spring of next year where the five-month period comes up for a large proportion of people so we cannot complete boosters for all those aged over 60 because their five-month period has not elapsed. Similarly the vast majority of the 300,000 healthcare workers will have received boosters except for the tail. We will have a significant churn of healthcare workers who would have just come into the system later in the year so they will not be eligible for their booster until early spring of next year. That would be the 60s. We are then working through the medically vulnerable, which we expect to commence very shortly. We hope to make good progress on those. That involves what were previously known as cohorts 4 and 7 - medically vulnerable. There are about 470,000 of those.

When might the HSE have worked through all the vulnerable piece? It sounds like it will be the new year before people under 60 who are not in a vulnerable position will begin to receive the booster.

Mr. Paul Reid

No, the 60s will be significantly progressed before-----

Including the non-vulnerable?

Mr. Paul Reid

Yes. On an age basis, the 60s will be significantly progressed but as I said, there will be a tail. We will then start to move through the 50s - most likely towards the end of December and early January - but we will have the medically vulnerable well started as well and the 60s significantly advanced with the exception of that tail.

The news headlines regarding PCR testing are pretty impressive. What has been brought to my attention in respect of schools, although I assume it also applies to the healthcare setting, is the delay in results. Sometimes it can take three days and that third day means that a teacher who is out cannot return until he or she gets a clear test but he or she might be fine on the second day so it is costing quite a lot of additional sick days. If he or she could get the test results quicker, he or she could be back in school a day earlier. Mr. Reid can see the cumulative impact on the education system.

Mr. Paul Reid

We aim to turn them around. There has been good turnaround for schools where our public health teams put a good focus on it. I would make the point all our public health teams want to us to make, which is that there is still a clinically recommended period of two days post test symptoms in respect of returning to work for someone who is symptomatic and has received negative test results because there are other illnesses that are very transmissible. I am happy for Dr. Henry to make some comments on that if it is useful.

It is in the context of a close contact but that extra day has a cumulative impact on the system. There has been a bit of confusion over Citywest. Is that now formally a drop-in centre for those groups that are entitled to go? It was on the HSE website and was then taken down. Could Mr. Reid clarify that? Mr. Reid spoke about bringing more beds into the system. How many beds will be delivered and when?

Mr. Paul Reid

I might ask Ms O'Connor to answer that question. The other question was about the walk-in vaccination centre at Citywest.

Mr. Paul Reid

We do not have walk-ins available just now but we are getting rapidly through the approved cohorts and will operate walk-ins at stages throughout because we have generally found that when you set an appointed date or time, it is utilised effectively and we also want the vaccination centres to work efficiently and get through those appointments quickly. Ms O'Connor or Mr. Woods might talk about the remaining beds we are bringing on as part of the winter plan, etc.

Ms Anne O'Connor

As of now, we have delivered 799 beds so by the end of the year we will have a further 50 through the acute hospital beds with 296 planned for next year. A total of 314 community beds have been delivered with another 238 beds yet to open.

This is a very challenging time for our health service and many people are anxious about what is going on. Some of us probably thought that after the very successful roll-out of the vaccine programme, the pandemic would be in our rear-view mirror. That has not happened because the virus has evolved. It is a very unpredictable disease. Credit goes to all the people who have put their shoulder to the wheel in our health service. There has been an incredible collective response to a pretty dire situation affecting hospitals. I am aware that it is a cliché but the health service staff have been superheroes in protecting everyone in this pretty bad situation. Collectively, we will come through it, and hopefully stronger in the context of both people and public health. In the past 19 months, we have shown that there should be only one health service rather than parallel private and public systems. That is not an ideological thing to say because it has been shown that a single health system, a national health service, has better results for everybody.

I have a couple of questions for Mr. Reid. Is there a reason why the winter plan was late this year? Normally it is issued seven weeks earlier.

Mr. Paul Reid

I have three quick responses for the Deputy. First, I thank him and his colleagues for their comments in recognition of the pressure on the health system overall. Let me make a very simple point on this: the health system overall is in surge everywhere. That goes for general practitioners, our testing and tracing programme, our booster programme, and our hospital and community staff. We are operating at a time when 5,800 of our staff are out because of Covid-related issues. This means just about 4% of our staff are out along with the 4% who are normally absent. As a result, there are very significant challenges and pressures on our health system overall if it is to meet all the demands, but our staff meet the challenges in a remarkable way, as the Deputy said.

My second point is not a political one at all but I agree in respect of the best use of public and private systems, particularly at a time like this. We are strongly engaging with the private hospital system. We have been using about 1,100 beds per week. We see that number scaling up significantly throughout the winter for utilisation for urgent care, non-Covid care and potentially some elective care to keep the latter going.

On the winter plan, while its publication may have been perceived as late, I can reassure Deputy Gino Kenny and the other members that we have been acting and actioning many aspects of the plan that were in our national service plan. Therefore, many of the community actions to relieve the pressure on the hospital system were activated well before publication because it was funded ahead of it. I reassure members about the perception of a delay regarding the plan.

On the breakdown for the winter plan, the total fund is €77 million. Twenty-six percent of that would be going to private hospitals. Could Mr. Reid give a breakdown of where the money goes in respect of the winter plan?

I have a second question that ties in with this. It concerns surge capacity associated with the pandemic. Last year private hospitals were commandeered in some ways by the State. We do not know the trajectory. What is the position on the safety net concerning the HSE’s contract with private hospitals? Are we in safety net 1 or safety net 2 regarding capacity? Could Mr. Reid answer those two questions?

Mr. Paul Reid

I thank the Deputy. On the winter plan, I will ask colleagues to give a little more detail. The use of private hospitals is exactly as I would have set out. The aim was to utilise them to support us in non-Covid care and, potentially, some elective care to keep it going. I am referring to urgent care, in particular. We are also using some ICU capacity. Right now, we are using about eight ICU beds in the private hospital system. It can go up to about 12. That is specifically where the winter funding plan will go.

On the question on the safety net, we are in safety net 2, which runs up to the middle of January. Between ourselves and the Department of Health, we expect to be engaged with the private hospitals on an extension revision. That will be part of the discussions. My colleagues might want to make a couple of comments on that.

Ms Anne O'Connor

As Mr. Reid said, parts of the plan were already being implemented as part of our national service plan for 2021 so the funding allocation is really for quarter 1 next year. We were not seeking additional supplementary funding for quarter 4 of this year; we are continuing to implement our service plan. The additional funding for quarter 1 of next year allows us to maintain an arrangement with the private hospitals and maintain our increased number of transitional care beds. We have €30 million in our base for transitional care. This gives an extra €20 million to keep going at the rate we have been going at this year. It also provides for front-door initiatives within hospitals for our emergency departments and enhanced liaison in respect of mental health. It also relates to discharge options. For example, there is disability services funding for those with very complex needs who need to be discharged from acute hospitals. It is a question of a range of measures, including, for example, medical aids and appliances. If we look back, we will see those in every winter plan. In reality, however, the winter plan funding allows us to accelerate certain initiatives that will also appear in our national service plan for next year. It gives us the go-ahead, using the €77 million, to start now for quarter 1 of next year.

I have a final question. On ICU capacity, there are currently over 135 people in ICU. At present, Ireland has 300 ICU beds. If the circumstances deteriorate beyond the projections, which we hope will not be the case, where will the additional capacity come from? Is there capacity in the private hospitals? In this regard, I understand that private hospitals' ICU capacity is limited. If there is a deterioration, where will we achieve the capacity? If the worst projections are realised, as I hope will never happen, it will be pretty dire. There would be 400 to 500 people in ICU. If we do not have that capacity, hard decisions will have to be made. In that scenario, where does the ICU capacity come from?

Dr. Colm Henry

As the Deputy said, none of us wants this to play out. Uncontrolled admissions to ICU are much harder to manage than preventing people from getting sick in the first place. That is absolutely true.

We worked with the critical care community closely, particularly during the last surge, to identify additional bed capacity outside conventional ICUs where we could provide temporary designated ICU care. That was much dependent on the redeployment of staff, the training of staff who do not normally work in ICUs, and the identification of areas contiguous to ICUs, such as anaesthetic rooms, theatre rooms and the like. During the surge in January, we went up from our then base of about 279 ICU beds to a peak of about 340, which included both Covid and non-Covid patients. We are going through the same exercise on this occasion. We are going to the hospital groups, the managers of each hospital and the critical care community, who are critical to this, to determine what additional bed capacity we can provide and to maintain the same care outcomes. That is the critical thing. We were able to say that we could go up to 350 beds and maintain good outcomes of care.

Our figures now show that despite the pressures we were under in the successive surges since March 2020, we maintained outcomes that are comparable to other European countries. We are finalising the latest exercise with the critical care community today. We expect we should bring it up to at least a surge capacity of 350, including, as I said, temporarily designated spaces using staff redeployed from other areas. That is the big condition, namely, it does not come without a price and that price is redeploying staff who are trained in this, and also providing care outside of traditional units.

I call Deputy Róisín Shortall, who has returned from the Dáil Chamber.

I thank the witnesses for their attendance. My first question relates to home care. Mr. Reid said the HSE is pursuing a home-first approach. I am curious. The witnesses said there were 5 million additional hours provided in this current year. It is not very meaningful to express that in the number of hours and it would be better if it was the number of packages or the number of people supported. For some reason, less than half of those hours have been used and I want to know why that is the case. In the past couple of weeks, I have had a parliamentary question reply telling me that almost 400 people are waiting for funding for new and additional home support. Almost 4,000 people were approved for or awaiting a carer to be assigned and more than 100 people are currently in hospitals waiting to be discharged because they have not had access to home care. Why has he HSE used less than half of those hours this year and we are close to the end of the year?

Ms Anne O'Connor

In terms of home support, we find ourselves in the position that funding is not an issue and we are now better funded for home support than we have ever been. The real challenge, both for HSE directly provided services and for our funded agencies, is in securing carers. We have a very serious problem in securing carers to provide home support and that is impacting significantly on us now in regard to the allocation of carers to people.

I am aware private providers have been objecting to the fact that visas have been restricted for this category of workers. I am also aware of the fact the HSE has identified reasons for people not taking up that role in terms of no contact hours, poor work conditions and so on. Has the HSE done anything to progress that and ensure employment conditions and contracts are improved for people working in that sector? They are desperately needed.

Ms Anne O'Connor

We are looking at different ways of trying to get carers in. One of the issues relates to the eligibility criteria, which are excluding people who may want to work as carers. We are looking at that and we are also looking at different models of employment, for example, an internship-type approach in terms of supporting people. Ms O’Neill might want to add to that in terms of some of the work that has gone on.

Who is responsible for setting the eligibility criteria?

Ms Anne O'Connor

The eligibility for employment would be us.

Why is the HSE not changing that?

Ms Anne O'Connor

We are looking at that. We are looking at eligibility and we are looking at a different model in terms of internship.

This is clearly an urgent situation. There are well over 5,000 people affected by this. These are very vulnerable people, struggling in their own homes. Why is the HSE not dealing with this?

Ms Anne O'Connor

The challenge is that they have to have a certain level of training and skills. In terms of the eligibility, people applying do not have the necessary qualifications such as having FETAC level 5 in some cases. That is why we are looking at an internship-type model to train people to the required standard and employ them earlier. Ms O'Neill might want to come in on that.

That indicates a lack of forward planning in this important area. We have known from the demographics that this was likely to happen and it is disappointing that this money has not been spent or it has not been possible to spend it. Vulnerable people are paying the price for that.

Ms Yvonne O'Neill

I would add that work has progressed in working with that internship programme. We have employed people and, as part of their employment, they would complete that internship from within our employment and we could roll that out. We have been proactively working through that. There is a 16.5% increase in the total activity of home support compared to this time last year, notwithstanding the challenges in the employment sector. To come back to the Deputy’s point, 55,000 people are in receipt of hours.

That is more meaningful, thank you. On the last point regarding ICU surge capacity, is it only 50 additional beds for ICU?

Dr. Colm Henry

Up to now, it has been 50%. We are analysing the most recent number with our critical care community today. We got figures back from all of our hospitals and hospital managers as to the additional beds they could provide, which may be in excess of 50. One of the critical parts for us throughout this pandemic has been to ensure that the critical care community can underwrite this. What we are seeing, and I want to emphasise this, is that we can surge up to a certain number and maintain quality and outcomes of care.

I appreciate the difficulties. Does that include any element of private sector ICU?

Dr. Colm Henry

Yes, we currently use eight beds in the private sector and, as has been pointed out, we are looking at this agreement again to maximise any additional use of ICU capacity within the private sector. I should point out that the great limiting step is the trained workforce around-----

I appreciate that.

Dr. Colm Henry

In some ways, we are looking at a common workforce across the service.

I appreciate that. I want to ask about the vaccination programme. I appreciate that the HSE is fighting fires on a number of different fronts and there are huge pressures, but at least we should be getting clear information regarding the vaccine programme. I am getting a large number of complaints about this because people do not know where they are supposed to go and how to get a vaccine. As an example, the message that is being put out about no-shows is infuriating people. More and more, we are seeing instances where people are getting multiple appointments and they cannot get through to the HSE to cancel. Presumably, a lot of those are being counted but there is then talk about no-shows.

I ask the HSE to please put out very clearly what the access is for vaccines for people. Last weekend, there were full-page advertisements in the newspapers talking about GPs and vaccination centres but there was no mention of pharmacies. What exact role will pharmacies play? I understand up to 1,000 pharmacists are more than willing to provide the vaccines. How do people access those with their pharmacists? Overall, there is a need for much clearer information because people are getting very frustrated about this and there is huge desire to get the booster.

Mr. Paul Reid

I will make a few comments in response. First, we make contact directly with everybody now because we have the details of people from their first and second vaccination, so it is ourselves contacting people, rather than people needing to contact us. That said, the Deputy is correct there was a level of uncertainty among people as to where to go and what to do, but what we are saying to people is to wait and we will make contact.

The over-70s specifically have had their boosters through GPs, as have the over-80s. We have completed long-term care facilities with our own vaccinations. Our vaccination centres are now primarily focused on the over-60s and healthcare workers, and we will shortly commence with the medically vulnerable, who will get appointments through theses centres.

Specifically on the role of pharmacies, there are just over 900 pharmacies across the country. We are in discussions with the Irish Pharmacy Union, IPU, and we would like to see the maximum number of them signed up. We are nowhere near that just yet, but they are working through that with us and we expect to see significant numbers signing up. The pharmacies are an important channel for us. On average, they were doing 20,000 per week during the vaccination programme. The big scale will be through the vaccination centres but we value the reach the pharmacies have to support that and, in one week, they had up to 50,000 completed and administered during the vaccination programme. We see them administering between 20,000 and 30,000 of the vaccinations, GPs approximately 80,000 of the boosters and our vaccination centres up to 140,000 or 160,000. Again, as I mentioned earlier, the breakdown of the scaling up of what we are doing is starting from approximately 230,000 per week across those three channels and moving up over the next few weeks to 270,000.

Those are the channels and the issues around appointments. I take the Deputy's feedback on board. However, we must also urge people to come forward for their vaccine when they get their appointments. That has also been an issue.

Okay. I am getting a lot of complaints about people not hearing anything. These are people in their late 60s. There is also confusion over the message that went out about Citywest. Who exactly-----

Mr. Paul Reid

I am sorry to cut across the Deputy. I made a point about those over 60 years when the Deputy was in the Dáil earlier. The Deputy is right and we are aiming to get the message out. The difference between this booster programme and the previous vaccination programme is that with the previous programme, once an age cohort was approved, everyone was eligible to come through.

I appreciate that.

Mr. Paul Reid

This time, there is the matter of the five-month gap. People are hearing that those in their 60s are eligible but some of them must wait because there will be a lag into March of next year for those who got their vaccinations later.

I know that and those aged over 60 feel particularly hard done by because they got AstraZeneca which wanes very quickly.

My final question relates to the 270,000 people who got the Johnson & Johnson vaccine. It is recommended that they get a booster after three months. The impact of that vaccine wanes very rapidly. They are predominantly a young cohort who are likely to be mixing and socialising most. What arrangements are being made to get the booster to this cohort as quickly as possible?

Mr. Paul Reid

We await the full approval of that recommendation from NIAC. It has given it careful consideration and we expect approval for all age cohorts. We will administer those as part of the overall programme. Dr. Henry might wish to say something on this. We will administer vaccines to those cohorts as part of the process too. The Deputy is correct that it is primarily younger people but not entirely. There is a good age mix across the 250,000 people who received that vaccine.

Where will those people get their boosters?

This is Mr. Reid's final reply.

Mr. Paul Reid

Our primary focus will be appointments through vaccination centres. We will work through this. There will be a facility for people to go to pharmacies too.

We need urgent clarification on pharmacies.

We will try to allow all members to contribute again but we must move on.

I welcome Mr. Reid and the team from the HSE. I thank all front-line workers for their work over the last year and compliment the staff on the booster campaign.

This is a national winter plan but in reality we need winter plans for each hospital. According to the winter plan, the figures for the national 8 a.m. trolley count for the past eight weeks show that University Hospital Galway, UHG, has 12.9% of the share. That is the highest share of those on trolleys over that period. The lowest share was in Tallaght hospital, and stood at 0.04%. What is the winter plan for UHG and for the Saolta hospital group? We need acute beds. How many additional staffed acute beds will be provided in UHG this winter? Are there closed beds in the hospital now?

Ms Anne O'Connor

The winter plan is an integrated winter plan. The solution to pressures in hospitals does not necessarily lie within the hospital. The plan in the past couple of years has been based on integrated pathways with investment in community and acute services to support the local population. The Senator is right that Galway has been under very significant pressure this year. The hospital has been very challenged around trolleys and very high levels of attendances. We have been looking at that and have been conducting an audit to see what is leading to those high levels of attendances. The hospital has significant capacity restrictions. Part of the problem in Galway is finding somewhere to open additional beds. That was the challenge last winter and this year. We are in discussions about a plan for that. Mr. Woods might have more specific detail about UHG. A temporary emergency department is in development and will open next year and it has a longer term plan. However, the hospital is very restricted in respect of its public capacity and unused units that can be opened. It does not have an option to add extra units or beds without very significant development. That is a challenge.

In respect of community services, Galway is also very challenged around home support and testing. It featured in the winter plan last year and this year by virtue of the high attendances and its limited infrastructure. It is under consideration for a number of big developments. Mr. Woods might like to comment on UHG.

Mr. Liam Woods

On this winter plan specifically, the key supports going in around Galway are in the community and some flow projects. It is not additional capacity. Galway is already undertaking what will be a multi-annual project around the movement of its maternity service and creating wards based on a new emergency department. However, that will take some time and will not be effective this winter.

We are looking at relying on integrated care and movement through community as best we can to support Galway hospital in what is going to be a difficult winter. In the last few days, its trolley numbers have declined a little, which is also happening nationally. We think the Covid effect has impacted somewhat with the restriction on elective activity, sadly.

That is all fine and well. It is all talk. How many beds will UHG get this winter. What does integrated care mean to a person on a trolley? Where are the beds going to be in UHG? The officials talk about an emergency department. We still have not applied for planning permission for the permanent structure which was promised by the Saolta hospital group to the previous Minister for Health, Deputy Harris, over three years ago. What will be provided in UHG this winter? There is no point publishing a national winter plan which includes an additional 205 acute beds if HSE cannot tell me what will be provided on the ground in Galway for this winter, fully staffed.

Mr. Liam Woods

To finish my answer, when we talk about additional beds in Galway in this winter plan, I have flagged in these timescales. There is no feasible additional capacity in Galway in that timescale. The key supports we can put in around the movement of patients to community and, where possible, GP support with diagnostics, which is already happening. We should be clear that the winter plan is not the only response. The HSE service plan entails a lot more action in terms of capital building in Galway. That is a key requirement for us. We agree there is a need for additional capacity in Galway but it will take longer than this winter to do that, sadly.

Are there no closed beds in Galway that can be opened and no facility in Merlin Park that can be used?

Mr. Liam Woods

The hospital group is looking at using all of its facilities across the group as best as it can to support emergency flow this winter. That includes the private hospitals in Galway, both the clinic and Bon Secours, as the Senator will be aware. It is already using some capacity there and will look to use more to support it as it goes through the winter. That is the most immediate available capacity to support the pressure that Galway is under.

Based on the national plan, if there are no beds that can be provided directly in UHG, surely there must be a huge focus on private capacity if that is the only capacity available in Galway, short of transferring patients elsewhere. No one wants that and clearly Limerick does not have capacity. Will there be a focus on resources and private capacity in Galway?

Mr. Liam Woods

On private capacity, as Mr. Reid said, we are invested heavily this year and next year in investing in private capacity. We will support everything that Saolta can do to access private capacity. The community response is also important because that is equivalent to hospital beds and can help keep people at home or move people back home quickly.

Ms Anne O'Connor

The winter plan sets out actions up to the first quarter of next year. Galway has been challenged. It is not the case that we have not approved anything. The Saolta group's ability to identify capacity is a challenge for it. We are working with it.

The Senator asked what integrated care was. The point of integrated care and the development of those additional pathways and services is to try to ensure people do not need to go to hospital and, as such, intervening earlier, particularly with older people. There is a lot of very good work being done on that with the integrated care programmes and supporting GPs. There are GPs and advanced nurse practitioners, ANPs, working in the emergency department in Galway. It is about trying to make sure that people are turned around in the emergency department to reduce the need for admission and thereby reduce the need for beds. However, it is one of our more challenged sites in respect of infrastructure. We are supporting it in every way we can otherwise.

GP facilities were mentioned. There is great demand for Westdoc services. Some areas, including my area around Moycullen and out to Oughterard, are not covered under Westdoc despite repeated attempts to secure funding. Could that be looked at? Enhanced Westdoc services could help limit pressure on emergency departments.

Ms Anne O'Connor

Absolutely. We have funding of €10 million in the plan to support GPs and GP out-of-hours services, specifically to support those practices and areas that will come under significant pressure. Last year, we invested in the winter plan and the service plan for single-handed GP practices, in particular, a number of which are in the west. We are very conscious that without sufficient GP coverage we will be in trouble across our acute system. Interestingly, in the audit we have just carried out, which is drafted at the minute in respect of Galway, approximately 50% of the people who attended had consulted a GP prior to attending. We know that where people have consulted GPs their attendance and need for admission are more appropriate. "Yes" is the shorter answer to looking at the need for enhanced coverage. We will certainly look at that in the west.

I thank the witnesses for their presentation and the work that has been done. I will raise a number of issues. The first relates to antigen testing in nursing homes. Is the HSE working with private and public nursing homes to provide antigen testing at this stage? What agreements have been reached in respect of making it available?

I will raise the issue of discharges from hospitals to step-down facilities. There are many complaints about how difficult it appears to be to have people moved out of hospitals at present; they are staying longer than normal. What is in place to try to expedite moving people into step-down facilities? What agreements or co-operation are there between public and private nursing homes, or any other step-down facilities, as regards trying to make hospital beds available in a faster timeframe?

I will also raise the issue of the use of antivirals. My understanding is that their use can help to reduce the effects of Covid. What arrangements are there for dealing with that and the use of antivirals? Is any work being done in this area?

I will touch on an issue I raised yesterday with Dr. Tony Holohan and Dr. Ronan Glynn, which is the lack of GPs in the Cork area at night-time. My understanding is that only one GP was on at night recently. That will obviously force people with no alternative but to go to accident and emergency departments, especially families with a young child they are concerned about. They are not prepared to take the risk, rightly so, of waiting until the following morning to get medical advice. What level of engagement has there been with GPs, not just in Cork, but throughout the country, in order that we can reduce the number of people who have to attend accident and emergency departments?

Mr. Paul Reid

With the Deputy's agreement, I will ask Dr. Henry to answer his first and third questions on antigen testing in nursing homes and antivirals. My colleagues, Ms O'Connor and Ms O'Neill, will answer the questions on discharges and out-of-hours services.

Dr. Colm Henry

We have worked through public health departments in a number of nursing homes to provide antigen tests, again, with public health guidance and direction. That is part of the overall range of how we provide antigen tests, which goes way beyond that setting. As the Deputy knows, antigen testing is beginning in the schools sector shortly and is also used for close contacts in household settings who are asymptomatic or unvaccinated.

Two antiviral drugs are currently being talked about. Some provisional information has been released about their efficacy but the trials have not been published yet. The first is Molnupiravir, from Merck, the release for which reports a 50% reduction in hospitalisation for people at certain risk of mild and moderate symptoms. The other is a corresponding similar drug from Pfizer, which reports a larger reduction. Neither of these drugs are as yet approved by the European Medicines Agency, EMA, but we are working with the Department of Health and looking at advance purchasing through a number of channels should it be the case that the initial promise is matched by published trial results and EMA approval. A clinical procurement group has been set up within my office, working with the Department on how we can explore possible purchasing of this drug, or future orders, should the promise live up to the initial information that is coming through.

The second line of drugs are antibodies, Ronapreve and Regkirona, which were approved by the EMA on 12 November, and a third from Eli Lilly. These drugs will probably be available in a couple more months, at the earliest. They have just received EMA approval and have to go through our own medicines management programme evaluation, which will occur rapidly given the possible gain they will provide. That is the situation at present in respect of the two drugs referenced by the Deputy. We are looking at possible procurement, either with other European countries or directly if, as I said, the promise in the trial results matches the advance information we are getting.

Ms Anne O'Connor

In respect of beds, we put a lot of focus on improving our non-acute capacity for HSE beds last year. As I said, 314 were delivered and 238 are yet to be delivered. We have contracted 468 private community beds to provide step-down options for people.

On our response, some guidance is due to be issued to the system because we are not satisfied that enough people are stepping down into these beds. For example, people are awaiting home support in our acute hospitals. We have invested a lot in providing multidisciplinary supports for our community beds. We have repurposed some of our longer-stay beds into reablement beds to provide the necessary multidisciplinary inputs to people. There are now also rehab options for people to access community services.

I will come in there. My understanding from the report we got from the South/South West Hospital Group is that 200 beds were lost in 2020. What has been done to replace those beds? There is in fact no evidence that they have been replaced.

Ms Anne O'Connor

I apologise. The numbers I gave the Deputy are national, not specifically Cork.

I understand that 200 beds were lost by the South/South West Hospital Group in 2020. That is because the number of people per ward had to be reduced for Covid-related reasons, but there is no evidence that the 200 beds have been replaced. I will move on from that. Those 200 beds have not been replaced in the South/South West Hospital Group.

On Saturday, I attended the opening of a new runway at Cork Airport that took 70 days to build. I know it is far easier to build a runway than a hospital, but we have been talking about a new elective hospital in Cork for the past ten years. A submission was made in November 2019 and we still have not even identified a site. We can complete a major infrastructure project in 70 days from start to finish, yet we do not even have a site identified for a new elective hospital in Cork. What is the problem that we cannot even identify a site?

Ms Anne O'Connor

The Deputy is correct in that Cork was impacted by some regulatory requirements in some of their older person facilities. I am not sure if those are the units the Deputy referred to. On identifying a site, is the Deputy talking about step-down beds or acute services?

No, just a site for an elective hospital in Cork. We have lost 200 beds in the past 12 months and we are talking about building a new elective hospital. I know I am going slightly off the issue, but we have not even identified a site despite talking about it for ten years. Where are we with that? Where are we with replacing those 200 beds?

Mr. Paul Reid

The issue around strategic decisions around elective hospitals is a policy issue led by the Department of Health and the Sláintecare process. We are committed and engaged with it but that is a policy process led by the Department, which we are contributing to.

Do we have an idea of when a decision will be made on this matter?

Mr. Paul Reid

I cannot give it to the Deputy today. I do not have it. We are contributing to that process.

What about the replacement of the 200 beds that were lost in 2020 in the South-Southwest Hospital Group area?

I thank the Deputy. This is the final reply.

Ms Anne O'Connor

In terms of our plans for next year, one of the challenges, for example, in CUH, is in respect of isolation rooms or single rooms. That is in our plans for next year but it will not be delivered within the period of winter, within Q1. Therefore, it is not in the winter plan. We are committed to developing a unit in Cork but I am aware that there are other longer-term plans that are also being considered in the context of the CUH site. We definitely acknowledge that there is a shortage of single isolation rooms in CUH.

But there is also a shortage of 200 beds compared with December 2019.

We must move on because we are well over time. There will be one final reply.

Mr. Liam Woods

For clarity, the 200 beds are not actually in CUH. The Deputy may understand that.

I do; it is the South-Southwest Hospital Group area.

Mr. Liam Woods

There is work under way - maybe we can come back to the Deputy on that - in terms of additional beds in the community.

I thank Mr. Woods. The good news is that we have completed the first round of questions on behalf of everybody except Deputy Ó Cuív, who was supposed to be deputising for Deputy Cathal Crowe. Deputy Cathal Crowe sent apologies but has decided to attend. He has not arrived yet. The bad news is that the next questioner is me. There will be a second round of questions involving everybody who spoke in the first round. It will be of short duration - two minutes or so each. When that is finished, we will take in a number of members who have indicated that they want to ask questions as well for one minute.

I congratulate the witnesses on the work that they do. It is a difficult task. No matter what you do or how hard you work, it will never be sufficient because the challenges are coming at pace. I want to record our appreciation for the work that they have done over the past couple of years in very difficult circumstances.

I have two or three questions. To what extent has the HSE indicated to the Minister and the Government its requirements, immediate and in the medium term, in respect of Covid and the winter plan? Has the HSE requested and informed the Minister to the full extent? Is the HSE satisfied that there will be a response sufficient to meet its requirements?

My second question relates to the degree to which the HSE can put in place emergency plans.


Somebody has a microphone switched on somewhere there.

Deputy O'Donnell cannot ask any questions just yet. I ask the Deputy to hold on and wait until I call him in due course.

As I was about to say before I was interrupted, the question is the extent to which the HSE has a plan B in operation in the event of there being a breakdown regarding hospital beds, ICUs or whatever between now and January or February.

Mr. Paul Reid

I will try to address both questions together. In terms of our setting out the immediate and medium-term requirements, that would be at two levels. The first is an engagement process we would have in the context of the Estimates process whereby we would have set out the requirements of the HSE. The second, right now, is finalising the national service plan following the allocation of those Estimates in the budget. We completed a process yesterday with our board in terms of submitting a national service plan to the Minister. That plan is under consideration by the Minister and it sets out the medium-term requirements, certainly into 2022.

Specifically, we would regularly set out at the Cabinet committee, as we did last Monday week, our approach and plan in terms of surge capacity and our requirements. That would be for Covid and non-Covid. Some of it would be the surging up of the resources we just spoke about in terms of hospitals but also the surging up of resources and requirements in relation to testing and tracing and the booster campaign, and, indeed, the supports required for the GPs throughout winter.

The short term position is set out in our winter plan. In the medium term, it is our national service plan. Right now, from a crisis perspective, we set out some of the immediate issues at a Cabinet committee level. I acknowledge that we got a response at each stage.

On the degree to which it might have to rely on resources not immediately under its control, does the HSE have a fail-safe plan in the event of there being unforeseen circumstances?

Mr. Paul Reid

Apologies, I missed that second part. Yes. That would be a whole set of scaling up of other resources not completely within our control, as the Vice Chairman describes. That would be at a few levels. The first would be private hospitals. The agreement that we have with them continues into January. We will be entering discussions with private hospitals for a further extension or a new agreement. That will encompass both acute and ICT beds. Separately, as my colleagues have said, we would utilise step-down beds and private nursing homes as part of that. Even today, as part of our testing and tracing programme, we are utilising private capacity in the context of swabbing. Some private operators are being used by us to cope with the current massive surge in demand. It would be scaling up resources not completely under the normal control of the HSE and utilising them effectively and to the greatest extent we can. It is fair to say that private hospitals have their own pressures at present. It is not an endless capacity or resource, but it gives us capacity. The safety net agreement gives us additional capacity of up to 30%. We plan to use that effectively and continue the dialogue with the private hospitals.

Has the HSE an arrangement with the private hospitals to be on alert and on stand-by in the event of a doomsday scenario arising?

Mr. Paul Reid

That is the very nature of the agreement we have with them. The Vice Chairman will be aware that one of the Deputies referenced it earlier. In the first days of the pandemic, we took a different approach that involved ring-fencing the private hospital system for public capacity. It was not needed to the extent we thought at that stage because of the great reaction from the public and the public health measures. We expect and hope that will continue. The public have taken some great actions again and have listened to the public health advice. We hope that it mitigates the extent to which we would need private hospitals. In the event we do, however, there is an agreement there which facilitates that.

I thank Mr. Reid. I will bring up to date what I propose to do. In order to accommodate as many members as possible, I propose to have a second round of questions. I will have to interrupt at some stage because we have to accommodate to those who did not attend so far for their first round. Senator Kyne is first.

Regarding the pressures by virtue of the amount of unvaccinated persons within the emergency departments, has the HSE figures for individual hospitals? I am particularly looking for those relating to Galway University Hospital. What additional measures can we put in place to urge people to take up the Covid vaccine? Is it Mr. Reid's belief that the unvaccinated are causing significant pressures and putting the lives of many vaccinated people at risk such is the pressure within and on the hospital systems?

Mr. Paul Reid

What I can give the Senator straight off the top of my head are the national figures. We do break them down by hospital. Nationally, close to 45% of those in hospital have at least not been fully vaccinated. The percentage of patients in ICU today who are not fully vaccinated is close to 55%. Specifically on or in relation to that, we are taking a number of initiatives. We are seeing between 1,000 and 1,500 people per day still registering for vaccinations. That is very positive. Separately, we have pop-up centres - I was in one last weekend in Ballyjamesduff - where we are trying to target local areas that have a low take-up or that may have specific sites, such as meat plants, that have a high proportion of non-Irish and a lower proportion of take-up. That proved to be quite successful. I saw it in operation.

We also communicate in 37 different languages to support the non-Irish community. As people come in, we are working with the Immigration Council of Ireland in terms of communication. We are working with vulnerable groups, such as the Travelling community, and with third level colleges. We have a very big focus.

Only about 7% of the adult population have not received two vaccine doses. That is a highly disproportionate number of people to have in hospital representing close to 55% of our ICU capacity. We continue to try to reach out, to promote and to encourage. We know there are issues with language and other barriers and we are focused on them as well, but unvaccinated people are having a very significant and disproportionate impact on our hospital system. That is what we hear from our clinical community.

I have a couple of follow-up questions. I thank the officials. The HSE raised in the winter plan the issues of vulnerability and securing what it describes as a high-calibre workforce and labour, specifically for home care and nursing home settings. Will the witnesses elaborate a little on that?

Ms Anne O'Connor

Yes. We mentioned earlier the challenges we have with home supports. We now have significant funding for home support, for both our own directly provided HSE services and those provided by funded agencies. We are struggling to get home support workers. We mentioned earlier the fact we are now employing people in different ways in an internship-type approach. We have people applying to be carers who do not have the necessary FETAC qualifications. Clearly, we need to have people with the right training to be able to do what is often a very difficult job. We are working in different ways now across the sector to try to increase the number of people who can work as carers, but we are very challenged at the moment. Notwithstanding the fact we have increased the number of home support hours being provided, we are concerned about the insufficient number of carers, as I said, in both directly provided services and services provided by funded agencies.

How is the HSE managing those concerns? Is there a supply available that just is not coming, or is it even a supply issue? If it is, it will remain a concern, clearly.

Ms Anne O'Connor

Yes, there is a supply issue. We have many carers from overseas who went home and did not come back and people not coming over. There are challenges and discussions surrounding permits, visas etc. There are also within Ireland people who would like to be carers but who do not have the right qualifications. We are employing people on an internship basis now to try to bring them up to the required level as employees to work with us. That is a new development to try to address that problem, but we certainly have a challenge with people from overseas not coming here to work as carers.

I will put my three questions together because of the time constraints. The first is about the cancellation of electives. Unfortunately, in some hospitals we have seen more time-sensitive care cancelled as well. It is not sustainable, as I imagine Mr. Reid would agree. The Irish Hospital Consultants Association has indicated that over 60% of procedures may well be cancelled over the coming months. This was happening long before Covid and, obviously, is exacerbated because of Covid. How sustainable is it that we have almost routinely this cancellation of electives and now surge capacity in ICU in some areas impacting other elements of time-sensitive healthcare?

My second question is about antigen tests. How many has the HSE got? There were reports of the HSE having a certain number, holding them back or having them in reserve. At this time, how many antigen tests has the HSE got and how does it expect to use them?

My third question is for Mr. Woods and is about University Hospital Kerry. I know Mr. Woods visited Kerry recently, as did I. There are major problems and challenges in that hospital. Mr. Woods committed to putting in place a plan, I understand, and going back there. Will he give us a sense of what that plan will look like?

Mr. Paul Reid

I will try to be brief. Of course, I agree that cancellations are not what we want to do. We have put in place a short-term action plan between now and the end of December to address increased public capacity in out-of-hours theatres, increased use of private capacity, and changing the clinical pathways to try to get people through, accelerated in a different, quicker and safe way. We are still making reasonable progress on that but, obviously, it has been impacted. To give the Deputy an idea of the number of cancellations that have happened, through September about 180 cancellations were happening per week. That stepped up in October to about 350 per week. We are concerned most about our model 4 hospitals. There have been about 1,000 cancellations in the past four weeks, which has had an impact. We have increased the total number of our consultants. Resourcing is a key factor in trying to get to a better place. The net increase in the number of consultants is 333 since January 2020. That is an assured increase.

As for antigen tests, we have a drawdown contract, so it is not so much a question of what we have in stock. We have about 2 million tests but we have capacity to draw down at least 10 million and we can extend contracts further. Stocks or supply are not the factor for us. First, we give public advice on antigen testing on our website. Second, we provide supports for public health advice for vaccinated people, for example. Third, we give advice to sectors, which then procure and supply. Those are three roles we play. I will ask my colleague, Mr. Woods, to come in.

Mr. Liam Woods

Yes, I was in Kerry recently, as was Deputy Cullinane. I have undertaken to go back and work with the group and the hospital to develop a plan to address some of the issues they are facing, including patient flow and resources. I will do that in the coming weeks. I have also undertaken to correspond and interact further, which I will also do.

My question is shrouded in a comment of thanks to Mr. Woods. About a year or a year and a half ago, when he attended this committee, I spoke to him about eye clinic liaison officers, ECLOs, to support the ophthalmologists in our country. Since that engagement, funding has been provided to appoint three. That will take care of Dublin, which clearly is where the major waiting lists are, but unfortunately there are waiting lists in other parts of the country as well. When can we expect the funding to be announced for the additional four ECLOs required to help drive down the waiting lists in ophthalmology and eye care.

Mr. Liam Woods

I did not realise it was a year and a half ago since we last spoke, but there you go.

Mr. Liam Woods

Since then, as the Senator will know, using our access to care funding, we have invested in supporting some posts to address eye care in the Dublin area. Under access to care in 2022, we are open to looking at that again. The investment is proving very successful and we would be keen to follow it through. I will take the Senator's comments away and will correspond separately with him on them.

That is very much appreciated. I have a final question for Mr. Reid about the booster vaccination programme we spoke about earlier. I am just getting some information from people that the text messaging system that was used very successfully by the vaccination clinics for the second jab does not seem to be working as efficiently for the third or booster jab. Are there technical issues there? Are there issues with the text messaging system? Will Mr. Reid give us a comment on that?

Mr. Paul Reid

I am happy to take separately any feedback the Senator may have on specific issues.

Our process has been to text people. For the 600,000 people who have come through, it has been through the text messaging. I believe Deputy Shortall raised the issue of people getting multiple appointments. People wanted to be facilitated to cancel appointments by text and we have worked with our IT teams to see if we can put in that process. Ultimately, I can reassure everybody that the texting process is working for people coming through.

As we have completed the first and second rounds, I will now take questions from non-committee members.

I am a Deputy in Limerick city. It is not possible to get a test at the Covid testing centre on Ballysimon Road today. It appears to be booked out and people need to end up going to Shannon. Will the HSE establish an additional testing centre in Limerick?

Mr. Reid will be aware University Hospital Limerick, UHL, has the highest number of patients on trolleys, with an average of 60 or more. The hospital also has a very high number of Covid patients, with nearly 50 on average in recent days. It has 13 of the available ICU high-dependency beds - nearly 50% - taken up by Covid patients. Will the HSE facilitate UHL applying under the winter preparation plan to get extra resources to reduce the trolley numbers as quickly as possible?

We need an extra testing centre in Limerick city. We are encouraging people to get tested but they cannot get a test on the Ballysimon Road and must go to Shannon. Under the €30 million available for the winter preparation plan for acute hospitals, will the HSE facilitate UHL in making a submission for extra junior doctors and other resources to deal with the winter period? A tender has gone out for the 96 acute beds, but UHL needs additional capacity to get through this winter.

Mr. Paul Reid

In response to the Deputy's first question, I am not sure if he heard the earlier comments on the scale. Throughout the country, 210,000 PCR tests have been completed in the past seven days. We have now carried out PCR tests for more than 1 million people in the past six or seven weeks, which is a major surge. We are putting in extra test centres throughout the country. It is public health led, some of it through the National Ambulance Service. As the Deputy has just said, we have also procured the support of private capacity in the three airports, including Shannon. We are looking at other potential private capacity. We are scaling to the maximum extent we can, using extra resources, including the Defence Forces, the National Ambulance Service, redeployed staff and private capacity.

We will examine where pop-up centres where extra centres go, but all centres throughout the country are experiencing high demand. We are prioritising symptomatic and clinically prioritised people who come through their GPs. It is important that anybody who is symptomatic isolates for at least four to eight days after the symptoms dissipate. While it is not as high as we would like, 82% of people last week were tested on day one with a tail into day two and day three. We are looking at extra centres wherever we can.

I ask Ms O'Connor to answer the other question.

Ms Anne O'Connor

I believe we have already received a local plan from the mid-west for the winter plan. University Hospital Limerick is challenged with the number of patients it has on trolleys at times. However, it is not the worst. Unfortunately, the hospitals in Galway and Cork have taken that over from Limerick of late. As of this morning, the hospital in Limerick had 32 surge beds in use and it has about eight closed beds. It is challenged and we will consider anything. The mid-west is one of our most integrated areas, between the community services and the hospital. We are also looking at enhancing community support to take people away.

Part of our challenge in winter is to reduce the number of people who attend hospitals. It is about reducing the footfall at our acute hospitals by enhancing our community support. That work is well advanced in the mid-west between the community health organisation and the hospital. As the Deputy knows, it has access to model 2 hospitals and it has been transferring people out there. It has capacity elsewhere which it uses very effectively. That is not to take away from the challenges it experiences; it is extremely busy. We will continue to support it in respect of the winter plan it has submitted. We are now working with the local areas in respect of their winter plan aligned to the national framework and the funding we have been allocated.

I thank all the witnesses for their presentations. I am also from Limerick city and many of my concerns relate to the overcrowding at University Hospital Limerick. I understand there can be delays with people getting discharged. Perhaps that is a matter the HSE could address. Regarding the bed capacity, the hospital got 110 extra beds and I know the treatment of Covid patients has used up some of those beds. At one stage, there was a plan for 120 replacement beds in St. John's Hospital so that more procedures could be carried out by the hospital and there would be long-stay beds in the 120 new ones. Are there any plans for that to be introduced? It was announced in the capital plan in the past when the Minister, Deputy Harris, was at the Department of Health.

I have spoken to many of the University Hospital Limerick staff about morale. They work hard to create a safe environment for patients and staff. Every winter UHL is to the fore and it is particularly bad this year. As the witnesses will be aware, it was particularly bad last week when, most days, more than 95 people were on trolleys. Are there any plans for doing things differently, for example, quicker discharges and using beds in other hospitals in the area for more minor procedures?

Ms Anne O'Connor

Regarding discharges, University Hospital Limerick has a very low level of delayed transfers of care. These are people who would be considered medically fit for discharge and are in the hospital. As of last night, 12 people were in that category and seven or nine of those were awaiting rehabilitation. It is most difficult to discharge people with very complex needs and specific requirements. The hospital would not have a high number of people who would be considered medically fit for discharge and who are delayed. It tends to be very effective in how it uses its step-down facilities and how it works with the community. It tends to move people very effectively between facilities. Obviously, there is a finite capacity at the end of the day. We will continue to work with the hospital in respect of any challenges it has.

Perhaps Mr. Woods can answer the question about the other 100 beds.

Mr. Liam Woods

As Deputy O'Donnell mentioned, there is a 96-bed block for the hospital in Limerick going through the capital plan process. It will be a replacement of old ward stock. That will help greatly in reducing the risk of infection, as the new capacity has already done. Most of the outbreaks are happening in the older Nightingale wards. That will be important.

I will need to come back to the Senator on the question about St. John's Hospital. I do not have information on that in front of me.

I will start an unprecedented third round of questions. Hopefully they will be helpful. We started the previous round with Senator Martin Conway, who is not available at the moment, so I will call Deputy David Cullinane.

I will come back to what is happening in the hospitals with regard to capital funding. It is a real frustration for hospitals. I must be careful in how I put this, but there is a disconnect between the lack of urgency I sometimes see from the system, and the real urgency I hear from the voices of hospital management, consultants and nurses. It is very frustrating when hospital administrators say that they have applied for a 40-bed, a 50-bed, or 100-bed unit, or there is a need for a new emergency department, or whatever the capital project is, and then we hear that an application is caught up in the system for three, four or five years. Many hospitals are very stressed at the moment, they do not have the capacity to treat patients or to get the patient throughput for the flow of patients because beds are not available to admit people quickly, yet they may have put in applications for rapid modular builds to get into the system quickly. It is very frustrating. Will Mr. Reid come back to the committee with information on all capital applications for additional beds that have been made by each of the hospitals? This is so we can see for ourselves what they have sought, either through hospital groups or directly with regard to HSE estates. Will Mr. Reid also come back to the committee on the point about the speed at which things get done? Demand is always going to outweigh what is needed in the context of our resources and capital funding; I get that. Once we make a decision that this is what we are going to do it should not take as long as it does to get decisions made and to get delivery on these projects.

In this third round, there is a bit of time to get a bit more detail on how Mr. Reid and HSE intend to speed up that process, once there is agreement on what we need to do about hospital beds, single isolation rooms, or whatever the capital projects are, so that they are delivered at greater speed and with greater urgency, as opposed to some of the delays I can see in the process because of just how convoluted it is. I would be grateful if he came back on that point.

Mr. Paul Reid

We certainly will commit to come back to the Deputy on the requests made and on the capital plan.

I reassure him that I do not perceive our capital planning teams and our capital execution teams as being disconnected from the reality of the pressures our hospital system is under. There are a couple of points I will make on this. The delivery of major capital projects by our in-house capital teams is not always seen. Over the past year alone the National Forensic Mental Health Service hospital in Portrane was delivered on target, on budget and on time, along with the National Rehabilitation Hospital with 120 extra beds. These are major capital infrastructure projects. Certainly, there is a level of constraint on the capital budget, given what is happening with other major capital infrastructure and the children's hospital. There is a limited budget in the first instance, and then there is the prioritisation after that. I reassure the Deputy that the urgency with which our capital planning teams and capital execution teams take this is very significant and they are not disconnected from the major pressures that we know the hospital system is under.

My point is more around how long the process takes. I am aware that a new appointment has been made in the Department of Health to look at this whole area, which I support. I can give Mr. Reid examples in my constituency where a cath lab has still not been built. It was promised years ago, committed to, and signed off on. I could name countless projects, which I do not have the time to do here. My point is more about speeding up that process with all of the steps that are required around approval, waiting for funding, and so on, even when a decision is made to do something. There is a lack of speed in the process. Surely there must be ways in which there can be a quicker turnaround on some of these projects and re-evaluate how we do capital projects in health once a decision is made. It is causing problems. It is a frustration being relayed back to me by hospital management.

Mr. Paul Reid

The Deputy is making the points and I will respond in simple terms. We will come back to him on what the demand has been, and we will simply set out the planning process, from design to execution, to hopefully give some clarity and information him.

I call Deputies Colm Burke or John Lahart but they are not available. We have finished off any remaining questions. You have been a very good audience, very good witnesses and very good members. I really appreciate that. We have covered all members of the committee who were available to speak. I thank the officials for their co-operation and I thank the members for their help and assistance.

The joint committee adjourned at 11.47 a.m. until 9.30 a.m. on Wednesday, 1 December 2021.