Joint Committee on Health debate - Wednesday, 7 Dec 2022

Sláintecare Implementation: Discussion (Resumed)

Chairman

The purpose of the meeting is for the joint committee to consider the latest developments in the implementation of Sláintecare. To enable the committee to consider this matter further, I am pleased to welcome from the Department of Health, Mr. Robert Watt, Secretary General; Mr. Derek Tierney, assistant secretary; Ms Sarah Treleaven, principal officer; Mr. Bob Paterson, principal officer; and Ms Grace O'Regan, assistant principal. I also welcome from the HSE, Mr. Stephen Mulvany, chief executive officer; Mr. Damien McCallion, chief operations officer; Dr. Colm Henry, chief clinical officer; Ms Anne Marie Hoey, national director, human resources; Ms Yvonne Goff, national director, change and innovation; and Mr. Liam Woods, national director, regional health areas, RHA, implementation. All present in the committee room are asked to exercise personal responsibility to protect themselves and others from the risk of contracting Covid-19.

I will read a note on privilege. Witnesses are reminded of the long-standing parliamentary practice that they should not criticise or make charges against any person or entity by name or in such a way as to make him, her or it identifiable or otherwise engage in speech that might be regarded as damaging to the good name of the person or entity. Therefore, if any of 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 from the Chair.

Members are again reminded of the long-standing parliamentary practice to the effect that they should not comment on, criticise or make charges against persons outside the Houses or an official either by name or in such a way as to make him, her or it identifiable. I remind members of the constitutional requirement that they must be physically present within the confines of the Leinster House complex to participate in public meetings. I will not permit a member to participate where he or she is not adhering to this constitutional requirement. Therefore, any member who attempts to participate from outside the precincts will be asked to leave the meeting. In this regard, I ask members partaking via MS Teams to confirm, prior to making their contributions, that they are on the grounds of the Leinster House campus.

I invite Mr. Watt to make his opening remarks

Mr. Robert Watt

I thank the Chair and committee members for the invitation to meet again to discuss progress with implementation of our Sláintecare reform. The Chair mentioned the members of the team who are with me - Mr. Tierney, Ms Treleavan, Mr. Patterson and Ms O’Regan.

As we approach the end of the year, I am pleased to say we can report significant progress in the delivery of Sláintecare. One of our key objectives was to increase the volume of activity in our public system and treat more patients in non-acute settings through improved integrated care. In terms of increasing capacity over the last two years, we have seen the largest ever increase in healthcare capacity. Over 900 additional acute beds have been delivered since 1 January 2020, while we have increased our number of critical care beds by 26%. As was discussed with the committee before, we have also increased recruitment significantly. We have recruited more than 15,000 staff over the past two years, including 4,500 nurses and midwives, 2,300 health and social care professionals and over 1,400 doctors and dentists.

Central to delivery of Sláintecare is integrating healthcare delivery between acute and community settings and delivering more care closer to where patients live. This goal is being significantly achieved through the enhanced community care, ECC, programme. Members of the committee will recall the progress outlined previously in establishing the relevant teams which are now substantially operational. The community specialist teams, for example, are providing consultant-led multidisciplinary care to older persons and those with chronic disease. Community intervention teams provide a rapid and integrated response to patients experiencing an acute episode of illness.

Under the chronic disease management programme, to the end of October this year, GPs conducted 333,000 consultations with over 284,000 registered patients, which was a significant amount of activity. The programme engages with patients to encourage a proactive management of chronic conditions. Next year, the hope is the programme will reach full implementation as it is extended down to all patients in the relevant categories aged over 45.

Sláintecare has also delivered GP access to diagnostics for patients, with more than 205,000 diagnostics being provided by the end of October 2022. GP access to diagnostics reduces referral rates to the acute setting and increases flexibility and continuity of care. An encouraging first sign of the impact of this innovation from a recent small study across 16 practices provides positive indications of significant reductions in referrals to emergency departments and outpatient clinics for diagnostics. In this context, the significant investment in the implementation of the ECC programme is being monitored in terms of its activity, outcomes and impacts, and the Department is working with the HSE on the provision of a suite of metrics to better report on its progress. We look forward to updating members in more detail on the outputs of this in 2023. This has been raised previously by the committee so next year we hope to have a fuller assessment of the impacts of the investment to date in this programme.

On affordability, 2022 has seen major developments in making healthcare more affordable for our citizens at a time when families are facing cost-of-living pressures. The drug payment scheme threshold was reduced to €80 in March, while we also saw the abolition of inpatient hospital charges for children aged under 16 years and the introduction of free contraception for women aged 17 to 25. The recent budget included additional funding that will allow the State to expand the free contraception scheme to include 16-year-olds and those aged 26 to 30. Next year will see a significant milestone when we will be able to abolish public inpatient hospital charges for all. We also will be able to extend free GP care to people earning no more than the median household income of €46,000. This will result in more than 400,000 additional GP medical cards.

Another Sláintecare project making impact is the Sláintecare integration innovation fund, SIIF. The aim of the fund is to test innovative care pathways and e-health transformation solutions, informed by front-line staff, which provide the right care in the right place at the right time by the right team. As members will be aware, round one was a success with more than 106 projects now mainstreamed and set to receive recurring funding annually. Key achievements of these projects include an estimated 19,000 inpatient bed days and 3,000 emergency department, ED, attendances avoided. We will have a further funding round to identify further projects and scale up those projects deemed to be successful and effective.

While we have not achieved all that we hoped to in terms of waiting lists in 2022, we have seen particular progress in relation to long waiters, which have reduced significantly from the peaks. The number of patients waiting longer than 12 months for an outpatient appointment has decreased by 35% since March 2021, while the number of patients waiting longer than six months for an inpatient or day-case procedure has decreased by 35% since September 2020. In terms of gastroenterology, GI, scopes, we have seen a 75% reduction since September 2020 in those waiting for these appointments longer than six months. While we are seeing marked progress in many individual hospitals in increasing activity, and thereby in reducing waiting lists, our challenge is now to replicate these success stories across the health system. That is a key goal for the Department and our colleagues in the HSE for 2023.

The Department and HSE continue to work in developing the new RHA structures for integrated care. I have updated the committee previously on the detailed approach taken to date. As the committee will know, an implementation plan is being prepared to set out the organisation and governance of RHAs and the relative roles of the regions, HSE national and the Department of Health. This plan will set out a critical path for implementation through 2023 and 2024.

The committee may have noted the Health in Ireland – Key Trends 2022 report which was published by the Department last week. The report sets out some of the progress we have made over the last decade in terms of life expectancy and overall health and well-being. While we now have the highest life expectancy at birth in Europe, which has been a very significant development over time, these welcome developments also show the scale of the challenge we now face as a health service in terms of increasing and growing demand. Over the last ten years, for example, the number of over-65s in our population has increased by 35% and these increases will continue as we progress and demographic changes impact our society. The number of people in this category is expected to double in the next 20 years, with a particular increase in the over-85 category. As our population grows and gets older, which of course is a positive element, it provides enormous challenges for our health service and how its structures are organised and deliver care to our citizens.

In conclusion, while 2022 has seen increased capacity and improved affordability, we must continue our efforts and accelerate the pace of reform in future years. Next year will see the highest ever level of expenditure on health in Ireland. We must continue to demonstrate progress toward our goal of transforming our health service in order to meet the ever-increasing demands of our population.

Our challenge continues to be to implement foundational system change through innovation and the delivery of integrated services by investing in people, new care pathways, new technologies and new ways of working that will enable us to better respond to the growing health needs of our population. This ultimately is the motivation behind the Sláintecare programme.

Mr. Stephen Mulvany

I thank the joint committee for the invitation to meet for an update on Sláintecare. The HSE is continuing to actively progress with the implementation of regional health areas in line with Sláintecare and the HSE Corporate Plan 2021-2024. The RHAs will enable the alignment and integration of hospital and community healthcare services at a regional level based on defined populations and their local needs. The implementation of RHAs is a fundamental reform of our health and social care system and will have far-reaching implications across the health service. Phase 1 of RHA design and implementation planning is ongoing, with each of the working groups focused on the system-level design, that is, the key functions and activities that will be delivered at RHA, HSE centre and at Department of Health levels. This work is feeding into the detailed draft implementation plan which will be prepared by the end of the year. Work has also started on the development of a population-based approach to service planning and resource allocation, the outputs of which will inform the allocation of funding to the RHAs that are being established from 1 January 2024.

The committee that produced the Sláintecare report defined integrated care as:

Healthcare delivered at the lowest appropriate level of complexity through a health service that is well organised and managed to enable comprehensive care pathways that patients can easily access and service providers can easily deliver. This is a service in which communication and information support positive decision-making, governance and accountability; where patients’ needs come first in driving safety, quality and the coordination of care.

The committee also recommended that the HSE strategic national centre "be supported by regional care delivery through regional bodies, recognising the value of geographical alignment for population-based resource allocation and governance to enable integrated care." The role of the integrated care regional organisations, now referred to as RHAs, "will be to ensure timely access to integrated health care services in line with the reform programme." This role, according to the committee, will include the following functions: resource allocation for integrated care, as appropriate; staff recruitment for integrated care, as appropriate; governance and co-ordination of established integrated care goals; and accountability through regular reporting to the HSE national centre.

In recent weeks, I have asked the HSE’s executive management team, EMT, specifically the national directors leading on Sláintecare and RHA implementation, to ensure that as we continue with the work I have outlined, our efforts have an overriding focus on, first, identifying the barriers to high-quality integrated care and the evidence-informed known ways to overcome such barriers; second, on how best to move to, and embed, a culture of appropriately self-managed local front-line teams; and, finally, on ensuring that all structures, roles and processes being designed at any level above the local front line, including RHA and HSE centre levels, are validated against how well they are aligned with the achievement of the first and second points just mentioned.

In summary, in keeping with the original intent of Sláintecare and in line with the requirements of the HSE board, which was established as part of the implementation of Sláintecare, the HSE is very clear that the primary purpose for implementation of RHAs is to create the conditions for improved integrated care.

By intent, and by design, it is the HSE's expectation that RHAs will provide input to and have influence over what agreed set of nationally consistent integrated services, outputs, outcomes, and objectives are to be delivered for the patients, service users and families of Ireland. RHAs will have a very large degree of autonomy over how the various resources and providers in their area are organised and networked to deliver on the nationally agreed integrated services, outputs, outcomes and objectives. RHAs will also provide input to, and have influence over, the agreed framework of standards, guidelines, policies, etc., that are required so that the population can have equitable access to quality integrated services regardless of location and other factors.

Full transparency and sharing of all available data within and between RHAs, and with the HSE centre, and strict compliance with data governance and data standardisation requirements will be central to ensuring the framework of standards, guidelines and policies can provide the maximum desired appropriate degree of independence and autonomy to the RHAs, and to their front-line teams, as possible, in keeping with the important principle of subsidiarity.

RHAs will have budget autonomy, within the framework of standards, to manage and allocate, within their region, the funding assigned to them in pursuit of the objectives, outcomes and outputs they have committed to. RHAs will have a large degree of staffing autonomy, within the framework of standards, such that the numbers and types of staff they can recruit will be a matter for each RHA, provided it operates within its overall budget and deliver the outputs, outcomes and objectives for which it has been funded. RHA chiefs will have direct access to meetings of the HSE EMT and to the HSE chief executive officer.

The EMT and I have agreed that there is significant merit in beginning immediately to make a start towards modelling the types of behaviours and arrangements that are expected to be in place when we have RHAs. Each national director has been tasked with reverting, before the end of 2022, with an initial list of the current types of approval requests and similar that community health care organisations, CHOs, and hospital groups are required to seek from the HSE centre. This is with a view to determining which of these can be dispensed with or reduced, subject to any appropriate guidance, starting from quarter 1 2023.

I have deliberately confined my opening statement to providing clarity in relation to the HSE’s expectation around the very important Sláintecare programme element of implementing RHAs. During the course of the meeting, my colleagues and I will be happy to answer questions on other Sláintecare related topics that may be of interest to committee members, including progress on enhancing community care programmes and general practice; eligibility; the Sláintecare consultants' contract, including the removal of private practice from public hospitals; the waiting list action plan; elective centres; and e-health, digital and IT systems.

Deputy Bernard J. Durkan

I welcome the witnesses and thank them for their opening statements. The most important task in the provision of health services is to restore public confidence in the ability of the service to respond to particular situations. During the Covid crisis the health service did exemplary work. The delivery of services was exceptional and the results bear out that assertion. However, there are still ongoing problems with recruitment methods and delays in making particular appointments. There are delays in filling positions at all levels. A system is needed whereby GP replacements take place smoothly and without impact on the local community. An increasing number of GPs are reaching retirement and there is a difficulty in achieving a seamless transfer to a new GP in many areas, including my local area. Notwithstanding all we have heard, what is being done to ensure appointments take place quickly and sufficient forward planning occurs to ensure no delays occur?

We still have the problem of hospital waiting lists being at an unacceptable level even though we know the issue exists and needs an urgent response. How much of an effect has the Sláintecare plan had on the sensitive areas where long waiting lists occur? The statements are excellent but delivery of the service on the ground is the important thing.

The capital programme works seems to work intermittently. Something is approved by everybody and about to commence and then it fades into insignificance. I know there were situations arising from Covid and so on but we cannot allow Covid to be used as an excuse forever. Has the capital programme been streamlined to be able to respond as we should? Delays in that regard are causing anxiety in people.

My final point is on the chain of command, in other words, how the system works from the regions to the central system.

How is the response? What degree of consultation - in both directions - is taking place? Are the changes brought about by the introduction of Sláintecare having an effect?

Chairman

As we have two groups of witnesses, will Mr. Mulvany and M.r Watt guide the committee on who will answer questions? Members can also indicate if the want a particular group to answer.

Deputy Bernard J. Durkan

I do not mind. People from either group may respond.

Mr. Robert Watt

I will kick off, and my colleagues from the HSE will come in, no doubt, on specific aspects. I will try to give a comment on each of the points made by Deputy Durkan.

There has been a significant recruitment over the past two years. We have had a record increase in numbers. This year, we are below the target we had forecast. That relates to the availability of people with the skills, capacity and experience to fill vacancies. It also relates to our processes. Ms Hoey may speak about this. We are trying to improve the processes. As ever, there is a balance to be struck between having an open and transparent process to ensure that we have properly qualified candidates and the best candidates competing for posts and meeting the need for efficiency and speed when it comes to recruiting people. I accept what the Deputy is saying. The Minister expresses frustration to us on a regular basis about posts that have been earmarked to be filled and that cannot be filled for whatever reason. Sometimes we cannot find a person or it takes too long to find a person and there are issues in our process. We are addressing the issues relating to process. We are increasing significantly the number of places available across the different specialties in order that, over time, we will have more graduates coming through and more qualified people who are in a position to fill posts.

On GP replacement, there is a specific issue in communities when GPs retire. There might be a gap. We have to ensure that the next generation comes in to take over practices. There has been a significant increase in the number of GPs who are in training. There is now a flow of newly trained GPs to start filling the gaps as their older colleagues retire. This is an ongoing issue. Again, HSE colleagues might touch on some of those matters.

Early in the year, we set out a plan in respect of waiting lists. Some €350 million was invested. Much of that money has been spent. Some moneys have not been spent because we could not access additional capacity in either the public system or in the private system through the National Treatment Purchase Fund, NTPF. We have delivered a lot. We were knocked off track by Covid for the first four or five months of the year but since then we have started to accelerate activity. We are making significant progress, especially in respect of those who have been on waiting lists for a long time. We focused on people who had been waiting for excessively long periods. I have set out the numbers in that regard. Approximately 80,000 or 81,000 people are waiting for procedures and slightly more than 600,000 - it may be starting to dip below that mark - are awaiting outpatient consultations. We are starting to see significant reductions in the number of people waiting for outpatient consultations. That has required significant focus by our HSE colleagues across the different centres and hospitals in the system. The big issue for next year is to continue to ramp up capacity and increase activity. If we see the end of Covid as a significant disrupter of the health system, we hope we will get a free run that will allow us to continue to ramp up scheduled care and have a big impact on outpatient consultations.

There are a series of reforms and measures to reform pathways and how we help people to access care and avoid the choke points. Dr. Henry is leading on reforming those clinical pathways and he may touch on some of that work, which is interesting in the potential impact it could have next year in ramping up in the context of overall volumes.

We will spend all our budget for capital projects this year. We are spending the capital allocated to us. There are issues around planning and getting projects to the stage when they can be approved by the Government. Three major projects that were stuck in the system have been approved this year, namely, the move from Holles Street to Elm Park and the elective hospitals for Galway and Cork. The two latter projects are with the Government since this morning, and the Minister will make an announcement about them later. We got those three projects through the various approval hoops and assessment processes that are part of the public spending code and are moving to the next stage. There are issues in how quickly we can plan and get projects approved and then there is the planning process and issues around construction which we are all aware of. The system is striving to be more effective.

I will stop there and ask my colleagues to respond, as appropriate.

Chairman

I gave some leeway at the beginning when we were warming up. I ask members to be aware that when they ask a number of questions they are eating into other members' time.

Mr. Stephen Mulvany

I will add to what the Secretary General has said. We can provide additional detail on recruitment. In any year we recruit a net addition, this year it will be close to 5,000, we also have to recruit for the turnover. The actual number we will recruit this year will be in the region of 15,000 because the level of turnover is much higher than planned and much higher than last year. That has a big impact.

As the Secretary General stated, there is increase in investment in the number of training places for general practice. Slightly more than a decade ago there were approximately 120 intake places each year. It is now 260. The plan is to get it to 360 by 2026. That means today there are more than 900 general practice trainees in the system across the four years, and that needs to be increased.

As the Secretary General stated, in the first five days of this year, we had more confirmed Covid cases than in all of 2020. In March, we had more people in hospital with Covid than in the previous 14 months. Our waiting list targets were impacted by that. By the end of the year, we expect that, compared with the target, 82% of those waiting for outpatient consultations will be waiting for less than 18 months. Some 83% of inpatient day-cases will be waiting less than 12 months and the figure will be 97% rather than 98% for scopes. In most cases, we are now close to the position that obtained prior to Covid. All the waiting lists peaked in 2021. Two of them are down approximately 40% since the peak and the scopes waiting list is down 97% since the peak. We are not where we want to be but substantial progress has been made. We will tighten the targets for next year again and move from 18 months to 12 months and from 12 months down to a position where nobody will be obliged to wait longer than 12, nine and nine months, respectively. We know these are only interim targets along the way in the context of Sláintecare. This is not where we want to be, but we need to make progress over time. I will stop there.

Deputy Bernard J. Durkan

On the capital side, will somebody send me a note on the progress of the upgrade and extension work in the oncology, endoscopy and mental health departments at Naas General Hospital?

Mr. Robert Watt

We will.

Deputy David Cullinane

I will come in now because I do not want to be robbed of time. I welcome Mr. Watt, Mr. Mulvany and their teams. I agree with the points Mr. Watt made about community services, including community specialist teams, community intervention teams, chronic disease management programmes and so on. Those services are an important element of Sláintecare. I do not require a response. I simply make the point that we need to get those teams fully staffed and up and running. That is an important part of taking pressure off the hospitals. We also need to put a real focus - we had a discussion about this yesterday with the Minister - on step-down, recovery and convalescence beds as part of taking pressure off acute hospitals. It is as important as putting beds into hospitals. It frees up capacity, as we know. That point was well noted in Mr. Watt's opening statement.

I will quickly raise the issue of strep A, because it is a concern. I say it as simply as that. Perhaps Dr. Henry could quickly outline what precautions are being taken by the HSE because it is an important issue in the context of public commentary at the moment. It is important that information is given.

Dr. Colm Henry

Deputy Róisín Shortall

I welcome the witnesses and thank them for their presentations.

I have one final brief question on the business case and the proposal to opt for number two in the list of three options. Does Mr. Watt accept now that it constrains the health service in terms of restructuring? Does he accept that there is a need to revisit that Cabinet decision?

Mr. Robert Watt

I do not think it constrains us. The Cabinet gave a general direction based on the option and within that general direction we are working through the details, as instructed by the Cabinet, and we will come back. If we reach a view and the Minister reaches a view that he wants to tweak that option and approach it a different way, that is obviously his prerogative and he will bring that to Government when he makes these decisions.

Deputy Colm Burke

I thank the witnesses for their presentations. Can I go back to infrastructure development and the timescale it takes to roll out infrastructure in the HSE? I know the last time Mr. Watt appeared before the committee he said the elective hospitals would be signed off by mid-October we are now into mid-December. My understanding is that there is a memo going to Cabinet today but I am not sure whether it will be signed off. As regards the whole roll-out of infrastructure projects in the HSE, the South-Southwest Hospital Group made its presentation in January and we are now in December and have not even gotten past the first step yet. Will the Department of Health review the procedures on rolling out projects? The population of the country has increased by 1.2 million in the past 20 years and we need to fast track projects now. We cannot go through five and ten year waiting times, in particular with the increasing population in the Cork and Kerry areas. Has the Department looked at reviewing the whole road a project has to travel and how it can be fast tracked to reach the end objective?

Mr. Robert Watt

With regard to the Cork and Galway elective hospitals that were discussed at the committee previously there is a memo to the Government this morning and we are very hopeful it will be approved by the Government and no doubt they will make an announcement on that later on.

In terms of the process, there is establishing the need for a hospital and then there is going through the various aspects of public financial procedures. That takes time and it is instructive in relation to the memo that has gone to Government this morning as to the time it has taken us to get from the conception that we need to build these hospitals to getting the Government to approve, and then to go to the next stage which is design-----

Deputy Colm Burke

Yes.

Deputy Colm Burke

I will move on to the challenges in our hospital system. Traditionally, when nurses graduate they want to go away for a year or two and get experience abroad. That did not happen over the past three or four years due to Covid-19 but a substantial number may leave over the next 12 months. What planning is being done to deal with this sudden change? Does the ratio of nurses to care assistants and junior doctors need to be looked at? This will be a challenge. I know of a number of facilities where clinics cannot be held because nurses are not available. The consultants want to hold the clinics but in-house issues in the hospital mean there is no nurse available and they cannot be held. Are detailed discussions taking place on how to best utilise staff in hospital settings, in particular given that nurses have so many skills and can do much of the work junior doctors are doing? At the same time, there is a question about the role of care assistants.

Will the role of theatre assistants be developed? I have raised previously the fact that a number of private units have theatre assistants. Where we are going in that regard?

Dr. Colm Henry

The Deputy is absolutely right that we need to expand the number of specialist roles for nursing, and we are doing that. In particular, the Minister for Health has declared an ambition to have advanced nurse practitioners, ANPs, make up 3% of the entire nursing workforce. Part of our overall strategy in nursing is to broaden the role of nurses and make sure they are working at the top of their licence. To this end, we have added 150 advanced nurse practitioners to give a total of, I believe, 850 is at this stage. They will complete loops of care within hospital specialist services, cancer services, palliative care services and also in the community. They will be a core part of the enhanced community care scheme where we have nurses working at the top of their licence and treating older people and-----

Deputy Colm Burke

I am aware of that. The challenge, however, is that we may not have the same number of nurses working in the system this time next year because travel is attractive to them. How will the role of care assistants be expanded and how will the ratio be changed? Is that being addressed? It has to be accepted there will be a challenge.

Ms Anne Marie Hoey

In addition to the comments Dr. Henry has made, similar to the GPs, the number of nurses in training has increased in recent years and again this year. In the last couple of years, there has been an increase of over 360 additional trainees coming into the nursing undergraduate programmes. We have also recruited significantly from the international market this year so by the end of this year we anticipate we will have recruited approximately 1,900 additional international nurses. The Deputy is right that we need to use the potential for skill mix to its maximum effect. As Dr. Henry has said, we have also increased the pathways for training for the more specialist nursing posts in our own system as well.

On the point about emigration, it is not unsurprising that will happen this year because there were a couple of years where people could not travel. What we need to do is to put all our efforts into keeping in touch with the people who do emigrate so that we can try to attract them back in a year or two.

Deputy Colm Burke

What about the development of the theatre assistant role, as is happening in the private sector?

Ms Anne Marie Hoey

As I said, that is part of the skill mix where we need to make sure we explore and maximise every opportunity we have in that space.

Deputy Colm Burke

There is a challenge as regards operations because we cannot-----

Chairman

The Deputy asked a number of questions. I ask him to wait until they are answered before asking further questions.

Deputy Colm Burke

Okay.

Chairman

Does Ms Hoey wish to continue?

Ms Anne Marie Hoey

I think I have covered the issue. The Deputy made a valid point that we need to explore and maximise our efforts in that area.

Senator Annie Hoey

I tuned in to the meeting from my office. I will go over a couple of issues. I did a cursory search through the most recent news reports on ambulances, various delays and so on. At Our Lady of Lourdes Hospital in Drogheda, we had 11 ambulances parked outside the emergency department with people waiting for five hours to be admitted. We have variations of that elsewhere. I pulled up reports this morning about hospitals in Tullamore and Dublin. Where is the resolution to this in the Sláintecare process? It seems to me the ambulance situation is getting worse rather than better. We had 11 ambulances outside the hospital in Drogheda and I need not even mention Navan hospital, which is being downgraded this week, with 999 calls to be transferred to Our Lady of Lourdes Hospital in Drogheda. This week, doctors in Our Lady of Lourdes Hospital wrote a letter stating they simply do not believe they will be able to cope with that. How will we get to where we need to be in this process? I am sure the answer will be to pump more money into it but the issue is across the board, with ambulances unable to access the services in the hospitals to which they are being directed.

Mr. Stephen Mulvany

The ambulance handover delays - ambulances at the back of emergency departments - are a symptom of the overall congestion in the emergency departments. It will not get much better overall until we make improvements in that situation and there is a lot of work to be done around that. Our target is around 30 minutes as an average. While 40 or 45 minutes might be more realistic, we are at about 55 minutes to 65 minutes on average at different times, which is not where we would like to be. We know that for every ambulance that is parked behind an emergency department for too long, somebody else potentially cannot get access to the ambulance. There are lots of actions my colleagues can talk about in terms of what the National Ambulance Service is trying to do to mitigate some of that but the overall solution is not necessarily within the ambulance service. We cannot be complacent about this but if we look abroad, our nearest neighbours experience average ambulance delays measured in hours. We are focused on what we are trying to do. I ask Mr. McCallion to comment on some of the other specifics.

Mr. Damien McCallion

As Mr. Mulvany said, the ambulance turnaround at the back of hospitals at emergency departments is a symptom of a wider challenge. We have to try to address that through a whole range of measures that we discussed at a previous meeting with the committee. Separately, we are seeing an increase in ambulance calls of 14% since 2019. There is an investment in the ambulance service and a plan around capacity so we can respond to that while addressing the core issue. In the short term, we have set up a group involving the ambulance service and the hospitals to examine the immediate issues. Some actions have already been taken. Emergency departments now have a screen showing what ambulances are en route, where they are and the nature of the patients coming in. To try to manage the situation better, this technology has been installed. This winter we have put liaison officers from the ambulance service in key EDs to improve the flow within hospitals. That is not to say there are not still challenges from day to day. There are a number of short-term measures. The group is also looking in the longer term at what we can do to address the congestion, as Mr. Mulvany said, and to invest in the ambulance service to deal with increasing demand.

On the demand side of the ambulance service, work is also being done to look at alternative pathways for patients who do not need to go to emergency departments but do need an ambulance. There is a pathfinder initiative which is being rolled out in a number of parts of the country. This is a multidisciplinary approach within the ambulance service that can be used. We have what is called a clinical hub in our emergency operations centre, which allows certain calls, perhaps from people who are in distress with mental health issues or other such issues that can be dealt with over the phone, to be bought to another pathway. We have also rolled out community paramedics who are licensed to work with GPs and other providers to have patients discharged or referred to other services.

There is a range of initiatives to try to deal with the increased demand on the ambulance service. There is an increased capacity to support, recognising that demand is growing, but the third piece, which is to work to improve the flow through emergency departments to minimise wait times, is fundamental as Mr. Mulvany said. In the short term we are trying to manage that as best we can with some of the measures I mentioned.

Senator Annie Hoey

I was scrolling through the remnants of Twitter earlier on my way here and I noted how many parents were talking about their concern about strep A and many different matters. People were talking about being in accident and emergency departments for ten hours and the algorithm promptly brought up underneath it, a message from the Chief Medical Officer, CMO, telling parents that if they are concerned about a child, they should bring them to seek medical attention. Are the witnesses concerned about the system? We have all of these things happening at once. Is there concern about the potential for parents' concern about strep? They must get medical attention if they are worried their child has a dangerous illness. Are the witnesses worried about that having an impact on the system this year and potentially knocking plans or has a potential surge coming into our emergency services been factored into the winter plan?

Dr. Colm Henry

I will take that question. Yes, this is the first winter for some years where we have multiple organisms instead of the one organism that was Covid-19. Respiratory syncytial virus, RSV, has not yet quite peaked, influenza is still rising, Covid-19 is steady and we have the spectre of group A Streptococcus infection. The Senator's colleague asked a question at the beginning of this session about group A Streptococcus. We highlighted that for the most severe end of this - the invasive group A Streptococcus - we have 55 cases to date, of which 16 are in the paediatric population. We have seen nine deaths in the UK and one suspected death in Ireland. We have engaged with the general practice community and with the clinical community in paediatric units to advise them to be vigilant and alert for such symptoms. However, the most important audience is parents who are worried about their children. Information is available for them on the HSE website about what to do if a parent is worried a child is sick with sore throat, fever or rash. We encourage people to access it.

In the first instance we encourage parents who are worried to engage with their GP. This is a bug we usually see in late spring and early summer. We are seeing a surge here and in other countries, which is perhaps explained by an increase in congregation in the absence of immunity after a couple of years of a Covid-19 pandemic. Our health protection facility, which is part of public health, is meeting paediatric specialist services this afternoon to see if we can take any enhanced measures, such as provision of antibiotic coverage where there are outbreaks. That will be considered this afternoon. We are taking all the steps to advise parents. As I said, information is available on the HSE website and we encourage people to access general practice if they are worried about fever, rash, sore throat or children being ill beyond a simple virus or flu.

Senator Annie Hoey

Dr. Henry thinks the capacity for it is already built into the plan for the winter.

Dr. Colm Henry

Part of what emergency departments do is see people with infectious illness who are acutely ill. Through our winter plan, we encourage people to be aware that there are other ways people can access emergency care. For example, more than 1.1 million consultations take place in out-of-hours general practices. Local injury units will also be expanding this winter so there are many ways in which people can access out-of-hours care, that do not have to be funnelled through ambulances coming into hospitals.

Senator Annie Hoey

One of my favourite topics is student nurses. I am sure the witnesses have seen the figures published recently about the number of student nurses who are planning to emigrate. I have asked this before in this forum. There are plans in Sláintecare for numbers of nurses to be brought in and how many are needed to increase capacity in the system in various different areas. Are there any concerns, have plans be recalibrated or have any conversations taken place about the fact there seems to be more student nurses leaving? There has always been a high rate. We have always known that. It seems to me this rate is getting very high. I worked around the higher education sector for a long time. We have always seen large numbers of student nurses going away for a variety of reasons and we hope they come back. However, from my engagement with the sector, there seems to be a particularly strong willingness or want among a large cohort that is planning to leave. Are conversations happening about the impact that will have on the plans for recruitment and retention of nurses? Has that report resulted in any conversations about what we need to do to look at it?

Mr. Stephen Mulvany

As the Senator said, every year student nurses leave. Typically they work for a year after they graduate and then a large proportion of them leave. We have offered every graduating student nurse a place this year. Ms Hoey can speak about how that is going. More are leaving, partly because the could not leave in recent years. As Ms Hoey said, we try to keep in touch with them. That is where the effort will be made to ensure that when they come back towards Europe, they come back into the healthcare system.

Ms Anne Marie Hoey

I will add, as Mr. Mulvany said, we offer all our graduating nurses permanent contracts. We have done that for the past number of years. Up to the end of last year there was a high uptake rate of that. It was approximately 95% each year and we are continuing to offer those contracts this year. It is not unexpected, as I said, as people now have an ability to travel that they have not had in the past few years.

We must be clear with all our nursing staff, and all our staff, about what the HSE can offer in further development opportunities, further career opportunities and so on. We are conscious people will travel and that is fine. They get good experience but we must keep in touch with them to attract them back to work in our services. We are working on developing a talent attraction and retention unit. It will be live in 2023 and will enable us to ensure we keep in touch with all staff who leave us for a while. We will keep in touch about the opportunities that are available in the HSE.

I note that in the past two and a half years, we have increased our nursing workforce by more than 4,500 in total. That, coupled with our international recruitment and the increase in the training places are the efforts we are making to increase our nursing workforce.

Senator Martin Conway

I thank the witnesses for attending the committee. Mr. Watt will be glad to hear the Cabinet has approved the consultant contract, the progression of the two elective hospitals in Cork and Galway and the establishment of surgical hubs in Limerick and Waterford. My first question is how long will it take to open the surgical hub in Limerick?

Mr. Robert Watt

I was hoping we would have a moment of congratulations and reflection, before we start criticising how long it will take us to get from here to the next stage.

Senator Martin Conway

I did congratulate Mr. Watt. It is a great day to get all those projects approved by the Cabinet. Well done.

Mr. Robert Watt

I am only joking. Perhaps Mr. Tierney can give a sense of our thinking. There is a bit work to do on the surgical hubs. It will not take as long as the hospitals, which require a longer time.

Mr. Derek Tierney

Approving the progression of the elective hospitals in Cork and Galway is a longer-term and more strategic intervention. Looking at demographic pressures we will face in this decade, the plan for the surgical hubs is to style them on the Reeves Day Surgery Centre that opened in Tallaght which I think took under 16 months to get up, running and mobilised, but I am open to correction. Mr. McCallion might have more information about that. The plan is to style it on what worked in Tallaght and look at opportunities to see how we can mobilise five similar centres around the country in urban centres as a way to increase capacity to deal with waiting lists. Limited procedures and specialties will be dealt with in the first instance while we wait for the longer-term intervention. The HSE has established a project group to examine that question. What is the planning consent framework? How long does it take to design? How can we engage with the market to procure mobile or temporary theatres and infrastructure? Perhaps Mr. McCallion will want to add to that.

Mr. Damien McCallion

Briefly, the Reeves Day Surgery Centre in Tallaght has been successful. For most of the day cases, the waiting list has dropped from four years to three months with the exception of some more complex procedures. With the Senator's good news of the announcement, we will put a multidisciplinary group in place to look at how and where we locate these. There are factors to consider. There was a building outside the roundabout in Tallaght, just outside the hospital and it was possible to move that project along at a rapid pace.

I thank the Senator. I do not have the exact figures for fatalities, but the severity of illness is greatly reduced compared with previous subvariants. Omicron is less likely to cause severe illness, conversion to intensive care and mortality. Some of this is also down the enhanced protection of the population through vaccination. I can source the exact figures for the Senator. There is always a bit of a lag, but I can get them from the Health Protection Surveillance Centre.

On vaccination, we saw widespread uptake in the population, approaching 96% of the eligible adult population, for the primary vaccination course. For the first booster, something of the order of 78% of those who took the primary course took it up. For the second booster, it was fewer. We are looking at 60% or thereabouts in that regard. The third booster, for those aged 65 and over and those below the age of 65 who are immunosuppressed, it is too early to say, but suffice to say that uptake is more sluggish than in previous rounds. The advice we are getting from the Economic and Social Research Institute, ESRI, and others is that some of the elements that motivated people to get vaccinated before are not as strong as they were during the worst phases of the pandemic.

Senator Martin Conway

On the flu vaccine and the low uptake among those under ten years of age in particular and in children in general, is that a source of concern? If it is, how does the HSE propose to address it? Is it possible to do so? I hope that it is. What are the HSE's plans to deal with it in the immediate term?

Dr. Colm Henry

It is always a challenge. When the UK authorities introduced this in recognition that this age group is a large reservoir for flu infection, in the first few years they saw very sluggish uptake compared with the eligible group. In our experience, when we first introduced the childhood vaccination, uptake in the first year was of the order of 20%. It is difficult and challenging. Serious influenza is not common among children, so people's belief that accessing a vaccination prevents serious illness may not be so much there. Through our general practice colleagues and our communication campaign, we are encouraging parents to come forward for a vaccination not just to protect their children - thankfully it is a rare illness - but in recognition that this age group is a big reservoir of influenza for the larger population.

Senator Martin Conway

I am always astounded by the low level of take-up of the flu vaccine among healthcare workers. What are the latest figures on that? Are there campaigns within the healthcare community to try to get those figures up?

Dr. Colm Henry

There are two aspects to that. For influenza, the uptake campaign has not finished yet; we are seeing figures that are comparable with previous years. Over 60% of healthcare workers so far have taken it. There is variation, as we saw in previous years, between hospital communities and different institutions. For example, one hospital may have a very low level of influenza vaccine uptake while others may have almost double the level of uptake.

For Covid vaccination, the level among healthcare workers is much lower. That is a source of concern. This has been escalated through direct communication from the CEO and from myself and others throughout the hospital groups and CHOs. This week, there will be another round of phone calls and direct engagements with leads in hospital groups and CHOs to maximise uptake. We want to be in a stronger position should there be a surge of Covid or influenza after Christmas. We do not want to see a rush of people trying to access vaccination after the horse has bolted.

Senator Seán Kyne

I welcome Mr. Watt, Mr. Mulvany and the teams from the HSE and the Department. I have a few questions; perhaps Mr. Watt may start.

There has been some commentary regarding the public spending code as it relates to capital projects. Mr. Watt is uniquely qualified, given his previous role in the Department of Public Expenditure and Reform, to comment on this. If the Minister for Health, the Cabinet or the CEO of a health group came to Mr. Watt and said that they needed a project, whether it be for a new labs or something else that would cost more than €100 million, fast-tracked as soon as possible, what could be done in respect of such a matter within the parameters of the public spending code? If there was an absolute commitment that the project was vital for a hospital or health group, how long would it take to progress it?

Mr. Robert Watt

It is a good question. The way to look at this would be in two stages. There would be the first stage, up until when the Government approves the project, and then we would go out for design and procurement. There is the period from then until there are shovels in the ground. There are two stages. Mr. Tierney will have a view about how quickly it can be done. If it was a project costing over €100 million, where it was clearly established by the Department and the HSE and at a political level that it was absolutely needed and there was a case for it, then, if we fast-tracked all of the different things, namely, doing a business case and going through the various reviews of that, we might be able to get it down to six to nine months. We would then go the process of procurement and planning.

Mr. Tierney spoke earlier about the derogations that we used during Covid in relation to procurement and planning. It is very difficult to sustain an argument that those derogations should apply now that we are in normal times, even though the case could be made that the particular infrastructure is urgent and its absence is causing pain and delays in treatment and so on. Maybe it is something that we need, as a State, to look at. It is quite instructive and we have learned a lot, particularly on bringing the electives to where they are now, with ourselves and our colleagues in the HSE, in terms of how quickly we can do this. We need to make it faster and then we need to manage the next stages. Mr. Tierney has further information on codes but it is about trying to shorten the process when there is an urgent need. As you can imagine, from our perspective as officials speaking to this committee or speaking to the Minister, we get a very frosty reception when we say we need to develop something but it is going to take us three or four years to build it. That is not met with a happy response. I will ask Mr. Tierney to give some sense of whether the timelines are realistic or whether we can do better.

Mr. Derek Tierney

The current code is built on four gates, which means we have to go to the Government for four decision points, from outline concept through outline funding and then we try to bring more certainty to that over the lifetime of the project until we engage in market. That code is currently being revised and it is possible that two of those gates will be removed, or at least one will be discretionary, to try to fast-track the process. As the Secretary General said, it is not just about the public spending code. We have a public procurement framework and a statutory planning framework that have to exist in parallel and we work in a complex stakeholder environment as well and that has to be borne in mind. In terms of getting and building consensus for any investment we want to bring forward, there is a stakeholder management and consensus process, as well as a guiding of investment through the public spending code, statutory planning framework and public procurement. There is certainly a realisation and an appetite to simplify the code arrangements to get to Government quicker. That is where we sit at the moment.

Mr. Robert Watt

To add to what Mr. Tierney has said, we criticise the rules because we find them frustrating, they cause delays when we just want to get things done but they are there for a reason. It is very easy to criticise our colleagues in the Department of Public Expenditure and Reform - which I would not do, of course - but the rules are there for a reason, which is to try to avoid some of the mistakes we made in the past. They are a genuine attempt to have the necessary assurances in place. I was involved in drafting some of these rules and the intent was to provide reassurance. The question is whether we have got the balance right. That is where the debate is and it is very much a judgment call.

There are also issues around planning. Members of this committee and others would know more about that than I would but the planning system is a challenge for everyone. We have to work with stakeholders. The stakeholder piece, in particular, is very difficult. We have to manage the stakeholders who have rights that they can enforce but as a system, we need to continue to do better at delivering.

Senator Seán Kyne

I welcome the review and the fact that we are looking again at the length of time. Six to nine months would be good in terms of some of these projects but I accept that the planning system is a different matter.

On the consultant contract that is being discussed currently, what in-built measures are included for weekend rotas for consultants, for example? As I understand it, part of the issue in emergency departments in some hospitals is a lack of consultants. Some hospitals are better than others in terms of the availability of consultants and we obviously have to learn from the better ones.

Mr. Robert Watt

Ms Yvonne Goff

The aim of our longer term, multi-annual approach is to focus on the long waiters, to have a ramp-down profile to achieve the Sláintecare targets over the next four or five years. This year we had the targets set at 18 months for outpatients and 12 months for inpatients but we accept that these wait times are still unacceptably long. Going into 2023, we will further reduce that by bringing down the target for inpatient day case to nine months and for outpatients to 15 months.

The Senator has referred to patients who are waiting extraordinarily long periods for pain relief. Working with Mr. McCallion's team we have weekly calls with each of the specialties to try to understand the issues.

The issue is not the 600,000 people waiting specifically at specialty level. There are 668 specialty teams and we must work with each of them to understand their specific issues to put in place the longer term capacity they need to clear the backlog and also to be in balance.

Senator Seán Kyne

I thank Ms Goff.

Deputy Róisín Shortall

I warmly welcome the decision by the Cabinet this morning to approve the public-only consultant contract. It is a very important breakthrough. As we know, that proposal was a key element of Sláintecare. I hope it will now clear the way for the filling of the 900 vacant posts within hospitals and, most importantly, clear the way for the introduction of timely access to care for public patients who are so dependent on having fully staffed hospitals. It will also enable us to set the targets for maximum waiting times for procedures in hospitals, again as set out in Sláintecare. Assuming that the representative bodies are fully on board in regard to this, what now is the timescale for commencing the recruitment of those additional posts? Could the witnesses confirm how many additional consultant posts are funded in next year's budget?

Ms Anne Marie Hoey

We have only literally heard that the Minister has brought the proposal through the Government, which is very welcome. As the Secretary General said, I and other colleagues have been involved in this for quite a long time. It is a massive change in terms of consultant-delivered care in hospitals. The core hours in which consultant-delivered care will be available now increases to 80 hours. The focus very quickly changes to implementation. As I understand a date has yet to be set for implementation. The representative bodies are undertaking their own internal processes these days as well.

Deputy Róisín Shortall

A lot could be learned from the private sector in that regard. I refer to the Sports Surgery Clinic in Santry, for example, which motors through waiting lists very quickly. It would be great if we could do the same.

On the Dublin hospital, the Sláintecare committee modelled this on what had been done in Edinburgh, where NHS Scotland purchased a private hospital. Has that been considered at all, in terms of speed and potentially cost?

Mr. Derek Tierney

We have not ruled any opportunities out in terms of how we proceed or progress. One of the first tasks ahead of us now is to agree a procurement strategy and how, ultimately, we design, build and commission services. Nothing is off the table at this stage.

Deputy Róisín Shortall

Chairman

Going back to the difficulties related to Covid-19, Mr. Watt spoke about the difficulties and that there are bigger numbers than in 2020. It is worrying that people are not taking up the third booster. Am I right to say that it is an adapted vaccine? Can the witnesses go into more detail on that? The attitude seems to be that people feel they have had all the different boosters, are boosted up at this stage and do not need to go for the additional one, and so on. The take-up of the booster, particularly for those who are immune compromised or older, is low. Are there any indications why that is happening? Is it just people being vaccine-wary? There was mention of the flu vaccine. Is it recommended that people get the two vaccines together? I have heard of people having this. Is there much of an impact on the individual's system when they get the two together? Are they feeling more groggy and so on? I ask because I presume there are people out there at the moment who are humming and hawing about whether they are going to get this third vaccine or not. Can the witnesses maybe speak on the importance of that?

Dr. Colm Henry

First, we have a very strong uptake, if not the highest then almost the highest in Europe, of primary vaccination. That is the initial two course regime. We had a very good uptake of booster one. Upwards of 78% of those who got the primary course got the first booster. Again, this is among the highest levels in Europe. That gives us good protection against serious illness but it does not give us good protection against infection. We know immunity begins to wane against infection after a few months and particularly among those who are older or whose immune system is not up to scratch for whatever reason. They just cannot muster the same antibody response both to a vaccine or to natural infection. We want people to continue to get vaccines, particularly those in these vulnerable groups. The direction of travel here and abroad is to focus on vulnerable groups such as people as they get older, those with immune suppression and those with chronic disease. The question then is what the impact will be if we do not see a good uptake in vaccines. While there is still some protection against serious illness, which is good, we will see waning immunity against infection which is not so good. As we know from previous surges of infection, if enough people get infected, eventually that converts into a bigger proportion of those, even with a subvariant that is not as bad such as Omicron, coming into hospitals, some people getting intensive care and some people unfortunately passing away.

In answer to the Chair's question, yes, we have a combined flu and Covid-19 vaccine for booster three which has been there since October. As he points out, that includes this new bivalent vaccine which addresses earlier variants of the Omicron variant, which is good, and gives marginal additional protection. The uptake has been sluggish, particularly among people with immunosuppression. At our discussions in the Covid advisory group, which is the successor of the National Public Health Emergency Team, NPHET, we are advised by representatives of the Economic and Social Research Institute, ESRI, in the group that perhaps the greatest single driver for uptake in the past has been fear, not so much vaccine weariness. Those factors which compelled and motivated people to get vaccinated before, whether it was fear from themselves or for other family members, is just not as strong as it was before. As was pointed out earlier, we certainly do not want to be complacent in the HSE, particularly among healthcare workers, because we are aware of how vulnerable healthcare settings can become if there is a surge of influenza or of Covid-19.

Mr. Robert Watt

Before Mr. Mulvany comes in, I will respond. It will over time enable us to have senior decision-makers in longer times in our hospitals to provide that care for people. Over time, we hope it will make a difference in terms of the emergency department situation and the trolley situation that becomes chronic at times and that causes great distress. In terms of waiting lists, we believe it will increase utilisation of our facilities and our theatres, and that will increase the overall activity of the health system at a time that suits. We hope the contract will be attractive, and that is the intention. Once we hear back from the unions and they have gone through their processes, and we have to respect their processes, we will be in a position to start advertising. Ms Anne Marie Hoey and Ms Pat O'Boyle at the HSE, as well as our colleagues, will be pushing ahead when the bodies have done their processes. We will sell this contract, make it as attractive as possible and try to get as many people as we can. That is what we are about. Perhaps Mr. Mulvany could touch on the final comment if that is not an adequate response.

Deputy David Cullinane

No, I think that is an adequate response. That is okay. I want to make one final point on the elective-only hospitals. Obviously, everything that has been said so far on those are sentiments I would agree with. We have had this tension for a long time between scheduled and unscheduled care. The first casualty of higher demand on unscheduled care is elective procedures. They get cancelled and that drives up waiting lists. Obviously, the elective-only hospitals are important therefore. We should look beyond them as well, though. I would certainly be looking at that in terms of future planning for health services. The example of Tallaght was given, which was a very good example because it was like a satellite mini-elective service. It was off site and it worked very well. There is a demand, as Mr. Watt will know, in Limerick, for example, for elective. An argument could be made for Waterford and for other areas. I would hope we would put the elective-only hospitals in place. There are three. We should then look at mini satellite centres that are modelled on the Tallaght example, which has worked well, and see if there is a role for them elsewhere. I think there is and that in turn would help. Is that is something that is being considered or that will be considered?

Mr. Robert Watt

That is something that has been considered. I think the Minister will be talking about this issue today as part of the announcement he will be making. The Deputy and I are therefore in agreement about that. There is a role there for these satellite surgical hubs, as we call them.

Acting Chairman (Deputy Róisín Shortall)

I thank the Department and the HSE for the attendance here this morning.

I also thank the delegates for their attendance throughout the year to discuss a number of different issues, particularly the progress on implementing Sláintecare. We look forward to further engagement on its implementation and continuing the good news on the reform programme. I wish everyone a very happy Christmas and a very healthy and happy new year.

The joint committee adjourned at 12.30 p.m. until 9.30 a.m. on Wednesday, 14 December 2022.