Joint Committee on Health debate - Tuesday, 17 Jan 2023

Challenges Facing Emergency Departments in Public Hospitals: HSE

Chairman

The purpose of the meeting is for the joint committee to discuss the challenges that have faced emergency departments in public hospitals in recent weeks. To enable the committee to consider this matter I am pleased to welcome in the committee room from the HSE, Mr. Stephen Mulvany, chief executive officer, Mr. Damien McCallion, chief operations officer, and Dr. Colm Henry, chief clinical officer. We are also joined remotely by the following HSE national directors: Mr. Joe Ryan, Ms Mary Day and Ms Yvonne O'Neill.

All those present in the committee room are asked to exercise personal responsibility to protect themselves and others from the risk of contracting Covid 19.

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.

Members are also reminded of the long-standing parliamentary practice to the effect that they should not comment on, criticise or make charges against a person outside the Houses or an official either by name or in such a way as to make him or her identifiable. I 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 thank the HSE for making its representatives available at relatively short notice to assist the committee regarding the current pressures on emergency departments in public hospitals and for the briefing material it has provided in this regard. To commence our discussion I invite Mr. Stephen Mulvany to make his opening remarks on behalf of the HSE.

Mr. Stephen Mulvany

Good morning Chair and members. I thank the committee for the invitation to meet it to discuss the current challenges facing public hospitals. This winter continues to be a particularly challenging period for our entire health system, both in our acute hospitals and across our primary and social care services. This is a situation that is being experienced by almost all health systems in western Europe. Attendances and admissions at emergency departments, EDs, throughout the country were higher in 2022 than ever before.

Levels of infectious respiratory diseases are exceptional with sustained peaks when compared with the past five seasons.

Health and social care professionals across the entire health system have responded to this sustained pressure and have acted to mitigate the impact on patients and service users. It is important to recognise the enormous effort and professionalism of our staff in what are extremely difficult circumstances. On behalf of the HSE, I would like to thank all of our staff and our colleagues in the wider health system for their continued work and dedication.

In respect of the epidemiological situation, influenza is already at levels that make this an exceptional season when compared to previous years. Respiratory syncytial virus, RSV, continues to be challenging and, along with influenza, is placing significant pressure on general practice and hospitals. In addition, Covid-19 levels have been higher in recent weeks.

On the operational impact, there are significant pressures on the system generally, particularly on the parts of it most impacted by the very significant level of respiratory viruses. This includes general practice. This winter, GP out-of-hours services are seeing nearly 39,000 patients a week on average. Attendance at EDs for the full year 2022 was up by 14.8% over 2021. Across the winter months, attendance levels reached the highest ever recorded by the HSE, at over 31,000 attendances in week 44. Admissions from EDs were also up across all age cohorts in 2022, with an increase of 11.2% over 2021 levels and, importantly, the level of increase of admissions of patients over 75 years of age was 15% in 2022. Patients over 75 years of age present to ED more acutely unwell and stay, on average, twice as long in hospital as patients from younger age groups. The impact on our EDs has resulted in increasing numbers of patients waiting on trolleys for admission to a bed, to a daily high of 772 patients awaiting admission on trolleys on Tuesday, 3 January. National Ambulance Service, NAS, demand increased by 15% between January 2022 and November 2022. Over the past two weeks, there have been nine days on which the NAS has received more than 2,000 calls a day, which represents a new record high. While every effort is made to minimise the impact of winter season factors on our patients' experience, the combination of the baseline increase in activity across the year and the severity of respiratory viruses this winter has resulted in increased numbers of patients waiting on trolleys and in surge facilities for longer periods. The HSE regrets that this has been the case. Our staff do not believe this is acceptable and neither do we.

In terms of the HSE response, we have previously briefed this committee on the winter plan measures, which remain in place. The current epidemiological situation surpassed the most pessimistic modelling and in response to the increasing pressure on the system, I convened the national crisis management team, NCMT, on 22 December. The purpose of this team, working in co-ordination with the integrated operations winter oversight group, is to ensure that all measures are being taken alleviate pressure and manage patient risk as effectively as possible. There continue to be regular meetings of the NCMT and the winter oversight group to analyse current performance, aid decision-making and facilitate rapid implementation of actions. Escalation actions and arrangements include additional seven-day working across both acute and community services since 5 January. Such arrangements include additional staffing support for patient flow, additional rostering of senior decision-makers, increased access to acute and community diagnostics and therapies and increased availability of community staff to enable discharging and admission to community beds. Through agreement with the Irish Medical Organisation, IMO, participating general practitioners have extended their clinic hours by up to eight hours per week per GP. Enhanced funding has been provided to GP out-of-hours services to enable them to roster additional GPs. The National Ambulance Service has engaged private capacity and voluntary ambulance services to support hospital discharges. Community first responder schemes are responding to elderly patients and doing welfare checks on patients waiting for emergency ambulances. The NAS has also put in place hospital liaison personnel to expedite turnarounds and co-ordinate care handovers. Some 180 beds have been accessed from private hospital and liaison is ongoing with private hospitals to secure additional private capacity and to ensure that all available contracted private beds are utilised. Available nursing home capacity continues to be identified and aligned with hospital need. Ongoing regular engagements continue with key internal and external stakeholders, with the staff organisations and unions, the Private Hospitals Association, PHA, Nursing Homes Ireland, NHI, private and voluntary home care providers, HIQA and GPs. Members of the national management team, including me, continue to visit acute sites across the country.

The purpose of these visits is to listen and observe the experience on the ground, offer visible support to local staff and assist with problem solving those issues that can be resolved at national level. The effectiveness of the existing winter plan measures previously discussed with members of the committee and these escalation actions continue to be monitored and evaluated to inform lessons learned and the ongoing responses. Variation in emergency department performance can in many cases be explained by variations in demand, complexity of patients or capacity. As with every health service, however, significant systemic improvements are also required in processes, clinical pathways and whole-system integrated working, and this will directly benefit patient safety and care.

Thanks to the significant efforts of our teams on the ground, supported by the measures I have outlined, there has been a substantial improvement in the situation over the past couple of weeks, with a significant reduction in the numbers of patients on trolleys awaiting hospital beds. We continue to work to drive these numbers down further in a safe and sustained way. While we will have to put all of our energy into managing the current crisis for the coming weeks, we have agreed that we will keep track of what has worked well and consider the lessons learned from this period. This will be factored into future planning. That future planning will commence as soon as we are over the worst of the current crisis and will include planning for both next winter and the longer term.

Alongside a review of capacity being conducted by the Department, the HSE will bring forward in 2023 a three-year unscheduled care improvement plan that will contain a combination of process improvement, expedited infrastructural investment and learning from sites performing well. That concludes my opening statement.

Chairman

I thank Mr. Mulvany. I will now invite committee members and other Members of the Houses to discuss matters with the witnesses. We will begin with Senator Conway.

Senator Martin Conway

First, I acknowledge the heroic work done by the men and women on the front line in accident and emergency departments throughout the country. One thing that was missing from Mr. Mulvany's opening statement was any kind of an apology to the thousands of people who found themselves on trolleys over the past number of weeks. In his capacity as CEO of the HSE, perhaps he would like to apologise to those people.

Mr. Stephen Mulvany

I have apologised before publicly and am happy to do so again. I thought I had mentioned it in my statement. Just to be clear, however, we absolutely do apologise for the situation many patients experienced and are currently experiencing. We also apologies to the staff who have to care for those people in difficult circumstances. It is not something-----

Senator Martin Conway

Does Mr. Mulvany feel that there were systems failures in recent weeks in terms of the HSE's response to what was a well-flagged emergency situation that had hit other countries prior to arising here? Does he accept that the HSE's response was lacklustre, to say the least?

Mr. Stephen Mulvany

That is always a question one will ask oneself in any crisis, but I would not accept that the response was lacklustre. In fairness, a number of other jurisdictions are experiencing similar issues. We had put in place a winter plan, but what we are currently experiencing is in excess of the most pessimistic modelling we had in that plan. Just before Christmas when it became clear, particularly with the increase in the levels of influenza, that the system was going to experience even further unprecedented levels of demand, we commissioned our crisis management team and took additional steps. While that led to 772 people being on trolleys on the worst day, namely, Tuesday, 3 January, matters quickly settled down thanks to the efforts of the staff.

We will seek to learn lessons. No response is perfect, but we would not accept that, overall, the response was-----

Senator Martin Conway

Why did Mr. Mulvany wait until 22 December to activate the emergency response?

I do agree that it is about planning. I agree that we will need to review everything we have done to see what we could have done better and improve for the future. On Limerick, in terms of private hospitals that have beds that would be suitable, there is none or are very few. It is a matter of geography and patient preference as to why there are only five. The question is whether, for example, Limerick could use beds in Cork if they were available.

That is something the hospital is actively considering but some of it is just a question of geography. If you look at where the private hospitals are, you can see they tend to be in urban centres and tend be used by hospitals within close travelling distance for reasons of patient safety and in some cases, staff, because in some cases we have to share staff with those private hospitals. It is not as simple as it might appear.

Senator Martin Conway

Has the HSE put in place new protocols in terms of engagement with private hospital groups?

Mr. Stephen Mulvany

We have been engaging weekly with private hospitals on a national level at least since the middle of December. The local sites are also engaging. Separately, we know the Department is looking at a longer-term strategic arrangement. Again, this is not solely but substantially about the elective care side of it. The arrangements are functioning well at the moment and we are happy we have visibility of the beds and as individual public hospitals can engage extra private beds,we are authorising funding to do that.

Senator Martin Conway

This is an emergency. The situation is extremely serious, which is why we are meeting here today. Can Mr. Mulvany confirm that nobody has lost his or her life as a result of this trolley-emergency department emergency? Have we ended up losing people because of what has happened?

Mr. Stephen Mulvany

That is a risk. I cannot give the Senator certainty because I do not have it. What we have certainty about is that health systems across the world can lead to patients suffering avoidable harm and in some cases, death. We also know that delays in admission are associated with excess mortality. That is what I do know. I cannot give the Senator what he is looking for in terms of a guarantee.

Deputy David Cullinane

All the warning signs were there well before December and January hit. In fact, Mr. Mulvany and his colleagues appeared before this committee during a very lengthy discussion on the winter plan. At that hearing, we told them that the winter plan was insufficient. Mr. Mulvany and his officials told us that many of the objectives in the plan would not be met because the staff simply could not be recruited and it would be the middle of this year if not next year before many of the resources that were committed would be delivered. Not just this committee but patient advocacy groups, the Irish Nurses and Midwives Organisation, INMO, emergency department doctors, the IMO and people working on the front line all said during the summer trolley crisis that we were in for one hell of a winter and that is what came about. What did not come was the leadership and urgency from the HSE centre and HSE leadership must take some responsibility for what happened. Obviously rising infections and sickness in the community put pressure on any healthcare system so I will take that as given but this has been matched and exacerbated by the failure to put in place the capacity.

A few moments ago, Mr. Mulvany said that we are not talking about scheduled care but about unscheduled care. He made the point that the references to elective hospitals are not relevant, which is staggering because it is directly relevant. One of the reasons trolley numbers are down is because hospitals are using day beds and medical beds as inpatient beds. The result of this is wholesale cancellation of elective procedures, which we know happens when a surge occurs. That is why we need elective-only hospitals. We have talked and talked about them, members of this committee have raised the issue for many years and it could be years before we see them. There is a direct relationship between that clash of scheduled and unscheduled care and its impact on citizens. I am afraid to say there has been a failure of leadership.

In his opening statement, Mr. Mulvany made a point that beggars belief and has angered people. He said that the HSE will bring forward a three-year unscheduled care improvement plan that will combine process improvement, expedite infrastructural investment and learn from sites performing well, which would be great. However, this should have been put in place years ago. In 2018, we had the overall health capacity review, which outlined the beds, staff and capacity that were needed in hospitals. In 2018, we had a delayed discharge review that made recommendations, not all of which have been implemented. In 2019, we had the unplanned care review or emergency department review, which the HSE kept under wraps and of which it fought the release.

It was only because of the Irish Patients Association that the report ever saw the light of day. We have had HIQA reports, many of them in recent years, which have laid bare capacity deficits. Mr. Mulvany talked on three occasions in his opening statement about lessons learned. This is not about learning lessons. We have long passed the point of hearing this rhetoric from the HSE and its senior management. This is about delivery and failure to deliver on plans that we are putting in place. This is the reality.

Why was the plan Mr. Mulvany referred to in his opening statement, the unscheduled care improvement plan that he said would be put in place and which I would welcome being multi-annual, not put in place in 2017 or 2018 when we had all the same warnings and all those reports I have spoken about that pointed to all of these problems in accident and emergency departments? Here we are, four years later, only now talking about a plan.

Mr. Stephen Mulvany

We, and I, accept responsibility for our actions and inactions during the current crisis. This is a given. To be frank, I do not accept there has been a failure of leadership. Regarding everybody knowing this was going to happen, we did know we were facing a difficult winter. We had done a significant level of modelling, and I will ask the chief clinical officer to talk about the complexity of that modelling in a minute, and what has occurred has been beyond or at least at the most pessimistic level of the modelling. The modelling is based on looking at recent years, and the RSV virus has come earlier and much harder than in recent flu seasons, as has influenza. At the same time we have had Covid-19. The three together could be predicted but these levels were not predicted.

Turning to why we did not have a three-year plan in place three or four years ago, I cannot speak for the history of this situation. Going forward, our view is that it is the correct thing to do. I believe that will be acknowledged. Equally, and particularly since 2020, 2021 and 2022, there has been substantial investment in capacity. This has included up to €1.7 billion in additional funding for permanent strengthening of the health service. What has this delivered? Up to the end of last year, it has delivered an additional 970 beds, and 209 more are coming this year. In home support, even though we have not been able to address it, we have moved to a situation where rather than people waiting for hours in the context of funding, they are now waiting, unfortunately, for us to get enough staff. It is still a problem if people are waiting but certainly progress is being made.

In respect of enhanced community care, the €240 million invested there has led to 2,200 staff being recruited. We now have 21 of each of our 30 community specialist older persons teams and community specialist chronic disease teams in place, as well as nearly all the 90 community healthcare networks.

Deputy David Cullinane

Here is the reality, however. I have listened carefully to what Mr. Mulvany has had to say for the past couple of minutes. It is my view that there was a lack of leadership, political leadership and leadership within the HSE. It is not just my view. Phil Ní Sheaghdha from the Irish Nurses and Midwives Organisation, IMNO, said, "We know that there is an inability to act fast enough, despite all of the issues being raised in the middle of the summer of this year, both with the HSE and with the department by our union." She made the point that many of these problems were "entirely predictable", as they were. Matthew Sadlier of the Irish Medical Organisation, IMO, said "we have been shouting about this issue of under-resourcing and the under physical capacity of the number of beds in our service for as long as I have been involved in the organisation, which is 20 years". He also said there was "a very real likelihood that some patients will have died as a result of avoidable delays in the health system in recent weeks". Fergal Hickey, of the Irish Association for Emergency Medicine, said that "The problem needed to be addressed now, it was time to stop moving the deck chairs on the Titanic".

The emergency department task force, to be honest, has been pretty much wound down by the HSE. When that group first met, very senior officials from the HSE and the Department were attending those meetings in big numbers and it was meeting frequently. It met twice last year. The HSE is not engaging with the stakeholders in the way it should. The consequence of all this is what we have been looking at, watching and observing over recent weeks. We even saw RTÉ going into accident and emergency departments and the resulting pictures and video footage of trolleys stacked up and patients waiting. We know people were sleeping on the floors in accident and emergency departments. People have also been waiting longer for ambulances and, in some cases, waiting for days on end for care. Mr. Mulvany went on to say in his opening statement that there had been a substantial improvement in the situation in the past week. He was referring to the number of people on trolleys.

There were 506 people on trolleys yesterday. That is a huge figure. It is well above the figure for this time last year. The reason it is 506 is because of the work ethic of those on the front line who are doing overtime and as a result of the repurposing of beds that were to be used for elective procedures and other medical purposes, which is a trade-off. That is why it is down. The pressures are still the same.

I want to make request to the Chair. We talk about capacity issues, and they need to be dealt with. I am really concerned about the welfare of the people who work in the healthcare system. They have been through Covid-19 and the cyberattack. They are working around the clock and being asked to do major amounts of overtime. Last year, more than 5,000 assaults or near misses were reported. I obtained that information in response to a parliamentary question I tabled. Obviously, the position in this regard in intolerable. The "Lunchtime Live" programme on Newstalk carried a feature on bullying and harassment within the health service. All these issues are intolerable for those working on the front line and are a consequence of the overcrowding and other difficulties we have in our hospitals.

I am afraid I cannot agree with Mr. Mulvany that there was not a failure of leadership. The evidence would point to a failure of leadership. When a winter plan that is not going to work is put in place, that is a failure of leadership. When capacity reviews, HIQA reports and all the warnings that point to real failings are ignored, that is a failure of leadership. It is not just Mr. Mulvany's leadership; I am talking about the entire HSE leadership. It is my view that the leadership of the HSE failed patients and staff. I strongly believe that this committee needs to shine a spotlight on the welfare of those working in our healthcare system because what they have gone through - they are still experiencing it - is intolerable. We need to look at workforce planning and at how we protect the health and safety and well-being of those who work in our healthcare system because they, as well as patients, pay the price ultimately.

Mr. Stephen Mulvany

I will make a couple of points. We will have to agree to disagree in terms of the failure of leadership. Like the Deputy, we do not feel that the numbers on trolleys today or yesterday are acceptable. We accept that staff are under significant pressure. No form of bullying or any kind of assault of our staff by anyone is condoned by us. Those matters are taken very seriously. We are trying to do everything we can to support those staff, many of whom we have met on visits in recent weeks, in practical terms.

In fairness, the Deputy cannot argue when it comes to capacity. Do we need more capacity? Yes. In terms of acute hospital beds, which is only one form of capacity, I checked the position over the past 40 years. There have never been as many beds put in place in a three-year period during past 40 years as the 970 that were put in place in the three years up to the end of last year. Is that enough? No. Is it the only type of capacity we need? No. Are the €240 million investment in enhanced community care and the €210 million investment in GP services, including €18 million worth of developments, enough? No, they not, but all these things are going in the right direction.

Deputy David Cullinane

Mr. Mulvany should give the full context about beds. We are only putting back in beds that were taken out. The capacity review actually talked about the 5,000 beds that would be needed if the reforms in healthcare are not delivered, which they have not been. We are well behind all of those targets.

Mr. Stephen Mulvany

I would not argue that we have enough beds, but we are making progress in those areas. In fairness, we made more progress in the past three years than in a lot of periods previously.

Chairman

I will move on to Deputy Crowe.

Deputy Cathal Crowe

I welcome our guests. I pay tribute to the many front-line health staff who have toiled over the past number of weeks to keep the system in some way functional. What we have seen as a national crisis in the last two or three weeks has been a perpetual crisis in the mid-west, particularly in University Hospital Limerick, UHL.

We have a population in the mid-west that is just shy of 500,000. There was a time when that population base had access to five accident and emergency departments, namely, those at the regional hospital, which is now UHL, Ennis General Hospital, Nenagh General Hospital, St. John's Hospital and Barringtons Hospital. There were five accident and emergency departments.

I remind members to try to focus on the emergency departments as that is the focus of today's meeting. I understand that people may drift off to other issues but I ask them to focus on that.

On the move made by the UHL management team, the committee wrote to management at the time and we got a response. Members of the UHL management team are not here today and cannot respond in regard to this matter, but I am sure if they were here, they would say they are on the ground in the hospital and going around the wards. There was a response from the team in that area explaining why it had moved up the road and that the move was not impacting on staff, particularly in acute services. I call Deputy Shortall.

Deputy Róisín Shortall

Deputy David Cullinane

We have not heard an answer.

Chairman

The witnesses do not have to respond.

Deputy Neasa Hourigan

I want to refer to something somebody sent me. They say that, for the second time in a matter of weeks, they had to go to Temple Street because the next available GP appointment was the week after next. They say they are lucky to have health insurance but that the first visit on Christmas Day was a result of no minor injuries clinics being open. They note that minor injuries clinics do not treat abdominal pain today and that D Doc and Northdoc just keep ringing out. They say that we have unnecessary patients in accident and emergency departments because our primary care service is not working and needs investment. The staff in Temple Street told this person that the majority of patients presenting could be treated by their GP or a minor injuries clinic but that they have no other choice but to present at an accident and emergency department. This person says they have had two eye-opening experiences in a matter of weeks. On Christmas night, they genuinely feared a child might die because of the absolute carnage in the emergency department in Temple Street. As a parent who is there frequently due to having a child with a lung condition, they say that they had never seen anything like it.

I have used that service and, every Christmas, children get sick and GP hours are disrupted. Why then are we only seeing extra hours click into place on 1 January at best, if the data hold up? We will come back to that. Why are we only seeing this on 1 January when we know that Christmas week happens every year? Even in previous years, people had to ring D Doc quite a few times to get through. We know this happens. Why are we waiting?

Mr. Stephen Mulvany

I have a couple of things to say. This is a perennial problem. That is accepted, as other Deputies have said. The longer term solution is a combination of investment in capacity, process improvement and integrated care, which is effectively the roadmap set out in Sláintecare. We are very clear on that. It happens every year, although it does not happen as badly as this year every year. The respiratory syncytial virus, RSV, which impacts the younger population in particular was much worse this year. It arose earlier than it had for a number of years and was much more sustained. Why did we not kick in the GP piece? There is a difficult part to this. In fairness to GP colleagues, even before the additional hours were put in, they were stretched in terms of time.

To come back to the question of what can sustainably be put in place earlier, GPs responded effectively even though they were struggling for staff. Ultimately, the reason only half signed up for the additional hours is mostly because they do not have the staff or capacity to do so. At one level, it took an element of crisis for us to get that whole-of-system response, including the additional GP hours. It is not as if the GPs were doing nothing. Could it be turned on earlier? That will be part of the lessons learned. Could we be ready to switch it on? Perhaps, if we reach a certain trigger level. One of the big issues for us is determining what should trigger these types of responses.

Deputy Neasa Hourigan

To be clear, nobody is suggesting that GPs are not doing enough. What I am suggesting is that, particularly when it comes to our younger patients and children under the age of 18, the reports I am receiving of people sitting in the accident and emergency department in Temple Street or wherever it might be for up to 12 hours are simply unacceptable. If you have a child who is not drinking water, for example, 12 hours is incredibly dangerous. We experience this every year. One of the articles I came across was from 2019 and detailed a Member of these Houses sitting in an accident and emergency department for a similar length of time. It just does not stand up. Mr. Mulvany is asking whether the HSE could have acted earlier. I do not understand why it was 22 December but I would love to.

What was the data point that led the HSE to act on 22 December?

Mr. Stephen Mulvany

There are a couple of points and my colleague, Mr. McCallion, might want to comment. First, I have sat in Temple Street hospital with young children for far too many hours and we agree that is not acceptable. I cannot comment on the specific case as to whether any or all of the people sitting there could have been dealt with by a GP because I do not know. As for why I decided to send the crisis management team on 22 December, we were not seeing the prospective clear-out that is usually seen in hospitals around Christmas and RSV was still on the increase, if I recall correctly, at that stage. Moreover, influenza was developing at a higher level than had been seen at least in the previous five seasons, which certainly influenced my decision. In terms of some of the specifics the Deputy mentioned-----

Deputy Neasa Hourigan

To be clear, it related not to trolley numbers but, rather, to rates of influenza. It was not triggered by a particular number of trolleys.

Mr. Stephen Mulvany

The trolley numbers did not hit their peak on 22 December. We acted before they hit their peak because the prospective data were telling us we were not getting a clear-out. Everything pointed to the idea that there was going to be a very high trolley number in the days after Christmas. It was not that it was visible at that point; we were facing a slowdown or a reduction in trolley counts at that stage, but it was nowhere near what might be expected at that time of year. All of that added together suggested this was going to be even worse than our worst predictions, and that is why I called for the national crisis management team.

Mr. Damien McCallion

The epidemiological data and the hospital data were the key triggers. It related to the levels of RSV and flu, which public health tracks and which are the key indicators we monitor. Dr. Henry might wish to speak on this. They allow us to see the impact of the viruses on the hospital system. Sometimes there can be a delay as those peaks come through in terms of the figures and the activity in the community and into hospital. As Mr. Mulvany said, that is what triggered the NCMT.

A daily process goes on all the time, working with hospitals, the community healthcare organisations and the National Ambulance Service, to track that. It involves public health data alongside hospital activity.

Deputy Neasa Hourigan

Is there a guideline for that trigger or is it just a judgment call by a particular team?

Mr. Damien McCallion

It is a judgment call. Dr. Henry might want to comment on the modelling.

Dr. Colm Henry

We are guided by the public health data and the surveillance data from the Health Protection Surveillance Centre, HPSC. As the Deputy will be aware, earlier during Covid that body tracked the progress of RSV, influenza and Covid-19, and looked at the confluence of those three viruses and their trajectory, which pointed upwards throughout December.

Deputy Neasa Hourigan

My final question relates to the performance of CHO 3 in Limerick hospital over recent months and the ongoing fundamental issues in that area. Some members of my family live in Limerick. There is a general feeling in the region that people do not even try to attend the emergency department in Limerick hospital now. Is the HSE undertaking a review of that CHO in the context of what needs to be done and whether it is fit for purpose? I refer to a fundamental review of operations and services.

Mr. Stephen Mulvany

The CHO is the community healthcare organisation and the community part of the service-----

Deputy Neasa Hourigan

I apologise for interrupting, but I am asking about the CHO because we have just established that failures relating to the primary care system and to accessing other services often lead to people presenting at emergency departments. We can include the hospitals in this question. Is the HSE undertaking a fundamental review of services in the region?

Mr. Damien McCallion

In terms of delayed transfers of care, which are one of the key indicators for the community, Limerick hospital has one of the lowest numbers, which Deputy Shortall referred to earlier. In that sense, it is part of a hospital system that performs well.

We work with all the sites with a view to improvement in that regard but there is a system-wide issue, as the Deputy will appreciate. The emergency department is a manifestation of the issues both outside and inside the hospital. As an area, Limerick is currently one of the best performing in terms of delayed transfers of care and keeping the hospital moving, and part of that is linked to the network of model 2 hospitals in some community services.

Deputy Neasa Hourigan

In that case, the HSE is perfectly happy with the operation in that area at the moment.

Mr. Damien McCallion

No, I am saying that in respect of any areas or hospitals, as the CEO outlined earlier, high trolley numbers are not acceptable. We are working with all areas to-----

Deputy Neasa Hourigan

As to what the way out of it is and why the situation is the case, as we know and as Sláintecare tells us, the health service is the wrong size and shape. That does not help us in the next three or four weeks or the next year or two, but we are on a journey and it is called Sláintecare. Government is investing in the different components of that and will need to keep investing to ensure the system has sufficient capacity, but it must be sufficient capacity in the right places, and it must start in the community. That is why more of the investment has, correctly, gone into the community area and into general practice as well as into hospitals. It is also about better integrated care, which Sláintecare again talks about with the move to the six regions. Then there is the piece that is probably not quite as visible in Sláintecare, namely, improved systems thinking. We need to get better at the overall operations management of processes. That is difficult to do when there is not sufficient capacity or staff, but it is essential nonetheless. No one of those things will resolve it.

Dr. Colm Henry

Mr. Stephen Mulvany

Yes, there is. We went through the overall numbers earlier on. While the number of 3,200 beds is very high, if one discounts sites that do not do the type of work we are talking about and the 600 public beds, there are potentially approximately 1,450 beds.

Most of those are focused on surgical work, not medical work, so the fact we have 180 means we have 12% or 13% of the real capacity of inpatient beds. We are pursuing more. There are another 50-plus beds that we might be able to get. We would take as many as we could appropriately get but eventually the private hospital system runs out of staff or capacity because it has other work going through it, or appropriate types of staff. It does not have large numbers of, for example, critical care beds or physicians. In some cases, we end up trying to provide clinical support to get access to beds.

Deputy Gino Kenny

What were the 180 beds in the private hospitals evaluated for in relation to patients coming-----

Mr. Stephen Mulvany

It was largely for urgent and time-sensitive care, including cancer procedures in some cases. In other cases, it was for unscheduled care patients, some of whom would be medical patients and some orthopaedic patients. It depends on the public hospital, the patients and the capacity of the private hospital.

Dr. Colm Henry

Beds in private hospitals are not akin to beds in the public hospital system. The public hospital system can easily flex to deal with unscheduled care, as members have heard with regard to surge beds and the space for elective activity. The private hospital system deals with some unscheduled care activity but is largely configured to deal with procedures and episodic healthcare. There is some complex healthcare too, but the public healthcare system more easily flexes towards dealing with unscheduled care at scale than the private healthcare system.

Mr. Damien McCallion

On private beds, community beds are another important part of that. We purchase what are called transitional care beds for up to ten weeks. This is where someone will have to go to long-term care and, rather than stay in the acute hospital, we purchase that bed so the person can go through the fair deal and all the medical assessment and so on before moving to their new home in a nursing home. That is important. Over 600 of those beds are utilised through that period. That is a big number that facilitates that flow from hospital we spoke about.

Deputy Colm Burke

I thank the witnesses for attending and dealing with the queries raised. I thank all staff who worked over Christmas and work week in and week out. It is important to acknowledge staff are in hospitals every weekend, whether consultants, junior doctors or nursing staff. An impression is given that sometimes healthcare is only provided from Monday to Friday between 8 a.m. and 5 p.m. It is important to acknowledge all the staff who work into the early hours of the morning and who are sometimes still in theatre or dealing with patients at 3 a.m. and 4 a.m.

I will speak about the plan to deal with a sudden increase in numbers entering hospitals and the discharge procedure. Witnesses are aware of the survey done by Nursing Homes Ireland. Out of 430 nursing homes, 210 responded and 147 of those identified 740 vacant beds in nursing homes. I contacted a number of nursing homes over the last three weeks, not one of which had been contacted by the HSE in the previous eight weeks. The calls only appeared to start happening once Nursing Homes Ireland published the survey. I do not understand why a backlog of people had been signed out by the doctors and discharged with no mechanism in place to get them into nursing homes or step-down facilities. Why were the nursing homes not involved in planning that?

What about the criticism that has been given by Martin Curley? This has been going on, and I have been raising this issue, for ten years. I spoke to Danish ambassador recently about how, in Denmark, they are down to five different computer systems in their health service. Their medical records are all computerised. They reckon that they are saving €2 billion to €3 billion per annum because of that.

Mr. Stephen Mulvany

We are talking about two different things. Undoubtedly, overall process flow and patient care will be improved by the rolling out of a full electronic health record. That will be a major system of record in hospitals, and it will start with the children's hospital. Our preference would be to roll that out more quickly and get it approved and funded. That is an ongoing discussion we are having with the Department of Health.

Again, I inform members and those listening that we will be looking at the whole area of HSE digitalisation next week. It is on our agenda.

Senator Annie Hoey

I thank the witnesses for coming in and for their presentations today.

Hospital overcrowding and hospital problems are among the most prominent issues in my political awareness. When I was a teenager in the early 2000s, it was floating around, with Brendan Gleeson on "The Late Late Show" talking about hospitals and all these other things. The representatives outlined very clearly in their opening statement the confluence of causes but I still struggle to understand how we, and it still beggars belief in what is quite frankly a wealthy country, continue to have these conversations every year. While we can talk about hospital overcrowding being due to a confluence of RSV, the various viruses and things happening, it is about a failure to invest in bed capacity, infrastructure and staff.

We all know people who have ended up in accident and emergency departments because they have been referred there by their GPs, although perhaps not in the past few weeks because I do not think any sane GP is referring someone into accident and emergency unless it is a very dire situation. However, we all know people who are referred to, or get appointments to go to, accident and emergency because they will have to wait a year to get an MRI scan otherwise. They are sent to accident and emergency, they stay for a couple of days and they eventually get that scan. I have been that person who has been sent to accident and emergency. We have a farcical system where we have been known to push people - although, as I said, probably not in the past couple of weeks - through our accident and emergency departments to get them what should be a very basic service available in the community through primary care.

I have four questions that I am happy to put out there and allow the representatives to answer as they want. I read an article regarding an estimate from a data person that at least 50 people a week are dying because of our hospital overcrowding. A figure of 500 per week was quoted in respect of the NHS. These are very stark figures. What is the HSE's response to that figure? The data person concerned stated that the estimate of 50 people a week was conservative. What is the HSE response regarding that in respect of the families who will lose someone because of overcrowding? Do the witnesses hold that figure in regard or not?

We have had the national care plan. We have done a lot around this issue. Some €23 billion and so on has been invested in the system. We talk about bed capacity all the time, and that people who are in beds need to be moved on elsewhere, but they have as much a right to care as the people coming up behind them. Why do we not have these beds? I ask the representatives to explain this in very basic terms. Is it because we just do not have the hospitals for the beds? Are there wards where beds are not open? Why are we still here, year on year, stating that we do not have the beds? I am being very pedantic, but is it that we just do not have the hospitals? Why are we saying every year that we do not have the beds? Where are the hospitals? Where are these beds? Why do we not have these beds?

Dr. Fergal Hickey referenced that he believes there will be a public inquiry into this issue in future regarding who knew what, what they knew and why they did not do anything about it. Do the representatives believe it is a likelihood that at some point there will be a public inquiry into how we have ended up in this situation?

The INMO is talking to its members about whether they will go on strike. There are many conversations around workforce planning and how we will manage all of that. Is there any comment the representatives can offer around the potential disruption that will come down the line via the nurses, who are beyond frustrated, beyond burned out and are at the end of their tether?

Mr. Stephen Mulvany

I will make a couple of comments. Before the Senator asked her four questions, she mentioned people were going to accident and emergency departments just to access basic services, such as diagnostics. That can be an issue. She may be aware - it was mentioned in our opening statement - in respect of GP direct access to diagnostics, which is one of the investments under enhanced community care, that in 2022, 250,000 patients were able to access MRI scans, CT scans and X-rays through that scheme. That is ahead of the target of 240,000. That is one element of us trying to make sure that the reasons people might be inappropriately referred for care into EDs are dealt with and that alternatives are made available. There is more work to be done in those cases.

Senator Hoey mentioned the 50 patients per week dying because of hospital overcrowding. As we said earlier, we cannot speak with certainty about this. That number is based on a particular NHS study, a large one of more than 5 million patients, which indicated that for every 82 delays in admission beyond five to 12 hours there was one associated excess death. Whether it was causative or correlative I am not clear. We know there is in every health system a level of preventable and avoidable harm but we cannot be sure of that actual figure.

What can one say to anyone whose loved ones are caught up in this? What else could one say other than that it is just completely unacceptable? Our words, however, will be meaningless to anyone in that situation.

As for bed capacity, and this is not just about hospital beds or capacity, but as for acute hospital beds, yes, as one of my colleagues here said, beds have been lost over the past 40 years. As I have said, the past three years have seen more beds put into the system - about 970, with another 209 to go - than in any three-year period I could see over the past 40 years. Are there a whole load of hospital beds lying empty? No, at this stage there simply are not. There will always be some beds closed for reasons of infection, staffing or refurbishment but, no, there are not a whole load of beds sitting there waiting to be opened. It is about building them where they need to be built and, again, not just about hospital beds or capacity. There is also a process piece and an integrated care piece, which is where Sláintecare comes in.

A public inquiry is a matter for the Government, not us, to comment on, to be frank.

We completely respect the fact that the INMO is going through a consultation process with its members. It exists to serve its members, and that is what it is seeking to do. We share and acknowledge the efforts of our nursing colleagues and other colleagues. We know that some of them are doing really difficult jobs in difficult circumstances. The consultation process will bring whatever it brings. Obviously, we engage regularly and will continue to engage with the INMO on all sorts of matters affecting its members, who are our staff, and the patients in whom we jointly have an interest.

Workforce planning, as we said, is one of the key issues in plotting the course out of this. We need to retain more as well as train more. While we do retain a large percentage of nurses - we have offered every single nurse graduate this year a job - we know that in a year or so a number of them will leave and they will not all come back. Workforce planning therefore remains a big priority area and one we have not fully cracked yet.

Senator Annie Hoey

May I ask a follow-up question about the beds? Mr. Mulvany says there are not beds just floating around. A couple of years ago people were talking about empty wards and so on. Mr. Mulvany says beds have to be built in the various places they need to be built. That will not happen in the next 12 months, if I understand how long it takes to build these things. Are we therefore looking at another series of winters of this continuing to happen, or does Mr. Mulvany see a year or a point in the next two, three, four or five years where the HSE can say, "This is the target, we will be out of this and we will not have this winter problem we have every winter?" Sorry - I am not sure if I am entirely clear. Are we looking at having this next year, the year after and the year after, given the amount of time it sometimes takes to build these beds? I acknowledge that not all the beds needed are in a brand-new hospital setting.

Mr. Stephen Mulvany

If one accepts that only one trolley, only one person awaiting admission, is too many, there will be a number of years where, during the year, particularly at wintertime, we will have a level of additional pressure on the system. That pressure will be measured by the number on trolleys and surge beds or what the INMO figures will show. That is, unfortunately, a reality.

The process to build beds is a long one. Again, this is not just about beds; it is also a process of improvement and structural issues. Those will make a difference but, fundamentally, the size and shape of the system, as we have said, is wrong. Sláintecare has recognised that and Government investment is tracking that but, as Dr. Henry said, we are kind of playing catch-up. We are seeking to catch up with a population which is ahead of us in terms of its ageing. Even in that 2018 bed capacity review we and the Department did, the levels of population growth since that was done have exceeded the estimated levels. We are therefore playing catch-up in terms of capacity, process improvement and, obviously, our need to implement Sláintecare. The reality is that we have, unfortunately, a number of years of extra pressure in the system, measured in terms of trolley rates, ahead of us until we can get ahead of those things.

Senator Annie Hoey

Unless anyone else wants to speak, those are all the questions I have. I thank the Chair.

Deputy Bernard J. Durkan

I welcome our guests. I pay tribute to the health workers, who have been under the cosh, for want of a better expression, for a long time. There have been three years of emergency treatment, with Covid and various outbreaks in various places, new outbreaks, and so on. It is necessary to pay due compliments to those who have soldiered on the front line in desperate situations. I also pay tribute to those who did not really have a break at Christmas-time or who had no break. They just went back into the workplace and faced greater demands, with nothing at the end of the tunnel other than more of the same.

Someone mentioned earlier that the Government should do more to exert influence at this committee. It is exactly one year since I suggested at this committee, with many people present from the HSE and Department of Health, including the Secretary General, that the structure in place during Covid should be superimposed on the health services in order to deal with the situation that was likely to happen. I was told that we would not have that until November. It is all too late. We need to plan for the kind of thing we are talking about now for next year. We also need to plan for what will happen in the interim. If we do not do that, we will never get ahead of it. If we are waiting to catch up on the demand, we need to recognise that the country's population has increased dramatically. I know we have lost beds for various reasons, including after some in the health services advised us that the secret to the future was to have fewer beds and more day beds. Now we know, but it took all that time to find out exactly what we need.

We were told that home care was the answer. We ran into trouble with that too. We need to make provisions. We cannot operate on the basis of what will happen next year unless we evaluate what happened this year and add our contingencies to it for what is likely to happen in the event of another pandemic or such. We have to factor that in. I do not think we are doing that. I do not want to criticise management or anybody else, but I am sick to my back teeth from listening to the same story again and again. One of our colleagues here mentioned that Christmas only comes once a year. It is just as well because if it came more often, we would have a serious crisis on our hands. We, the members of the committee, need to have confidence in the system now and in the future, and in its ability to deal with situations, including unforeseen circumstances, since those will always arise. This is nothing new. Management has to deal with this as a matter of urgency.

I suggest that the Secretary General of the Department of Health and the management of the HSE come together and work out a plan that works on an incremental basis as the year progresses, dealing with the situation now and what may arise in the future. They need to identify which areas are likely to come under pressure first, last, or never, and try to make sure that whatever we do from now on, we have the confidence to stand over it and say to the people outside, the patients and the staff on the front line of the health services that help is on its way now, not in five or ten years. We cannot have a situation where we go from crisis to crisis each year when it is well-known in advance that certain things are likely to happen or to reoccur. We are not doing that at present. I am not blaming anybody in particular but asking what in God's name we are doing about it that is visible and making the required contribution.

I have heard various experts on the health system in recent years at this committee, or on the health board as I have often said. We are not picking up the challenge the way we should. It is not happening and the public knows it is not happening, as do the staff at the coalface. The staff want to emigrate and go elsewhere; they do not want this unknown quantity and crisis hanging over their heads the whole time. This crisis is always around the corner waiting to happen. What we need is a plan that works. It must have stages 1, 2, 3 and 4 and if stage 1 is not working we must examine why it is not working and the same for stages 2, 3 and 4. We need to do something about that urgently.

The time for waiting is gone and from here on in we need to make a conscious decision that certain things are expected of us and that we are in the position where we can do something about it. We do not have the cheapest health service in the world. As time goes on it will get more expensive unless we deal with it. We need efficiency, effectiveness and positive outcomes for the health service. That has to happen soon.

We need to identify where the deficiencies are and fix them. Whether they are beds, staff levels or home care, we need to identify the deficiencies and deal with them because talking about them does not do anything at all and they will be there next year. If there are shortcomings in it now they will be there next year and if there are shortcomings this month they will be there next month and the following month and we will be hoping for the summer and hot weather to relieve the pressure. That is not the way to plan a health service. This is not a criticism or a lecture; it is a simple recognition that if certain things are not done then the service that is provided will become irrelevant because the people will lose confidence in it. The people are the patients and the staff are the ingredient that needs to be looked after in terms of working conditions, pay and whatever the case may be, in line with everything else. The fact of the matter is that as long as we go on the way we are going, with crisis after crisis and only chasing after it, it will not work. Whoever is alive this time next year will be back here again doing the same thing if we continue like we are.

Mr. Stephen Mulvany

There is a lot in that. I acknowledge and agree with the Deputy's thanks to all the front-line staff who are doing great work. I would include in that, as I hope other colleagues would, all of the staff, including the managers out there because we also have managers who are working without breaks or holidays, etc. It takes a whole system and that involves all of the staff.

If the Deputy’s point is that hope is not a plan then we totally agree with him. Simply having a plan does not mean you will change some of the fundamental issues but the Deputy is not saying that nothing has been done.

Deputy Bernard J. Durkan

No, but if you do not have a plan you will not change anything.

Mr. Stephen Mulvany

Agreed. There is an overall plan, as we know, which has cross-party support and Government has invested. One of the ways to look at the current year's performance, which we accept is nowhere near where we would like it to be, is to ask what it would have been had we not had all of the investment, particularly the investment in the last three years. As I said, we have more additional beds than during any other period over the last 40 years, albeit that is not enough. There has been a complete change in the levels of resourcing for home support, albeit we are caught up in the challenge of getting the staff to do the necessary hours. That is a different problem from what we had previously and we have nearly doubled the size of that budget. I mention the enhanced community care efforts, which are starting to change the shape of the community specialist older persons teams, teams community specialists and chronic disease management. Those are all positives and there is evidence of significant investment, which needs to continue.

Deputy Bernard J. Durkan

I mean no disrespect but this is what I am talking about. The plan is vague as far as I am concerned, and I am a member of this committee.

The plan is not manifesting where it needs to in a crisis, that is, at the coalface. It manifested during the Covid crisis and the system worked, but it was necessary to have all hands on deck and weekly indicators of progress. Why can the same not be done on an annual trial basis?

Mr. Stephen Mulvany

Elements of what are done during a crisis are not sustainable. A system that is largely built to be at its highest levels of activity for five days out of seven cannot immediately become a seven days out of seven service. We need to identify which parts of what we have done recently have had the most impact. We accept that the learning process, the planning for next winter and longer-term planning need to start as soon as we get out of the current crisis. We accept elements of what the Deputy has said, but as Dr. Henry has stated, we are chasing to catch up with a different set of problems that have the same symptom each year, that being, delays in admissions to hospital, otherwise known as trolley waits. In terms of capacity, process and the integrated structures that Sláintecare has laid out for us, we need to catch up with a demographic that is ahead of us.

Dr. Colm Henry

The analogies with Covid management come with their own health warning. We configured our whole healthcare service towards Covid and the vaccination programme at the expense of displacing other activity. One of the consequences of the pandemic and the way we had to management it was that a great deal of other activity was delayed and is now presenting at a later stage. For example, there was a drop in cancer registrations of 15% in 2020. This is not to mention the mental health difficulties and scheduled care deferrals. While Covid-19 presented some opportunities for learning, it was dealt with in a singular way at the expense of healthcare in almost every other domain.

Deputy Bernard J. Durkan

I am aware of that. I am also aware of the need to have a plan, but it cannot be a plan that just goes on forever. It has to achieve some targets, which need to be clearly visible to all and sundry at the coalface in the health services and among the general public. Be it a one-year or two-year plan, let us get something working. What we have now is not working and we regularly have crises. We can plan for some of these issues and cannot for others. Let us plan for the next crisis now.

Senator Seán Kyne

I welcome Mr. Mulvany and his team. I thank the front-line staff, in particular nursing staff, for their important work in the health services over the Christmas period and, indeed, at all times.

Which hospitals have performed the best in recent weeks and why? Which hospitals have performed the worst or have seen the poorest outcomes and why?

Mr. Stephen Mulvany

If we take the numbers awaiting admission - the trolley count - as the measure of how a hospital is doing in unscheduled care, which is just one part of its business, I will not be able to list them all off from memory, but the obvious examples are University Hospital Waterford, Midland Regional Hospital Tullamore, Beaumont Hospital and Drogheda. Any trolley wait is unacceptable, but we have a list of hospitals with us that have a low level of trolley waits, if that is the measure of performance in this instance.

In some cases, the level of trolley waits is due to the overall imbalance between capacity and demand. Some hospitals have less of an imbalance. For example, some have been able to get additional beds. Others may have got additional beds but been unable to use them as a catalyst to make change. The hospitals that do the best tend to have a combination of capacity and a better grip on process flows, although this is not always the case. I was in Clonmel hospital recently. It is a medium-sized model 3 hospital that has a strong operational grip. It has 209 beds, so it is not overly resourced in that respect. It has a relatively low level of trolley waits, although this has increased recently, with the hospital being unable to keep up. As in Waterford, it has a strong grip on its processes, given its capacity.

Therefore, there is no one factor. We have to be careful not to be simplistic. That said, we accept the point – and I certainly, as CEO, accept the point – that we need to help all of the sites make ongoing systems process improvement. There is not a process anywhere that cannot be improved.

Senator Seán Kyne

Management can be a factor.

Mr. Stephen Mulvany

It is not just about management, as in, if there are good processes, there are good managers and if there are bad processes, there are bad managers. It is not as simple as that. A combination of factors come together, such as the right staff and right capacity. Often, an investment in beds can be, as I said, a catalyst to enable people to get some hope, make some changes and build on that. Sometimes it is down to relationships. Clinical managers and clinical leaders are important. There are a range of factors and we do not want to oversimplify it. It is not in the interest of patients, staff or managers to point at a hospital and say that big trolley numbers equals bad managers. There is room for improvement in processes everywhere, including in places like Waterford. It is everywhere. The issue is supporting the system to adopt. Health does not generally adopt a much more systems and operations approach to how it manages processes, recognising that these are patients and not products that we are making. However, there are elements of that thinking that can, will and should be introduced into healthcare to the extent that they have not yet. One will hear people talking about “lean”, which is an overall way of approaching services that puts the patient first and looks at what improvements can be made - not to make the staff work harder, faster or longer, but to help staff take out steps in a process that add no benefits to patients or staff.

Senator Seán Kyne

In Galway, the temporary emergency department has been open since late summer or early autumn. In fairness, that has helped and it is certainly a better environment for patients. That is welcomed. As that temporary emergency department has opened, it has allowed ten beds to be provided in the old emergency department, if you like, which has also improved flow. That is not to say there are not issues; I think yesterday morning there were 21 patients there, which is 21 too many. However, it could have been worse. This goes to show that beds make a difference where they are provided.

Those additional ten beds were not there in the previous winter because the temporary emergency department was not open. The concern is that the building will be handed over the builder to clear the site to start the process for a new emergency department. Will those beds be available next winter? That would be a concern. Clearly, if ten beds make a difference in a major city and regional hospital such as Galway, then everything should be done to ensure that all hospitals can avail of similar small and important numbers of beds. That is an important point. If you are preparing for next year’s winter plan, that the additional capacity would be provided in some fashion would be of concern in regard to Galway.

Mr. Damien McCallion

I might ask my colleague, Ms Day, to come in in a second. I would agree in terms of even five or ten beds. I was in another hospital yesterday where five beds are making a difference. Small numbers can help. As Mr. Mulvany said, it also gives people that little bit of hope that there is something there. Clearly, bigger developments take much longer. As the Senator knows, there is a big development planned in Galway but it will take a number of years. Therefore, it is about also trying to maximise the existing physical infrastructure, both in the hospital and the community.

I will ask Ms Day to come in on the Senator’s specific point on Galway because she has been there and worked with the group.

Ms Mary Day

I was in Galway last Thursday, where we saw some good processes and integrated working with the community partners. We have been working with Galway as well over the past of months on the improvement the CEO mentioned and looking at planned dates of discharge of reviewing patients over 30 days. They are opening up a new navigation hub next week as well. We have seen the ten beds and the Senator is correct that they make a difference in respect of the additional surge in the system and help improve the situation. The Senator will see from TrolleyGAR over the past couple of weeks that Galway has improved. Today, there are 22 beds there. We will be working with them on identifying additional capacity. There is much work ongoing there at the moment.

Senator Seán Kyne

I thank Ms Day. One of the measures the witnesses mentioned is the additional rostering of senior decision makers as part of the arrangements and escalation actions the national crisis management teams have promoted. Is this something local hospitals or hospital groups should be doing ordinarily, as routine? Is it being done, or has it been done prior to this, in some hospitals as a routine management issue?

Mr. Stephen Mulvany

I have a couple of points to make. First, the hospital system is a 24-7 system. It works seven days of the week. The issue is that it does most of its diagnostic and discharge-related work Monday to Friday. It is not built to do other than emergency work at the weekend. Our senior decision makers and other staff are in hospitals at weekends and have been before we made any change. Typically, however, the focus of consulting staff is on the unwell patients, keeping an eye on them and making sure there are no difficulties with them, and less so on discharge. In fairness to consultants, discharge, particularly any complex type of discharge, is not just about the consultant making a decision. It may be that a scan is required or some capacity in the community needs to be assessed, etc.

Yes, we have senior decision makers onsite at the weekend. Yes, we now have more of them and more of other staff, both in hospitals and in the community, at the weekend. It is too early to say what the impact of that has been. This measure was part of the overall steps that made an impact. Our key issue will be to determine which of the various actions, including that extra weekend working, made the biggest impact and which of them should be sustained. Most of them will have to be stood down for a period and we will have to make a change, including investing in more staff or whatever it is, if there are some elements of the changes that were both impactful and make sense in the longer term. It is not as simple as saying the impact was because there were a few more doctors around. Doctors are often in hospitals, and certainly are on call, over weekends.

Dr. Colm Henry

We have senior decision makers in place all the time. However, what we really focused on for the past two weekends were the enablers for senior decisions to be made. It was those actions and interventions, whether the provision of additional radiology capacity or additional support for community services, that allowed additional people to be discharged at weekends, which normally would not happen. As we said, we have a 24-7 covering hospital system but decisions senior decision makers make cannot necessarily be followed through on a seven-day basis.

Senator Seán Kyne

During the Covid period, there was a huge emphasis on hand hygiene in all public buildings, places of worships and shops. Towards the end of the period, that was becoming lax. One would go to get hand sanitiser and it would not be available. Should there be a refocus on that issue in such settings, which are places of maximum throughput, every winter? Should there be a greater focus, particularly for the elderly and immunocompromised, on wearing masks? Until very recently, my local church required people to wear masks and they are still encouraged to do so. Should there be a greater focus on that? I still go to use the hand sanitiser in local shops and, thankfully, it is there most times. However, there are other shops in which it is not available. More could be done on this.

Dr. Colm Henry

The Senator has made a very good point. There has been a huge focus on this; the question is one of acceptance and compliance. The danger has not passed, as we found out this winter, and it is not just about Covid. We have a much more transmissible variant of Covid, namely, Omicron, with its subvariants, and another coming through in the United States, XBB.1.5, which will be even more transmissible again. It might not be more serious than any previous variants but it will nevertheless present a threat. Of course, we know influenza is very transmissible every season.

We have been very consistent in our public health advice. We are telling people to adhere to the basics of washing hands, coughing and sneezing into a sleeve, keeping up to date with vaccines and wearing a mask on public transport and in any place where there is overcrowding and congestion. However, as the Senator knows, people's acceptance of that advice has waned as the worst of the pandemic passed over. The experience of the past few weeks shows how important that public health advice is and that prevention is much more effective than treatment of problems once they emerge.

Deputy David Cullinane

I want to make a quick point on immunocompromised people. For many of them, March 2020 is still their lived reality. We need to look at a combination of therapeutic tools in order that we can support them. There are ongoing issues in the context of antiviral medications, medicines and so on. This is important because while the rest of us can get back to some level of normality, that is not the case for many of those people. It is a very frightening problem for them to have to battle with on a daily basis. When one considers the mix of flu, RSV and Covid in the community, one realise that these are the people who are most at risk. We need to do everything possible, where we can, using all of the necessary tools to support those who are immunocompromised.

Mr. McCallion inadvertently hit the nail on the head earlier regarding some of the problems we have. In responding to questions on the decision to activate the NCMT on 22 December and the additional escalation crisis-management measures that were put in place, he correctly stated that we have to be careful when using such measures because they are only to be used in the short term. He said that these are time-bound actions because we cannot expect staff to work the levels of overtime we are asking them to work on a continuous basis. We cannot cancel elective procedures forever. There are other time-bound measures that are not possible to do on an ongoing basis. The problem is that we actually need to have those measures in place for longer. That is the problem. The reasons we have to adopt these measures is because of all the capacity issues. Rather than depending on the crisis management responses - and then having to make the toughest of decisions as to when we activate them - what level of crisis needs to exist before we can make these additional interventions, we need to understand why they are needed?

Mr. Mulvany said we can learn lessons from the additional measures that were put in place and from what worked more effectively. I do not think there is a silver bullet here. Nothing will come from the past number of weeks that we do not already know. When there is a surge in demand, we do not have enough beds or staff, we do not have the diagnostic capacity in hospitals and we do not, despite what Dr. Henry stated about the community interventions, supports and multidisciplinary teams that are there to support older people, have the care in the community. That is true to an extent, but some of those beds that are in place are not fully staffed. For many people, we are not delivering the right care, in the right place, at the right time because we do not have enough of what is needed. All these things are going wrong at the same time. I would argue that rather than concentrating on when we should use those very serious, additional escalation measures, we should get to a point where we do not need to use them. We will get to that point by putting the necessary capacity in place.

Earlier, I asked Mr. Mulvany about the three-year plan for emergency departments and unscheduled care. The worst thing we could do is go off and develop another plan that would operate in splendid isolation from everything else. At this stage, we should know that there is a direct relationship between community services and people who cannot get access to GP care or a community pharmacist and people with chronic conditions who are not being cared for in the community; they end up in emergency departments. We talked about admission avoidance earlier. That has to be part of this. I would argue that if whatever plan is put forward involves a silo when it comes to acute hospitals, that would be a mistake. I hope it will be a plan that has community and primary care at its core, because that is what these regional health areas will do.

Outside of that 1,228 figure, how many beds were funded in the budget we have just had?

Mr. Stephen Mulvany

As I understand it, there were no new beds.

Deputy David Cullinane

There were no new beds. Exactly.

Mr. Stephen Mulvany

In fairness, we are playing with words here to some extent. A couple of points arise. The Deputy made a point about investment. We all agree that more investment is required. I hope the Deputy will also accept that using that investment in a process of improvement is also necessary. Some of these things will take time. We need to improve services for patients today. We need people to say this is about investment, which is essential, but it is also about improvements.

Deputy David Cullinane

I know what I am talking about because I have tabled questions on many different occasions and received various responses. Having pencilled then all together, I know what the number means. A substantial number of beds were funded in budget 2021. Some of them have not been delivered, some will be delivered this year and some were delivered last year. That makes up the figure of 1,228. Since then, no additional beds have been funded, and that is a problem.

I ask that the committee be provided with this information on a daily basis for those days. That would be helpful.

I know we cannot always use beds in Mallow. I know also that part of it is being transferred to Ennis but is it going to be looked at in the long term? If we take UHL, and we are talking about the winter crisis today, it is in crisis all year round. Are there plans to expand that on a more long-term basis? My understanding is that more than 60% of the people who present at the hospital have not been referred by a doctor. They are self referrals. In England, there is a GP in the accident and emergency unit who sees patients who present without a referral. The person may be sent home with two paracetamol or to triage. I suppose the person is sent to a relevant department, whether it is the minor injuries unit or wherever. Are there any plans to look at a similar model here? In the briefing with UHL some days ago, the Minister referred to the fact five clinics would be opened around Ireland with Limerick as a location for one of them. When is it envisaged that the clinic will open in Limerick? The sooner the better, in my opinion.

Mr. Stephen Mulvany

I will start with the last point first. When two of the three major elective centres were announced just before Christmas, the Government also announced that a particular day surgery model which Tallaght operates, the Reeves Day Surgery Centre, would be considered for up to five other sites around the country. While the elective hospitals are a four to five year piece, those smaller day surgery sites are more an 18 to 24 month piece, generally speaking, so they are currently being worked on.

Regarding self referrals, yes it is the case that we encourage people, where practical, to access a GP first. Depending on how busy those services are, people may or may not be seen, so there will always be a certain number who come to accident and emergency departments without a GP referral. In fairness, there is a limited of number of people who come to our accident and emergency departments and only need two paracetamol. The key issue we are focusing on is people whose admission is delayed. Nobody in that category is likely to be admitted so in regard to people who need to be admitted to a bed, the question is whether we admit them in a way that does not involve a long wait in the accident and emergency department. Sorry, the Senator had one other question-----

Senator Maria Byrne

I have another example concerning an elderly person who took ill. An ambulance was called. The ambulance service advised that the hospital on call was St. James's Hospital which is not a place they would want their elderly mother to go to at the moment as it is packed. The mother could pick up the 'flu or some other virus. It is a dangerous place. I sound very depressed about the system. I accept there are many positive things about it but that is a challenge. We have to convince people that if they are really sick to get the ambulance to the accident and emergency department. If they cannot get an ambulance just go there directly, as bad as the system is.

Some of the things suggested over this period included that staff should work longer hours. That was one of the solutions the Minister had. I ask the witnesses today if that is a solution. I am being told that staff are burned out because of Covid-19 and everything else. Is it viable for staff to work longer hours in this situation? That is one question for the witnesses.

In regard to the average turnover, I know this differs between hospitals. There is a huge challenge in this regard. Some people suggested cancelling elective surgery. That is terrible for anyone in that situation. If we are going to keep repeating this cycle of challenges that we face some were suggesting we should have a plan. There are plans in place but they are not working. It has to be about increasing capacity in terms of both staff and beds. In the case of hospitals that have sites I cannot understand why there is a delay in clearing the opportunities for those beds to go into the system. It is frustrating, when we know there is a shortage of beds in a particular area, that there are sites and recommendations from five years ago. University Hospital Limerick, for example, will have a number of beds put in two years from now which will still not be sufficient based on what was recommended a number of years ago. We know the population is growing. It does not make sense that we are not building sufficient bed capacity in those areas. It is playing catch-up all the time. I know this sounds like a rant but I am articulating some of the frustration of members of this committee. We tried to have a meeting earlier in the crisis but we were unable to do that.

I want to send a message out to staff that we do appreciate the work they are doing and we understand the war-zone situation in which they work in some hospitals. We want to try to resolve the situation. There are solutions.

We need to put our heads together and come up with those solutions.

The last thing is the frustration in losing key members of staff within the HSE and the Department and so on. We lost one person from the digital transformation team last night. What many of them are saying and the common theme has been frustration with the resistance to change within the organisation. That is a big problem. Will Mr. Mulvany comment on some of those issues? We are losing public confidence in the system, which is really worrying.

Mr. Stephen Mulvany

Senator Martin Conway

That is great. I presume Dr. Henry might share my frustration and that of others with the slowness of NIAC's advice. Perhaps it is understaffed. If something will happen, NIAC ought to get on with it; it has been slow to react.

How much waste has there been in Covid-19 vaccines that have gone out of date? How many vaccines have we needed to discard because they passed their expiry date? Does Dr. Henry have any figures on that as I am led to believe it is substantial?

Dr. Colm Henry

I do not have figures to hand but I will come back to the Senator with a written answer.

Senator Martin Conway

That is fine.

Chairman

I thank the representatives of the HSE for their assistance to the committee on the current pressures in emergency departments in public hospitals which is justifiably of huge concern to citizens and communities. On behalf of the committee I again thank staff, not only those in emergency departments but all those in hospitals and other medical settings, for the additional effort they have put in during this crisis. I wish them and their families well.

The committee hopes to see a continuing improvement in the situation in this regard and we will continue to keep the matter under close scrutiny.

The joint committee adjourned at 12.59 p.m. until 9.30 a.m. on Wednesday, 18 January 2023.