Skip to main content
Normal View

Joint Committee on Health debate -
Wednesday, 26 Apr 2023

Challenges in Hospitals: Minister for Health

The purpose of today's meeting is for the committee to meet the Minister for Health to consider and discuss the ongoing acute challenge facing public hospitals, in particular pressure on emergency departments, shortage of bed capacity and the consequent overcrowding. To commence the meeting's consideration of this matter, I welcome the Minister for Health, Deputy Stephen Donnelly, accompanied by officials from his Department. 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 a person or entity either by name or in such a way as to make him, her or it identifiable or otherwise engage in speech that might be regarded as damaging to the good name of the person or entity. Therefore, if their statements are potentially defamatory in respect of an identifiable person or entity, they will be directed to discontinue their remarks. It is imperative that witnesses comply with any such direction.

Members are reminded of the long-standing parliamentary practice to the effect that they should not comment on, criticise or make charges against a person outside the Houses or an official either by name or in such a way as to make him or her identifiable. I remind members of the constitutional requirement that they must be physically present within the confines of the Leinster House complex in order to participate in public meetings. I will not permit members to participate when they are 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 any members participating via Microsoft Teams to confirm, prior to making their contributions, that they are on the grounds of the Leinster House complex.

I invite the Minister for Health to make his opening statement on the issue of challenges in emergency departments, bed capacity and overcrowding.

I thank committee members for their invitation to discuss the very real challenges faced by patients in public hospitals, progress in the past three years and, critically, plans for ongoing expansion of capacity in parallel with fundamental reform of patient care. Like many of my colleagues on the committee, I have visited emergency departments across the country to hear first hand the experiences of patients and healthcare workers. I have seen the distress overcrowding causes for patients, their families and front-line staff. I have visited hospitals in which conditions for patients and healthcare workers are simply unacceptable and listened carefully to solutions proposed for these hospitals. I have also visited hospitals in which patients are seen quickly and very few patients - in some cases, none - wait for admission to hospital beds. I have listened carefully in these hospitals to what healthcare professionals tell us about why things are better for patients and healthcare workers in these hospitals.

Our emergency departments are run by skilled and experienced staff, providing access to healthcare for those in urgent need and access to beds for patients requiring admission. Not all of the solutions to overcrowding are found in the emergency departments nor even in hospitals. As we continue to build capacity, we must ensure that new and expanding community services provide alternatives to hospital for all but the sickest of patients. Hospital waiting lists are too long in too many hospitals and in too many specialties. Waiting lists were far too long before Covid arrived and were made worse by Covid in Ireland and around the world. In Ireland, waiting lists for scheduled care increased by almost 60% between 2015 and 2021.

In late 2021, as the worst effects of Covid began to recede, we began to tackle the waiting lists in a meaningful way. We are now in the middle of a multi-annual approach to achieving the maximum wait list times of ten and 12 weeks, which were agreed by all parties in 2017. As a result of the efforts being made, last year saw an 11% reduction in patients waiting longer than these targets. That is about 56,000 men, women and children. In fact, from the Covid peak to the end of last year, 150,000 fewer people were waiting longer than the agreed Sláintecare maximum waiting times.

Without the intervention of the waiting list action plan last year, it is estimated that waiting lists would have increased significantly to over 1 million people. Instead, critically, last year was the first year since 2015 in which overall waiting list numbers decreased. A 4% reduction was achieved. This year will be the second year in a row that that happens. These reductions are contrary to what is being seen in many countries, with waiting lists increasing due to the after-effects of Covid.

In March we launched the 2023 waiting list action plan as the next stage of our multi-annual approach. The Government allocated €363 million to remove 1.66 million patients from the waiting lists. This is projected to result in a reduction of 10% in the number of people on waiting lists. It is important to say that in the last month alone, we have seen a 5% reduction in the number of people waiting for longer than the ten to 12 week targets, which equates to about 25,000 fewer patients now waiting for longer than those targets than there were just one month ago. I want to acknowledge that this has been achieved by huge efforts within my Department, within the HSE, and most importantly because of the work, effort and commitment of our front-line healthcare professionals to getting these waiting lists down and getting these patients seen quicker. I thank our healthcare professionals and acknowledge that this is not easily achieved. They have the full support of Government and deserve great credit for the achievements that are being seen.

The waiting list plan allocates €32 million to the three priority areas, which are paediatric orthopaedics, gynaecology and bariatrics, to address long-term capacity gaps and significant waiting lists. We are also rolling out important changes to how patients and waiting lists are managed. They include patient-initiated reviews and patient-centred booking arrangements, both of which will improve the patient experience.

As well as growing the workforce at record levels, improving how patients are cared for and implementing the urgent care and waiting lists plan, we are also expanding health infrastructure. We are fast-tracking development of new elective surgical hubs in Cork, Galway, Dublin, Limerick and Waterford to address shorter-term capacity demands, providing new elective day case capacity in the shorter term while the regional elective hospitals are built in the coming years. Over the last three years, we have added nearly 1,000 extra hospital beds, 410 community beds and 65 critical care beds. Some 261 acute beds and 16 critical care beds are expected to be constructed under the capital programme for this year. In addition, I am in discussions with Government colleagues on a proposal to create a rapid-build plan for an additional 1,500 hospital beds around the country.

The strategic plan for critical care is continuing to deliver additional beds this year, and we are leading strategic reform of pre-hospital emergency care through the development of a new National Ambulance Service, NAS, strategic plan. I am pleased to say that I was looking at the echo and delta targets just this morning for the year to date and there has been a significant improvement by the National Ambulance Service in meeting both the echo and delta targets. It is important that we recognise the work that has been done by our National Ambulance Service Teams to achieve that. The new NAS plan is focused on increasing permanent capacity in the services and developing alternative care pathways, including aeromedical services, which includes commencement of the new helicopter emergency medical service in the south west.

At the same time as these important changes and improvements to capacity, workforce and infrastructure, changes to working practices are also required in our public health service. Critically, we have to have senior decision-makers on-site and available to patients more often, both in hospital and community care. We have seen the positive impact this has. We need to ensure strong connections between hospital and community sectors, which is being addressed in part by the move to regional health areas, which is progressing this year. We need to see more discharge options available to the hospitals. We need a consistency in approach to patient flow, within the hospital and out of the hospital, with what is being seen in the best performing hospitals becoming the norm in every hospital.

I will touch on enhanced community care because it is an essential part of keeping people out of hospital in the first place and then accelerating their discharge from hospital. Annual funding of €195 million has been allocated to continuing the implementation of enhanced community care this year. I am delighted to be able to say that much progress has been made. Some 94 of the 96 primary care teams are now in place. Some 21 of 30 specialist teams for older people, or integrated care programme for older persons, ICPOP, teams are now in place. Some 21 of the 30 specialist teams for chronic disease management are now in place. All 21 of the community intervention teams are now operational with national coverage for the first time.

These community health networks, or primary care teams, for the first time in Ireland, mean that general practice is being properly integrated into community service. The feedback we are getting from our primary care teams and from general practitioners is positive. We have some way to go and the new ways of working are still bedding in, but the feedback has been good. This provides a foundation for truly integrated care, meaning more local decision-making and improved access to primary care services for individuals and their families.

Alongside all of this, the community specialist teams are now providing consultant-led multi-disciplinary care to older people with chronic diseases in the community. This embodies the shift away from a healthcare service centred on hospitals to a healthcare service centred on community-based and primary care-based care.

The community intervention teams are another really important innovation. These teams provide a rapid response to patients experiencing acute episodes of illness. The services facilitate the delivery of enhanced care in the community and at home. We are further expanding the community intervention teams, with a particular focus on the mid-west and the north west. Essentially, these community intervention teams provide some of the services in people's homes that they would typically have only been able to get in a hospital. It means people have options other than being admitted to hospital. Critically, it means people are being discharged from hospital earlier and getting some of that lower acuity but traditionally hospital-based care in their homes now. The patients I have spoken to said it makes such a difference to their care and recovery.

The committee will be aware that we are investing heavily in GP access to diagnostics. We are looking at heart failure virtual clinics, facilitating delivery of shared and integrated care between GPs and cardiologists, which again reduces the need for GPs to refer their patients to hospital. We have had a very strong response to the programme for access to diagnostics. We are targeting about 500,000 scans this year and about 500,000 last year. Again, the GPs are saying that this really makes a big difference to their ability to care for their patients.

We will continue the implementation of other important reforms. Just some of these include advanced practice, community-based care, and more decision-makers available to patients more often. This is how we achieve our goal, which is universal healthcare. We are driving down costs for patients. We are rolling out new services such as those in stroke, diabetes, bariatrics, women's healthcare and genetics. Critically, while we acknowledge that access is our biggest challenge, whether through emergency departments or waiting lists, we are now making real progress. As I said, it is encouraging that last year was the first year since 2015 in which the waiting lists fell. They are falling again this year. The HSE is ahead of the extra volume that was seen last year. We are working closely with the HSE to make sure it has the support to get these waiting lists down to what we have all agreed, which is that no patient waits for more than ten or 12 weeks.

I welcome the Minister. It would be remiss of me not to acknowledge all the positive indicators that have been outlined regarding hospital waiting lists. A reduction of 4% is very welcome. The indications that we will have a further reduction this year are also very welcome because it has been the other way for far too long. This is the first time the Minister has appeared before the committee since the major incident that was declared in University Hospital Limerick, UHL, just before New Year's Day. I want to give the Minister the opportunity to give us a brief update on what has been happening at the hospital since then. Unfortunately, the number of people on trolleys is going in the wrong direction. There are too many people on trolleys in UHL, and they are on those trolleys for too long. It is not going in the way we want to see it going and, as far as I am concerned, this is not acceptable. I know the Minister does not believe it is acceptable either. What is the current situation at UHL?

I share the concern of the Senators and Deputies who represent the region regarding patients in UHL. It does not get discussed much, but it is important to state that when we are discussing UHL and University Limerick Hospitals Group, the focus, quite rightly, is on what is happening in the emergency department. However, I acknowledge, and we might come to it on a different day, that the hospital group is making great progress on the waiting lists. In fact, in some areas it has been one of the strongest performers in reducing the number of people waiting for care. I know that is not the Senator's question, but I want to give credit where credit is due.

The situation in the emergency department of UHL is simply not acceptable for our patients or our healthcare workers. I have visited the hospital on several occasions, including an unannounced visit at night to the emergency department. There are several parts to the solution. Quite rightly, the hospital has called for more beds. I have some figures on the increased capacity of beds and consultants at UHL over the past three years. The hospital has asked for more capacity, which is being provided. A significant number of beds have been added since the onset of Covid. More consultants and nurses were requested and a significant number of consultants and healthcare professionals have been added.

The Senator may be aware that I turned the sod on the new block at the hospital. We are now looking, as a priority, at the second of those blocks. To summarise, many beds have been added and many beds are in development. The level of staffing of the clinical workforce has been increased very significantly over the last while. The first thing we need to do is acknowledge that the requests for more capacity from UHL are fair and reasonable. That is the ask of the hospital to us in the Oireachtas. I agree with the ask and the Government is stepping up to that by adding more capacity. We also have a condition for the hospital. This condition is that the hospital be run according to the ways we know work in some of the hospitals that are doing the best in emergency departments. For example, I compared University Hospital Waterford, UHW, with UHL and looked at the normal rostered hours for senior decision-makers. In spite of the fact that UHW has about half the emergency department workforce of UHL, the workforce is rostered on over many more hours, later in the evening and at weekends. We need to see that happening in UHL also. This has to be a partnership

Is there pushback on that from management of UHL?

There is healthy engagement with UHL. They have said that in order to do that they need more staff. Those staff members have been allocated. The changes to working practices have to be seen. I need to be very clear that we are not singling out the emergency department consultants. This is about senior decision-makers right across the board.

It does need to be called out. If there is pushback and they are not prepared to implement structures that have been proven to work in other areas, the committee needs to be aware of that and to be told what is being done about it

I have outlined some of the things we are doing about it. The hospital has an ask of Government, which we are stepping up to, and that can be seen. We have an ask of them, which is that reforms of working practices are implemented. There is also an ask, quite rightly, from the Senator and other Members who represent the region. This is to do with the services outside the hospital being built up. I will give some examples of how we are doing this. The medical assessment unit, MAU, ambulance protocols for Ennis and other areas are now in place and working well. There has been investment in Croom Orthopaedic Hospital, St. John's Hospital, the national ambulance fleet and GP out-of-hours services. All of these have to come together in order to solve this problem.

How well are the new ambulance protocols working at Ennis General Hospital? Has it had a positive impact on the number of people on trolleys and the situation at UHL? At this stage, we need to get some figures as to how successful it has been and clarity on whether it is going to be made a permanent arrangement.

Yes, it is successful, which is good to see, and a significant resource is going in to support it. The group has been approved for over €5 million in funding to support extended operational hours of the MAUs at St. John's Hospital and Nenagh General Hospital to seven days per week. That began at Easter. We are also keeping in place the extended MAU hours that were put in place in Ennis. I hope the Senator will be pleased to hear that recruitment has been sanctioned and is ongoing for more than 50 extra staff across a number of specialties for those three MAUs. That will make a big difference. Ennis General Hospital, which I know is close to the Senator's heart, will see an additional 20 full-time equivalents once all of these staff are in place. This will really make a big difference

Several reports, including one by HIQA, into the situation in Limerick have identified the lack of a model 3 hospital in the region. I know this has been raised with the Minister many times. Has the Minister's position changed regarding a model 3 hospital for the mid-west region? Has the Minister taken into consideration any of the reports or suggestions that the lack of a model 3 hospital is causing significant problems in the region?

We can always keep an open mind on these things. I know there was a lot of talk, for example, about an elective-only hospital for Limerick in collaboration with the University of Pittsburgh Medical Center, UPMC. I might ask Dr Henry or Mr. McCallion for their views on this. In my view, we should always keep an open mind to these things while acknowledging that there is very significant investment, quite rightly, going into the region. UHL is now in the middle of a very substantial increase in its capacity regarding beds and other services. The Senator will be aware that we are rapidly deploying a new elective hub to the hospital areas well. This will make a big difference

When is it expected to be opened?

I hope it will be open as early as possible next year. We are putting significant investment into regional hospitals. Many in the region would like one in Limerick, but the Cork and Galway regional hospitals are intended to serve the Limerick area as well.

Before I go into the substance of this session on hospital overcrowding, I have questions on two other matters for the Minister.

Last week, when the Minister was in, we talked about the report from Dr. Maura Quinn. Can he again confirm that the Government has accepted all of the recommendations in that report, and that they will be implemented, and , more importantly, that every civil servant, including senior civil servants in his Department, will implement the recommendations of that report, once the Government does so? Can the Minister give that assurance to members of this committee?

Yes, Deputy, categorically.

Could I also ask the Minister about the report into the Health (Regulation of Termination of Pregnancy) Act 2018, which is being published today? Perhaps it has already been published. The Irish Times published it last night for the Minister, I understand, but it is being formally published today.

Given that there are legislative changes as part of that, could the Minister, very briefly, outline to us if the Government is minded to accept those legislative changes, or what is the process that will allow it to arrive at that point? If the Government accepts the need for legislative change, has it a timeframe in mind for that? What is the process that will allow the Government to get to a point where it can make decisions on those recommended legislative changes? Once it gets to that point, is there any indicative timeframe as to when we can expect to see legislation which would give effect to that?

Minister, I am conscious that it is not on the agenda, but there has been a lot of speculation in the media regarding this committee and its role on that. He might address that in his remarks, if he has a view of what he would like this committee to look at regarding that legislation.

I thank the Chair, and I thank Deputy Cullinane for the question. I brought the report to Cabinet yesterday. The Irish Times did have it up, and it is obviously very well informed. We are putting it up publicly today, and obviously sending it to this committee for consideration.

My ask of Government yesterday was that the report would be referred to this committee, so it will be referred to members today. The committee will be asked to report back to Government, presumably through me, on the legislative proposals. Obviously, the committee will take a view on some of the operational recommendations as well, and the committee will decide its own scope on what members want to cover. The piece on which I would really value detailed engagement with the committee is the legislative recommendations. There are ten or 11 legislative recommendations. Some are pretty straightforward; others will, I think, be quite sensitive, like the three-day wait for example. It is going to require the kind of solid, reasoned, respectful debate that this committee did in the previous Dáil regarding the original legislation.

I want to finish on this point and go on to the other issues. The committee should absolutely engage with the author of the report and have discussions about how those recommendations were arrived that, and can form opinions but, ultimately, the Government, or whatever Government is in place, has to make decisions on the implementation of the recommendations. Whatever legislative change comes will not come from this committee. It will ultimately come from the Minister and a Government decision. We can advise, and give observations. I would like to make that distinction. It is a political call that now has to be made, and we all have a responsibility to engage. I will, and I support many of the recommendations from what I have seen in the report. However, we will have that engagement.

I would like to move on to the overcrowding in hospitals. The Minister mentioned the waiting lists, and there has been some reduction in recent times. However, the reduction is quite small compared to the growth of the waiting list that he outlined, quite rightly, since 2015. The National Treatment Purchase Fund, NTPF, publishes waiting lists for acute hospitals. It does not publish all waiting lists, by the way. It does not publish diagnostic waiting times or community waiting times. However, regarding acute hospital numbers, in January 2020 it was 776,000. In March 2023, it was 885,000, which is still a significant increase. Then there are the numbers of people on hospital trolleys. Yesterday, according to the Irish Nurses and Midwives Organisation, IMNO, there were 592 people on hospital trolleys. Trolley numbers are averaging 560 patients a day, every day this month. It is almost the new normal, that we have arrived at a point where more than 500 seems to be normal. However, we can never accept it as anywhere near normal. Then there is the average wait time for admission to a bed in hospitals. In February 2019, it was ten and a half hours; in February of this year, it was 11.4 hours. All of those metrics are going in the wrong direction, including the time people are waiting in emergency departments and the number of people on hospital trolleys. The number of people who are waiting has come down slightly in terms of long waits, but it is still exceptionally high.

Does the Minister accept he has a long way to go before he gets anywhere near meeting the Sláintecare targets?

I fully accept it, with one addition. More than 490,000 people are waiting above those ten- and 12-week targets. I fully accept it. However, it is important that we acknowledge that very significant progress is also being made. Dr. Henry, Mr. Damien McCallion and Ms Mary Day in the HSE, and then the officials in the Department, are working night and day on this. We are very focused. I meet the senior HSE team regularly on the waiting lists. We have an urgent care team as well. I fully agree that the waiting times are far too long, but progress is under way.

Can I come to some of the proposals and solutions? I accept there has been some progress but it is quite limited given the major increase that we have seen since 2015. We certainly have a long way to go to get anywhere near the Sláintecare targets.

I want to come to some of the solutions, because they are important. Of course, I welcome the rapid build plan for beds, and the 1,500 additional beds. We discussed that last week. Is anticipated that the Minister may bring something to Cabinet before next year's budget, or is this something that he intends to include in the budget this year, and not just the actual capital allocation? Is he satisfied that these beds can be built rapidly? I would see "rapidly" as a maximum of 18 months to two years. That is the kind of timeframe I would want to see them done within, because they are modular units. Is he satisfied that the staff to open those beds can be recruited? Will we see a plan not just for the beds, but also for staff?

I am satisfied, but this is not easy. I might ask Mr. Derek Tierney, who is leading it from within the Department, to comment. We are doing something that has not been done before. One issue we can all agree on is that it takes the State far too long to build hospitals, wards, and new bed blocks but what we saw during Covid-19 was something new. There were derogations for planning and rapid building technologies were used. What I have done with the Department is go through systematically all the things that slow us down.

There are cases where we can have derogations on planning. There are locations we can use that do not require environmental impact assessments. There are rapid build technologies that were used in Kilkenny, for example, which Wexford is very interested in using. We can do the procurement in greater lots, so a full procurement is not required for every hospital. When all of that is added together, I believe we will get to an accelerated beds plan.

We will wait and see what comes to Cabinet. We need that to happen very quickly. What is the indicative timeframe for the delivery of the elective-only hospitals? There is a lot of talk about these hospitals. We all support them, whatever about the locations that some people might have their own views on. What is the timeframe for their delivery?

I want to make a final point to the Minister before Mr. Tierney comes in. The Minister talked about management at University Hospital Limerick. I am not singling out any management as being good or bad. That is not the point he was making, and is certainly not one I am going to make. We have good practice in hospitals; the Minister gave the example of University Hospital Waterford. It can also be seen in Bantry General Hospital as well with the medical assessment unit. My understanding is that is colocated with step-down beds as well, which seems to work very well. There are lots of examples we can see where things are being done better in some hospitals. With that said, I would be troubled if hospital management was not being mandated to implement best practice.

The new chief executive of the HSE was before the committee recently, and he said that one of his first tasks would be to bring together all of the managers of the hospitals to identify best practice and then mandate it. That is his job, but it is also the Minister's job. Whether it is pushback, or whether there are issues with staff or whatever it might be, it is unacceptable. Best practice is best practice, and if there is to be any chance of reducing those wait times in emergency departments, every hospital needs to work to the highest standard. It is our job to make that happen.

It is the Minister's specifically and that of the head of the HSE. Will the Minister comment on that, followed by Mr. Tierney?

I thank the committee, including all members present, for their strong support of the consultant contract because that is the cornerstone of this. When I discussed exactly this matter in Limerick, the contract was referenced. The intent from the Government's perspective is reformed working practices; I fully agree. Using UHL as an example, I asked for information on the increase in workforce before the committee meeting and can provide it to the committee afterwards. Pre-Covid to now, the number of consultants has gone up by approximately one quarter from 165 to 205; the number of non-consultant hospital doctors, NCHDs, has gone up by almost one third from 388 to 505; and the number of nurses has gone up by approximately one quarter from 1,600 to 2,100, so there has been a lot of investment. As the Deputy said, while we are putting in this investment, we must also support those workers to work in a modern way that works for patients.

Mr. Derek Tierney

I will respond to the question about the 1,500 accelerated acute bed plan. Early in April, we engaged with the market through an expression of interest, EOI. That is about understanding whether the market can deliver capacity; it has until Monday to respond. There have been approximately 30 responses so far from Irish, UK and other international companies. There has been a strong response to our EOI. We set out in the EOI that we expect capacity to deliver at least 1,500 beds in total across 15 sites over 2023-24 and at least a start in putting capacity in place within 75 weeks from the EOI. We are currently examining 11 to 15 sites - model 3 and model 4 - with a 24-7 emergency department service, the capacity already delivered across hospitals between 2019-22 and what is in the pipeline in terms of appraisal, funding and permissions. We are also examining, as the Minister said, known bed pressures using data about bed utilisation rates projected 12 to 18 months and calibrated for an 85% occupancy rate. Just as important is hospital performance in length of stay and the performance oversight and management group. That process will, I hope, yield 11 sites which will be targeted in two phases for capacity and investment. The capital plan is set on an annual basis within a multi-annual ceiling guideline. Our approach with the Department of Public Expenditure, National Development Plan Delivery and Reform, in the context of this year's Estimates, is to give a broad indication of what will be needed on a multi-annual basis but trying to lock in a commitment for 2024 and beyond. We will, hopefully, within the next three to four weeks clarify or confirm site location, coupled with the response from the market and then start to proceed and engage with the Department of Public Expenditure, National Development Plan Delivery and Reform, local authorities in the relevant area to get on with planning engagement and permission, and with hospital groups and management to start firming up plans. We will present that through engagement with the Department of Public Expenditure, National Development Plan Delivery and Reform and ultimately bring it to Government in the context of the Estimates.

On elective hospitals, the Government decision in 2022 clearly gave the go-ahead to progress Cork and Galway within the overall elective programme context. That was on the premise that we would see operational service start in 2027 or 2028. That is a longer-term strategic intervention, which I would call "the next". Now, there is rapid development of surgical hubs in five locations to support bringing in capacity to reduce waiting lists in the shorter term. There is a next-and-now model for electives and acute bed. The 1,500 accelerated bed plan is designed to accelerate that capacity. In the context of Sláintecare and its requirements to examine demand and capacity through the PA Consulting report published in 2018, it presented two targets: one reform and one no-reform target. Looking at acute capacity at the end of 2022, we are midway. We surpassed reform targets for the end-of-2022 position and are midway to the 2031 position. We recognise that there is more to do and we can see that there is pressure on the system. This is the response to try to face that head on.

Do not forget Waterford when it comes to the site locations.

How could we with the advocacy going on? If the committee wants, Mr. Tierney can provide an update on what we are doing in changes to working practice. It is entirely up to the Chair and the committee - I know we are out of time. Dr. Henry indicated he would be happy to give an update on changes to processes within emergency departments, if that is of value to the committee.

I let Deputy Cullinane go on. A number of members are absent today so there is some leeway. It is okay to bring in the officials? I think it is important that we get as much information as possible.

Mr. Damien McCallion

I will kick off. Others may also wish to come in. The Deputy referred to variation and how to ensure the learning is taken from places such as Waterford, Tullamore, Portlaoise, Beaumont, Connolly and other hospitals, which are doing really well, and apply them to other settings. That is always the challenge. Each place has a unique set of challenges. We are not talking about a carbon copy, which we must recognise. In some industries, you can lift and implement quickly but healthcare is not one of them. Factors such as capacity, resources and ways of working and links with the community also come into play. To summarise, we bring the locations operating best together. We have run a number of sessions with staff from University Hospital Waterford, both clinical and operational. We bring staff from other hospitals together to examine the lessons and how they can be lifted and applied. Some are based on clinical best practice, which Dr. Henry will speak about shortly, while others are based on pure operations and how the flow into the emergency department is managed but also out into the community. For example, there has been a huge increase in admissions and attendance of older people, at more than 10%, whereas it is approximately 3% for the general population. We, therefore, need to do more for older people to stop them coming into hospital and, if they do, allow them to get home sooner. To give one example, I visited the older persons team in St. Mary's Hospital, Phoenix Park, north Dublin recently, which takes direct referrals from the emergency department in Beaumont Hospital. There were three in that day, which allows those people, instead of being admitted to hospital, to be cared for in the community. Those are important examples. Dr. Henry may speak to that. Best practice is important and that needs to be clinically-based, evidence-based, and applied. There is also an operations piece, which we also try to do.

The second piece is that some sites - we referred to Limerick - are under more pressure than others. An improvement team works with those sites to try to take that on, which is on the ground to support sites in places like University Hospital Galway, UHG, Cork University Hospital, CUH, UHL and one or two others, in which we work intensively. Small improvements can be important. In CUH, for example, the ambulance turnaround time has been reduced by more than 25% through an initiative over the past six months, taking best practice from other hospitals. That is an important example because probably one of the biggest risks in the emergency department is delayed ambulances, particularly in large geographical areas.

The final piece s performance. We, from the centre, work with sites on their performance every day in regard to emergency care. It is a weekly process for waiting lists. Overall performance is monitored and measured on a monthly basis. We look at targets and how the sites are doing, and readjust based on what we see. They are the levels of engagement and intensity with the sites. Ultimately, it is about trying to empower them to improve the services in their hospitals with their staff for their communities. As the Minister said regarding available resources, it is important that it has to be a system solution. When we move to the regions, it will important, but even now, the community is a key part of those engagements. I will ask Dr. Henry to speak about one or two of the key pathways and clinical, evidence-based approaches that have been shared around the country, some of which Deputies referred to.

Dr. Colm Henry

There is a huge array of tasks in trying to improve trolley numbers and patient experience. As has been alluded to, it requires resources, but equally important is how those resources are used, including admission avoidance, seeking alternatives to presenting to emergency departments, reducing length of stay, improving flow through hospitals, expedited discharge and links with the community. Members of the committee will be aware of our work on enhanced services in the community. Focusing on two particular hospitals, in UHL earlier this year, where we tried to do exactly that, namely, share the lesson from a good practice site, such as University Hospital Waterford, and applying it in UHL, notwithstanding whatever capacity issues there may be. While there clearly are trolley issues in Limerick, we see some early improvements.

The total patient experience time, for example, in Limerick last year was 9.7 hours. It is now down to 8.9 hours, which, when it is applied over the entirety of patients, takes a huge amount of work based within existing capacity. That included patients who were awaiting admission, which reduced from 14 hours to 13 hours, and those who were not and were discharged, which reduced from 7.7 hours to 6.8 hours.

In Cork University Hospital, CUH, equally, it is about breaking it down, looking behind the trolleys and lifting the bonnet, so to speak, on all of the actions that are required. Mr. McCallion already referenced the reduction of turnaround time for ambulance response. A few years ago, it was at 57 minutes and now it is at 21 minutes. It is a major risk, not just in terms of the patients waiting in the ambulance but the availably of ambulances for people who need them in the community. Likewise, CUH has focused on, again through looking under that figure of trolleys, many different quality improvement projects that require leadership and resources but also changing the way people work, and it has reduced its conversion rate. That is the proportion of people who present who are admitted. It was well over 50% for those aged over 75 a couple of years ago and now it stands at 40%. To get that figure down to that level requires huge work in terms of senior decision-makers, availability of diagnostics, linking people to community and early discharge to GPs. It does not happen easily. The total patient experience time in CUH requires more work but its work on admission avoidance is a product of the kind of spread of learning we have from sites such as Waterford.

We need to act as quickly as possible. We would like all sites to be as good as Waterford or the other well-performing hospitals. That involves not just resources but changing the way people work.

Mr. Damien McCallion

On developing people, I have worked with a director of HR to develop a new operations management programme. We are using the people - the hospital manager in Waterford, Tullamore and some of the other sites - to develop that programme to try to support people who come into those jobs, help them to do those jobs, and strengthen the resources and what they have available and their confidence and skills to do so. It is trying to bring that through in the system to develop more people who have that capability to support and show the improvement in sites.

I apologise to Deputy Shortall for the delay, but I think that was useful.

I thank everyone for their attendance. It is important to recognise all of the hard work that is going on within the Department and the start of the progress that is being made to turn things around in respect of waiting lists. That is very welcome. Obviously, there is a long way to go.

I wish to talk about infrastructure and beds in particular. I have to express some concern that there seems to be backtracking in the proposal for three elective hospitals. This was a key recommendation from Sláintecare. It was based on experience in NHS Scotland, where huge progress was being made. There was a recognition of the need for an elective hospital that did not have all of the pressures and threats from an emergency department, ED, that operated efficiently and was essentially doing operations. That was the key concern. There is the example here of the Santry sports clinic, which is efficient and has a high throughput and that was the idea. In Scotland, they bought a private hospital and used it for elective purposes. They then built a second one.

I feel the Department is moving away from that. Certainly, there has been an inordinate delay in progressing that proposal. With Cork and Galway, it is being said that they would be essentially day hospitals to start. The location for the Dublin one has not yet been announced. Instead of that, the Department is talking about starting work on 11 different sites to produce 1,500 hospital beds, which will be latched onto existing pressurised hospitals with their EDs and all that goes with that. That is a mistake. The Department should be progressing the three hospitals that will operate efficiently and motor through the waiting lists for orthopaedics and a whole lot of other specialties, and can do that without anything else getting in the way or operations having to be cancelled because of pressure from EDs. Will the Minister explain why there is that change in policy and divergence from a key recommendation in Sláintecare?

There is no divergence or change in policy, but I fully share the Deputy’s frustrations. It takes years longer than it should to build new hospitals in this country. Mr. Tierney is leading the work. If the Deputy wants, he can give her some detail, if that is of use. I know it does not feel like this, but I can assure the Deputy that the Department is moving through the public spending code quickly for the public. The public spending code is not fit for purpose. It is has 17 steps and five different approval gates.

It has been relaxed recently.

Recently, the Minister, Deputy Donohoe, to his great credit, has agreed to bring it from €100 million to €200 million when it kicks in. He is reducing the approval gates, I think from five to three. Mr. Tierney will have more detail on it. I fully share the Deputy’s frustration. To be honest, it is why I wanted to push forward on the surgical hubs. We can do them in about 18 months, whereas the elective hospitals take years. I assure the Deputy that there is no change in policy. I know it does not feel like this but they are-----

Why has the Dublin site not been announced?

There was additional work required. The original review that came back recommended three sites. We went with the Cork and Limerick sites. We did not agree that the Dublin site was the right one to go for. I am not sure how much I can say but I will say it anyway. The proposal for Dublin was a private site that could have taken a long time to get and would have cost a lot of money. The view within the Department, which I share, and I think has been expressed by members of the committee, is that we should build on our land wherever we have it.

If that is the Minister’s thinking, why did he not go with the Cappagh hospital? He is familiar with it and knows that it is a publicly-owned site. He knows there is a great willingness to develop that. He knows the expertise on orthopaedics is out there. Why did he not select that site?

We have not selected any sites for Dublin.

Why is the Department not selecting that site?

I cannot comment on the sites that are being assessed at the moment. What I will say is that I will have a proposal on my desk very shortly in terms of the two sites – or one site.

It is hard to understand why the Department would be considering an expensive private site when there is a publicly-owned site available that has expertise as well. It is also a good location in terms of accessibility.

We are in agreement on that, which is why, when the private site was recommended, we did not go for it.

But why was it recommended? Why not go with the blindingly obvious?

That is a matter for the team that did it.

When does the Minister expect a decision on that?

Pretty soon. I will have a recommendation on my desk pretty soon.

Obviously, there is much work going on. However, I am not hearing the data behind these decisions. Perhaps it exists and I hope it does. There are a number of areas where I want to know whether there is data available and whether it can be made available to the committee. The first one relates to EDs and the overcrowding in them and all of that. What analysis has been done of the reasons people are attending EDs? What are the different conditions that they come with?

There is much work that the HSE does. Dr. Henry might be in a position to speak to that.

Dr. Colm Henry

We analyse based on age and need. For example, for those over the age of 75, we know that 82% come within category 2 or category 3, showing a compelling need to attend.

Has the HSE analysed the reason people are attending, specifically in each hospital? Presumably, that information is taken when somebody checks in. Why are they there? Are they there with an asthma attack? Are they there because they have had a sports injury? Are they there because they have nowhere else to go? It might be an elderly person. Is that data available? Unless the HSE has that data, I do not know how it can respond to the need and provide alternative opportunities for people. Does that data exist and can we see it?

Dr. Colm Henry

Yes. We break people down into triage category in attendance, category 1 being needs immediate resuscitation, category 2-----

No. Sorry. That is not what I am talking about. I am not talking about severity or priority but rather the reasons people attend.

Is it because of diabetes, or what is it? Does Dr. Henry have figures on that so they can design and provide services to meet the actual need for people who are attending emergency departments, ED?

Dr. Colm Henry

Yes and that is exactly what we are trying to do, basing and designing a service for chronic diseases and older people in hubs that are outside hospitals.

Can Dr. Henry provide that data?

Dr. Colm Henry

We can provide Deputy Shortall with as much data as informs the model we have for developing services outside hospitals. It is informed by the way people with chronic diseases present to emergency departments, and older people, whose needs we feel might be better met elsewhere.

Do we know what percentage of people arrive with a sports injury?

Dr. Colm Henry

We currently have data from our local injury units largely which have been diverted-----

I am talking about EDs.

Dr. Colm Henry

I am sure we can come up with that data.

Mr. Damien McCallion

We collect data at national level as Dr. Henry said around triage, age, and other categories like that. If Deputy Shortall is looking for granular data relating to individual attendance the hospitals look at that themselves locally in terms of analysing the mix. If one takes St. Vincent's Hospital for example, we know there is a different population profile there. We do not collect the granular level of detail that Deputy Shortall is talking about on a national basis.

Mr. Damien McCallion

Sorry Deputy, just to briefly finish. The hospital would do that but what we do nationally is to look at the prevalence of say diabetes, as Dr. Henry said, cardiac disease and so in a general population. If one takes Letterkenny hospital-----

Sorry, I am not talking about in the general population. I am talking about the reason people turn up at EDs. From what the witnesses have said I do not think they do collect that data and I think it is a mistake not to do that.

Mr. Damien McCallion

We do that, sorry-----

If it is available for any hospital I ask the witnesses to provide it to the committee, and I will leave it at that. They can come back and let the committee know whether it is available or not.

Mr. Damien McCallion

Sure.

The second type of data I think it important is on outpatient waiting lists. The standard thing seems to be that if I go to see my GP with an issue and need to go to a consultant, that GP in the main will refer me to a consultant they know. They may have been in college with them or know them personally. That consultant might have a 15-month waiting list. Am I not entitled to know if there is a consultant who has a three-month waiting list that I could go to instead? Has consideration been given to publishing the waiting lists for consultants?

I thank the Deputy. It is a very timely question and I could not agree with her more. We had a meeting with Mr. Bernard Gloster, Mr. McCallion, Dr. Henry and the full senior Department team also about the waiting list plan on Monday. This is one of the topics I raised. The answer is categorically yes and I would expand it further, as I am sure Deputy Shortall would.

Categorically yes to what?

I am agreeing, the Deputy is asking if a patient should-----

Is that happening?

No, it is not. What is now happening in a small number of cases is the GPs can only refer into say urology - they cannot refer to a consultant - and the hospital manages the workload within the hospital, which is how it should happen. I asked the HSE on Monday how quickly we can bring in what is exactly the Deputy's proposal as a national policy. There are some individual specialties where the advice is that one might want to have the ability to refer to consultant A or B because they have a very specific skill set. However for general dermatology, urology, orthopaedics or any of this stuff my clear view is to say a GP should only be able to refer into a hospital and the hospital must load-balance, and I have asked the HSE to implement this. For example, I do not know whether we will discuss this today but on scoliosis, one of the people involved who is a brilliant surgeon said to me that one of the single greatest determinants of how long a child will wait is which surgeon their GP happened to refer them to. That is totally unacceptable so we want that removed and I want to go further than that. That is step one.

Step two then has to be, what about one hospital versus another hospital? If the urology waiting list in St. Vincent's hospital is a lot lower than the urology waiting list in wherever, then we should load-balance there as well and move patients across. The national treatment purchase fund, NTPF, is doing a little bit of load-balancing but not on a systemic level.

My last question relates to data. Can the Minister provide data relating to the ratio of acute beds to population in each of the hospital groups?

Yes, we have that.

If that could be provided, that would be helpful. Following on from that, obviously there has been a lot of concentration on Limerick and the logjams there. Why is it the only hospital group that does not have a level three hospital?

That is a fair question. It is for historic reasons and the answer to that probably goes back quite a long way in terms of reconfiguration of hospitals.

That must be a factor with the long wait times. Does the Minister accept that and why can it not be then corrected?

It is a fair question. It is hard to say. I certainly believe the current ED problems are eminently solvable without adding a level three hospital there. The solutions are there. I do not think anyone would ever rule out new hospitals but I do not think-----

I am not saying new, I am just saying level three.

A level three, yes. I hear the Deputy and it is a fair question. I do not think that is something that would ever be ruled out but based on what I have seen the solution is based on the current configuration. With a lot more capacity and some important reform the solutions are there.

I have to move on.

I welcome the Minister and thank him for being here. He mentioned in his opening statement the work undertaken around ambulance services and optimising those. At a committee meeting recently we heard from both the Dublin Fire Brigade and the National Ambulance Service, NAS, itself that they were engaged in a task and finish group and that there were some issues around phone services and technology between the two groups. Is there work being done on this? At the session itself we were given to understand that there would be a new set of technology available to the NAS in the second quarter of this year and are we still on time for that?

I do not have a detailed update as to how the negotiations are going but as the Deputy will be aware there are ongoing talks between the HSE, the National Ambulance Service, Dublin Fire Brigade, Dublin City Council and the Department of Health to try to resolve the situation in Dublin. The current situation in Dublin is not sustainable. It is the only part of the country where we cannot guarantee a patient will be allocated the nearest ambulance. There is a live patient safety risk, one that has been going on for many years and in my opinion it needs to be resolved urgently.

Do we have a timeline for resolving that?

We may but I do not have the timeline here with me this morning so I will ask the officials to put a brief together. I have been informed that good progress is being made.

Okay. If the information on who would eventually run that service and will have overall operational control over that service could be included in that briefing it would be very helpful. I know that it is a it is British telecom service that will probably be amalgamated.

Yes, that is no problem.

This might not be for the Minister but for some of the officials. I have a question about risk assessments and how often they are undertaken by ED departments outside of the HIQA process?

I will ask Mr. McCallion or Dr. Henry for their views on that.

Mr. Damien McCallion

In terms of risk assessments HIQA comes in to do an independent assessment and that provides learning for all sites and they develop an action plan.

Is that annually?

Mr. Damien McCallion

No it is usually unannounced so HIQA will schedule those, but it is typically one to two times per year. It depends on the site so it is more sporadic.

Is the HIQA risk assessment fully publicly available?

Mr. Damien McCallion

Yes, it is. HIQA publishes the reports on its website and it also published a useful document before Christmas where it looked at the combined learning across a range of sites as well.

Mr. Damien McCallion

We have our own risk management systems in place internally and it would not just be the emergency department; it looks at the impact right across the whole hospital and into the community. Each hospital has a risk management policy and process, a nominated person to lead that, clinically and operationally within all the hospital's services. Those risks are managed daily at an operational level in terms of an emergency department, and decisions are made. There is what is called an escalation policy in terms of how they respond if pressures become increased through that day. Risks are managed effectively on a daily basis and also weekly through their own operational management teams. There is then a formal risk management process where the hospital looks at its overall risk because the emergency department is also impacted in terms of scheduled care because if there is no extra capacity and day beds are being used, for example, to accommodate emergency patients then the waiting lists cannot be run. So we have to look at the hospital as a whole.

Is a standardised schedule provided to hospital groups by the Department for the completion of risk assessments on a regular basis?

Mr. Damien McCallion

Yes, we have a national policy on risk assessments and Dr. Henry might want to comment on that also in terms of how it is applied. That national policy is worked down through the system on a daily basis where decisions are made in terms of risk, because it is important it is not just a technical process.

Separately, the operational management teams in every hospital will look at it. As I said, at a formal level, they will look right across the whole hospital on a regular basis. Dr. Henry may wish to add to that reply.

I take Mr. McCallion's point about the kind of operating procedures, day in and day out, but I am more interested in the formal document.

Mr. Damien McCallion

Sure.

Dr. Colm Henry

As that risk assessment translates into actions, there is an escalation protocol that goes back to 2015. It responds to different key metrics in individual departments, including the number of people waiting and the length of time people are waiting post triage. Following January, we are reviewing that escalation protocol because we think we need to make it more sensitive to patient safety issues such as the length of time people are waiting to be seen after triage. That is an escalation policy that responds to risk but we are updating it based on safety concerns.

Dr. Henry says the HSE is "updating it based on safety concerns". Will he elaborate?

Dr. Colm Henry

We want the system to be responsive not just to metrics, such as trolleys and the length of time people are waiting, but also to other safety issues, such as the length of time people are waiting after triage.

That is great. I will return to the more formal document. What would be the standardised schedule for the completion of a document? Is it monthly?

Mr. Damien McCallion

The management team for the hospital as a whole would look at that monthly but it would also be looking at it during that month. It would not just be a monthly stock take, if the Deputy knows what I mean, in respect of the overall risk for a particular hospital.

There is ongoing assessment.

Mr. Damien McCallion

There is, and that is important. The Deputy might remember a meeting of the subcommittee on mental health to discuss child and adolescent mental health services, CAMHS. One of the criticisms was consistent application of that policy. It is a constant process to reinforce and ensure the policy is being implemented in a consistent way. Equally important, and crucial in an emergency department, is to ensure risk is managed on an hour-by-hour and day-by-day basis because it does vary in terms of the pressures that can come onto a site. People must have an awareness of the escalation policy to which Dr. Henry referred and the steps they need to take. That brings us back to consideration of best practice in respect of how people respond to those sorts of pressures.

I totally take those points about best practice and continuous assessment. Is there a Department requirement for hospital groups to provide a risk assessment on a weekly, monthly or six-monthly basis? What is the requirement?

Mr. Damien McCallion

From our perspective, if we lift the focus higher than just the emergency departments, we meet hospital representatives weekly in respect of scheduled and unscheduled care. We consider and assess with them their ongoing risks. As part of hospitals' overall performance engagement every month, we look at their risk registers and ask what their key risks are, whether they are managing them and whether there are any risks they need to escalate to the national system for support. We ultimately want risk systems, as with all good risk systems, to be owned locally but issues can be escalated if there is something over which hospitals do not have control or cannot address, or where there is something that is common across the system, as was identified in respect of CAMHS.

I will ask a relatively dumb question. Somewhere in the files, there is a risk register or schedule of risk registers where people report monthly to say a hospital completed an assessment and it has been given to the Department.

Mr. Damien McCallion

That is correct. It is not so much the case in terms of the Department. The site would manage that each hospital-----

It is for the HSE.

Mr. Damien McCallion

Yes. The hospital would manage it at that level.

There is a file somewhere outside the hospital group.

Mr. Damien McCallion

There is. Each hospital, in simple terms, would have a risk register it uses to manage the risk within the hospital. It would complete actions within that. The hospital would track and manage those on a monthly basis at a minimum. Each hospital will have a quality, safety and risk co-ordinator who will track the information and look at it on a daily basis. He or she will follow up with people to make sure issues are being addressed. The regulatory piece also comes in, which should also be reflected in that process, through HIQA, the Health and Safety Authority or any other regulator that would visit a hospital or accredit the services of laboratories. There is an active risk management process running in every hospital - of that I am certain. The hospitals manage that intensely at a local level through resources and management systems. We will only look for that information when we are going in through the performance side to see if there are things that we need to be aware of or that the hospital needs support to address when issues cannot be managed locally.

How much of that is reflected in hard-copy notes and is conducted through meetings, and how much of it is technology based?

Mr. Damien McCallion

It is a combination. A national incident management system is used to record incidents and to inform. It can obviously highlight risks that need to be addressed. Some hospitals have very good IT systems to manage that. It will all be electronic in some shape or form but some records will be more sophisticated than others.

There is no standardised nationwide technical system.

Mr. Damien McCallion

A centrally developed system has been rolled out but some hospitals already have systems that work. If a hospital has a functioning system, we do not try to impose on that. We do not necessarily need to see that changed. The key thing for us is not that the system allows us access, but that a decision is made by the hospital in respect of the risk it is dealing with, whether we need to be aware of it or not. There are very clear processes around all of that, including if there is a safety incident or risks that hospitals can manage themselves.

Is the approach of the Department that as systems are upgraded, hospitals move towards the central system or are we allowing them to continuously upgrade a system that runs parallel to, and not with, the central system?

Mr. Damien McCallion

This is a system to support people locally in respect of risk. There is a separate process for escalation. There is a very clear policy about when people should escalate risk or the notification of serious incidents to the HSE, the Department or any of our committees. The technology is just a means to capture it and to use-----

I accept that, but are we encouraging groups to align with the central system?

Mr. Damien McCallion

We are doing that, where possible.

How much of all of that is publicly available?

Mr. Damien McCallion

The risk would be managed within the sites. They are things that would be very operational. A hospital group would not necessarily publish its entire risk register. The HIQA report and independent reviews are all public.

We have established they are available. If there is an emergency department or hospital that has an ongoing risk assessment process, is the Department encouraging hospital groups to make some of that information available?

Mr. Damien McCallion

The policy and processes are publicly available, if people want to see them. The registers themselves-----

I am asking about the ongoing work. Our hospitals are experiencing different levels of operation at the moment.

Mr. Damien McCallion

Sure.

How much of that is legible to the public?

Mr. Damien McCallion

It is very operational. The Deputy will understand that hospitals have a lot of operational documents around all of this, including risk assessments and so on. Those documents are internal. They are reviewed by the regulator but are not typically published because they are for internal working purposes. However, the regulator would look at those documents as part of a visit, as would the Health and Safety Authority. The policy and the way a hospital functions-----

I am sorry for interrupting. Is Mr. McCallion saying those documents might, in some senses, be available through the HIQA report or something like that because they are a part of the decision-making process?

Mr. Damien McCallion

HIQA would refer to some of the risks. As part of its representatives' visits, it is inevitable that they will talk about the risks that are live in the hospital at that time. Some of those would then be included in the report. However, there are many operational working documents that are used to make the whole process flow. The policy for how that is set out is published and is available if people want to look at it.

My first question relates to hospital bed occupancy in Ireland at the moment. What is hospital bed occupancy now? The EU average is 63%. I am curious where we are at in Ireland.

I thank the Deputy. Perhaps Mr. McCallion has the occupancy rates.

Mr. Damien McCallion

I do not have the exact figures but I have the range. It changes every week but would range from percentages in the high 80s to the early 100s during periods of surge. It varies across sites and at different times of pressure. We would have to look at the figures over a period of time. I can provide figures if it would be helpful.

A ballpark figure is 80% or higher.

Mr. Damien McCallion

That is absolutely right. It is high. I would say it would be a percentage in the 90s.

Would that be deemed dangerous in comparison with normal occupancy levels?

Dr. Colm Henry

There are certainly very high occupancy levels. It is certainly unsafe. Advice for a functioning hospital system would be to keep occupancy levels at 85% or less. During periods of surge, as Mr. McCallion said, we find that people coming in through unscheduled care occupy beds designated for other purposes and, as we all know, people also occupy trolleys. That is the subject of the meeting. It is a function not only of bed capacity but also of how beds are used. The average length of stay nationally is six days. It may also be a function of the existence or otherwise of alternatives, such as community services, particularly for those who are most in need. In our urgent and emergency departments, even though older people, those over 65, comprise a minority of presentations, they comprise a majority of admissions. How we provide services and alternatives to the main groups attending is another influencing factor on occupancy rates.

An Irish Government Economic and Evaluation Service, IGEES, report on bed occupancy within public hospitals was published in recent months. We will forward that report to the Deputy and the other committee members.

It would take enormous additional capacity to get the occupancy rate down to the EU average of 63%. There are obviously challenges with regard to how long people are staying in hospital settings but to get the rate down to 63% would be some undertaking.

I will respond. I am open to correction but I think the Sláintecare target was 80%. I am speaking from memory.

That was looked at across Europe and 80% was seen as a decent level. I see here that the OECD level is about 85%. We are regularly in the high 90s. The current situation is not sustainable. Regarding the targets set out, there was the 2018 capacity review, which the Deputy will be aware of. That had a very wide range. In a no-reform scenario, in excess of additional 7,000 beds would be required and in a full reform scenario, the figure would be about 2,400. The Government plan was to add beds in line with the lower number, which was 2,400. The good news is that by the time Covid arrived, that target was being met in terms of a 13- or 14-year increase in beds. We have significantly increased the rate at which we are adding through Covid. We are now well ahead of 2018 report and the Government position, which is that we need 2,400 beds. We are now about halfway - correct me if I am wrong - between the no reform and full reform scenarios. However, my view, and that of the Department and the HSE, is that we have to review the 2018 report. Demographics have changed and our population has increased. My suspicion is that the report might have low-balled the number of beds we need. Hence, even though we have added nearly 1,000, we now have an accelerated plan for another 1,500 on top of that. In parallel, there is long-term planning going on. We have the national children's hospital, the national maternity hospital, the elective hospitals and so on coming through.

In his statement, the Minister mentioned that he visited many emergency departments in recent times and said that some of it was quite distressing. It is obviously distressing for patients, staff, families and so forth. What did he actually see that made him distressed? We have all been in situations in emergency departments. I know the staff are doing their absolute best but certain circumstances are just not acceptable, with people lying on trolleys for days in some cases. What did the Minister see that made him so distressed?

I thank the Deputy for the question. It was a combination of things. In some of the emergency department wards there were long corridors where patients were on trolleys, where they are not meant to be. These are meant to be corridors for people to walk or transit through. I have seen cases, and the HIQA reports point this out regularly, where patients are being denied the dignity they need. I have seen patients waiting on trolleys, particularly people who might have certain injuries or older people - people who are more vulnerable. They are in a compromised state. There in a state where they must be afforded dignity and privacy. In some of our hospitals, particularly, for example, during the January surge, I saw elderly patients in situations where they needed their own bay and needed privacy but they could not get it. I thank the Deputy for his point. This is not the fault of the healthcare professionals providing the care. Healthcare professionals are under intense pressure. There is a human dignity aspect to it and there is a comfort aspect to it. There is also more than that. Dr. Henry can speak to this far better than I ever can-----

How can we stop that? Obviously nobody in this room, including the Minister, wants to see situations like that but how can we stop it so it is not a situation that just constantly goes on?

That is the seminal question. At its most basic level we can stop it by doing two things, namely, expanding the permanent capacity in our public health workforce at a record level and reforming our public health service in line with universal healthcare and the reforms called for in Sláintecare. That means a massive investment in community-based care and the National Ambulance Service to keep people out of the emergency departments in the first place and massive investment in general practice. It means investing in discharge options, such as short-term beds and home care provision. We also have to reform the way patients are cared for and the patient flow within hospitals. We must, for example, have more senior decision-makers available and they must have access to diagnostics. They must have access to health and social care professionals. They must have access to discharge options. Essentially, everything we are doing in order to achieve universal healthcare, and this is a core element of that, really boils down to two things: a massive investment in capacity, workforce, e-health, beds, theatres and community-based care etc., as well as a fundamental reshaping of how we deliver care in line with Sláintecare to deliver it in people's homes, in the community, in general practice and then, only when necessary, in a hospital.

My final question relates to waiting times. This is one of the pinch points in the whole health service. I have said many times that the Irish public health system is a really good system once you get into it but the main thing is getting into it. Waiting times of, in certain instances, a couple of years are just not good enough because intervention is key. Cutting them down to ten or 12 weeks is extremely ambitious but that is where we want to get to. How ambitious is that? Is it possible during the Minister's timeframe as Minister for Health to get them down to that period of time? There are other pinch points around waiting times for speech and language therapy and occupational therapy supports. Those lists are very lengthy. How will the Minister address them in his tenure?

Probably for the first time ever, we can now see universal healthcare as a reality in our country. There are three simple tests here. For me, one of the most important unfinished projects of our Republic, which must be the cornerstone of any decent society, is universal healthcare. There are three tests. The first is whether it is affordable for patients. The Deputy will be aware that we are radically reducing costs for patients. The second is whether the services are there and if they are good services. To the Deputy's point, I think we all agree the services are excellent and he will be aware we are adding a lot of new services that patients need in the community and in the hospitals. On that second test we are moving quickly. The third test is the biggest, namely, access. That is really what today is about. It is about access to scheduled care, which is the waiting lists, and access to unscheduled care, such as GPs, minor injury units, emergency departments or out-of-hours doctors. It is a huge task but critically we are beginning to see the waiting lists fall.

We are all signed up to the targets for ten to 12 weeks. Those numbers have fallen by about 25,000 people just in the last four weeks. From the peak of Covid to the end of last year they fell by 150,000. That is 150,000 fewer men, women and children waiting longer than those agreed targets. That is really important progress. There are still about 495,000. The aim in the waiting list plan for this year is to get that down by about 10%. We will get it further if we can. My numbers will be slightly wrong but those numbers have fallen by over 20% from the Covid peak already.

This is what we are doing. Our healthcare professionals, my Department and the HSE are mobilised around short-term measures. At the same time, Dr. Henry is leading an important structural change. Some €43 million has been allocated in recurrent funding and Dr. Henry is working across the system with Mr. McCallion and others to put in place new pathways of care. For example, the programme for Government, and this may well have been referenced in Sláintecare as well, included a Sligo ophthalmology pilot that was really good. That essentially made it much quicker for patients to get the care they needed. More use was made of opticians and their skills were used more than they are typically. That is one of the programmes Dr. Henry is rolling out. We are aiming to have seven of them - correct me if I am wrong - fully completed this calendar year, which is going to make a big difference. The team is also starting an additional 23.

We are doing a lot of short-term things in respect of the waiting list action plan but, just as importantly, we have to have integrated care. We have to use our pharmacists, opticians and dentists to the fullest extent of their licences. Much of the work we are doing is around that.

I wish to go back to the issue of the elective hospital. I know I dealt with it and the roll-out of this in the past week with the Minister. I am extremely concerned about CUH. The reason I raise the matter again is the issue of getting people out of CUH. It now appears that the bed management team have a huge problem in trying to get step-down facilities for people who require full-time care but do not need hospital care. I have had quite a number of families on to me - I think six - where the period they are in the hospital longer than required ranges from over three months to more than 12. The families now are going from facility to facility trying to get step-down care and it is not working. We have a new premises acquired, the old golf links hotel in Blarney. My understanding is that the refurbishment is completed. There is capacity for 50 beds at the facility. All the indications are that it will not open until January next. Is there any way we can now bring this forward? People are complaining about getting into hospital and about people getting out of hospital and into step-down facilities. It is not working. I do not care what anyone says to me. I have heard from families who are now onto their fourth or fifth facility as regards trying to get that facility to take them in. There seems to be a standoff between the hospital wanting to get people out and the nursing home saying it cannot take them in because they require additional care compared with the normal nursing home patient or resident. I am talking about the Cork area specifically and I am sure it is happening around the country as well. We really do not have efficient use of hospital beds if this is the problem. What can we do to fast-track this issue?

I thank the Deputy for the question, and I fully agree. Probably the single biggest opportunity in respect of trolleys is more discharge. The biggest solution lies outside of the hospital. The Deputy will be aware that there has been a very significant increase - an increase of millions - in the number of home care hours being provided.

I know that, but I am talking specifically about Cork. We have a problem now in that we cannot physically get people out. We do not seem to have a co-ordinated plan in place for getting out people who have additional needs rather than the normal needs of a nursing home resident. The Minister may not have the answer, but I ask that this issue be looked at. There are at least six beds that I know of that are being jammed up because of the fact that we cannot get people out. That is one issue.

The second issue I want to talk about is the elective hospital. We are talking about putting the surgical hub into CUH. It is chaos there at the moment as regards even simple things. Trying to get in there now is a challenge, and we are talking about putting the new surgical hub in there as well. Is that the right decision in view of what is going on in CUH? There are huge challenges there for staff and management. Should we have been looking at a facility away from CUH rather than in CUH?

I will answer the question about the surgical hub. I will ask Mr. Tierney to give the Deputy a quick update on the elective hospital for Cork, if that is helpful, and I will ask Mr. McCallion to give a quick update on specific discharge from CUH. I think Mr. McCallion is working on some of the issues the Deputy has just raised.

For my part, I am of the view that the surgical hubs should be close to the hospital. The reason for that is in order that the workforce can move because we have consultants who will be working in the hospital who can then travel across at short notice, do their elective lists and move back. Also, even though a lot of these are fairly standard procedures, there are always a small percentage of those for whom acute aftercare is required, and having the patient close to the hospital for that can be quite useful. It is worth saying that there is a very significant package of investment now being planned for CUH, including a lot of extra beds, the surgical hub, the paediatric wing, upgrades to oncology, a new trauma centre, including the helipads, and a new medical education centre. There is a very significant package of investment in infrastructure going in to support the new chief executive, David Donegan, and all the workers in CUH.

I will ask Mr. McCallion about the Deputy's first question about specific discharge from CUH.

Mr. Damien McCallion

We look at CUH, the Mercy and the South Infirmary together because, obviously, they interact with one another. The numbers waiting for home care are very low relative to other parts of the country, so that is a positive in the sense that, as the Deputy said, it is long-term care-----

I got a reply from the HSE about a 90-year-old lady who lives on her own and who uses a walking frame to move around. The HSE replied that she is getting one hour a week. With all due respect, to say there is no waiting list for home care is wrong.

Mr. Damien McCallion

To clarify, and to be sure because that is a fair point, what I meant is that for people waiting in hospital for discharge to get access to home care, I accept there are constraints as to how we are having to spread the home care capacity in all parts of the country, but there are additional hours there. I take the Deputy's point about the cases to which he referred. What I mean, though, is that the numbers of people directly delayed in hospital to get access are relatively small compared with those in other hospitals. There is a challenge, as the Deputy has set out, with long-term step-down care and rehabilitation beds. Those numbers are certainly higher in the Cork area.

The Deputy mentioned that additional capacity is coming on stream in Bantry, on Farranlea Road and in St. Mary's. Clearly, there will be some challenges until that comes on and those facilities are opened. I can come back to the Deputy directly, if it helps, on the dates around those openings, but that capacity will help. There is no question - I have been down there myself - but that there is a constraint in respect of step-down capacity in the Cork area, particularly around the city. That is a challenge, and those investments will help to start to address it.

Separately, other things going on in Cork are around, as the Deputy mentioned, older people but also trying to prevent some of those admissions in respect of the older persons' programme, Frailty at the Front Door. That tries to take referrals for people coming in to prevent them from going to hospital. It is hoped that it will help mitigate the risk that they will need long-term care and can try to keep them at home earlier than was previously the case.

On the issue of the 50-bed premises completed in Blarney, though, can we bring it on faster in order to assist the hospital in getting people out?

Mr. Damien McCallion

I know the team down there and the new chief officer coming in. One of her priorities is to make sure that we expedite as quickly as we can getting the staffing to get that in place because, as the Deputy said, the construction is being completed. They are absolutely focused on trying to get those places open for the simple reason that it will support the hospital but also to support the communities. I can come back to the Deputy with dates on those.

As to how bad it is now, though, this week I had two families on to me and they were being requested to be placed in a nursing home in Limerick. One of them was living just on the outskirts of Cork city and their elderly parent was asked to go into a nursing home facility in Limerick. There now needs to be a priority in dealing with that issue.

Mr. Damien McCallion

I accept that. Clearly, that is a long distance. I do not know whether that was on a transition basis. Sometimes-----

No. These are two families. Both patients referred to Limerick.

Mr. Damien McCallion

Clearly, people should have opportunities closer to home to live out their lives in long-term care. I absolutely accept that. I can revert to the Deputy on the exact dates on the opening of those new facilities.

I appreciate that.

Mr. Damien McCallion

They are an absolute priority. I fully accept the point that capacity in the community in terms of beds, both long-term and short-term, is a priority in the Cork-Kerry area. It is a deficit we are trying to work to address. We are also working with the private sector on any availability we have in private nursing homes. The transitional care scheme assists people who need temporary accommodation or who perhaps have to wait for a period to get to the long-term care home of their choice under fair deal.

What about the elective hospital?

Mr. Derek Tierney

On the elective hospital, as the Minister stated, the policy has not shifted. We are going as hard as we can to deliver the longer term solution. When we were before the committee last week, we confirmed that the design team has been appointed and that we are engaging with the planning authorities. We have to go through due process in respect of planning permission, engagement and a procurement timeframe. I assure the Deputy, however, that the foot is heavy on-----

I have a letter dated 25 April from the deputy acting national director of change and innovation. It states that the HSE is working towards 2028 as an indicative timeframe for operational commissioning of elective hospitals in Cork and Galway.

Mr. Derek Tierney

It is envisaged that services will commence and that they will be fully operational in 2027 or 2028.

Hold on a second. Surely if we get through design and planning by this time next year, it should not take another four years to build them.

Mr. Derek Tierney

I cannot forecast what the market will do or how it will respond, but I will give an assurance that we will move as fast as we can. We will not be setting out-----

I am concerned about the target date of 2028. Why can we not bring that forward? At least that would keep the pressure on. The letter I received is dated 25 April. This is the thinking at national level in the HSE. That is not acceptable.

Mr. Derek Tierney

I will take the matter up with the HSE. The Deputy can leave it with me.

On surgical hubs, I have been on site and met David Donegan. It is a landlocked, congested and busy site. For all the reasons the Deputy mentioned, we must confirm an optimal location for the surgical hub in relation to CUH. That work is under way.

Can the paediatric unit that has full planning be expedited?

Mr. Derek Tierney

We will also look at that.

I am working on expediting as much of this as possible. As I said, we are putting a package of infrastructure investment in place for CUH. It is the biggest hospital in the country. It needs a level of investment it has not had in a significant time. The Deputy will be aware that Mercy University Hospital has had some recent invest and is doing well with it. I fully acknowledge the issues the Deputy's constituents are facing. It is worth saying in the context of the additional capacity, that it is being added quite quickly. For example, approximately 17.5 million hours of home care were delivered in 2020. Last year, that went up to 21 million hours. If my numbers are correct, that is approximately 3.5 million more hours of home care support delivered last year than in 2020. We know more is needed. We are adding it as quickly as we can grow the workforce.

I fully accept that. I know there are challenges in getting staff. Can the conditions of employment of home care workers be reviewed with a view to trying to make it more attractive to come into that area? I fully accept that it is a challenge for management to get staff. Is it now time to look at the conditions, pay and all the issues relating to home care to see if we can encourage more people to come into it?

We have some good news on that. We are in the final phases of discussions between the HSE and providers to do a few important things, which are: to ensure that everyone is paid at least the living wage; that they are paid for the time they are travelling between different homes; and that their travel expenses are covered. That should make a big difference. The Deputy will be aware that an additional 1,000 international work visas were allocated at the start of this year to people coming to work in home care provision.

I thank the Minister.

I welcome all the witnesses. I apologise for arriving a little late. I hope that some of my questions might already have been covered.

I will highlight one issue. Some weeks ago, this committee heard harrowing stories about the abuse and violence faced by hospital staff, especially nurses. This issue seems to be exasperated by overcrowding. Will the Minister say what is being done to support staff who are faced with violence and whether security has been increased?

I will ask Mr. McCallion to provide some of the operational details. First, however, it is completely unacceptable, regardless of the context, for any of our healthcare workers to be assaulted or abused. We must have a zero-tolerance approach. We all know patients and their families can end up in distressing situations. I fully acknowledge that, but it is never acceptable for our healthcare workers to be on the receiving end of that kind of abuse or the assaults about which testimony was given to this committee recently.

Mr. Damien McCallion

I thank the Minister and the Senator. I reinforce that it is completely unacceptable in whatever area it happens. Emergency departments are one area but staff also face challenges in many others. We track and monitor this and look at the reported cases to see whether there are any trends in behaviours, services or locations where there is perhaps more pressure. We also provide training to staff to assist them in how to deal with those situations. Many of our staff have to deal with trying to de-escalate situations. As the Senator can imagine, it is complex but supports are put in place where possible. When things happen, we also try to support staff through that process.

The Senator mentioned security. We increased the security presence during the pandemic. We have retained those levels to try to ensure we can avoid those situations. It is impossible to say that we will ever get to a situation where an emergency department will not face those challenges. Unfortunately, this reflects wider society in some cases. However, our responsibility as the employer is clear. We must try to mitigate the risk for our staff, try to support and train them in how to deal with those kinds of situations, and not only in emergency departments - as I mentioned many of our other staff face challenges - and try to track incidents to see whether there are trends and whether there are things we can do or certain locations where a particular focus is needed. As part of the performance discussions I mentioned earlier between hospitals and our community, we look at those kinds of issues, such as staff welfare, whether there are particular issues in certain parts of the country and whether things could be done in certain sites and locations.

That sounds really good. It is important to track whether it is especially bad in certain areas, where that is and what is happening. It is great the HSE will be tracking it and that security has been increased.

Out-of-hours GP services are an important way for people to receive urgent care without having to go to emergency departments. They relieve the pressure on the hospital system. However, there are major shortages in this area. Forgive me if this was already covered. Will the Minister say a little about what is being done to support GPs in their work?

I acknowledge that in some parts of the country, the GP out-of-hours services are struggling to provide the kind of response times people want. It is also important to say that in other parts of the country, an excellent service is being provided. I met some of the GP out-of-hours providers at the Irish Medical Organisation, IMO, conference the weekend before last. They asked me to convene a forum of those providers so they can meet to exchange information, advice and challenges with regard to what is and is not working. I have asked the Department to pull that together. The Senator will be aware that we are kicking off a strategic review of general practice. Opportunities for out-of-hours services will be included in that. Put simply, the other thing we need is many more GPs. The 2018 capacity review showed us to be broadly in line with the countries Ireland was compared with. However, we have a growing and ageing population and we are asking our GPs to become more and more central in our health service. They are now providing access to diagnostics, chronic disease management, vaccinations against Covid-19 and other new services.

We are doing a few things. We are working with the Irish College of General Practitioners, ICGP, to bring GPs from abroad. For example, it is working with South Africa and other countries to bring GPs in with a particular focus on rural practices and on some urban areas. There are issues as regards access in some of the more deprived areas. The other thing we are doing is to triple the number of GPs in training compared with 2009. In the coming years, we will have many more GPs in training who will be moving through the country. They provide medical care directly to patients and ultimately they will become qualified GPs.

In the meantime, we are working with the ICGP and the IMO. There is a substantial fund available this year in the context of the expansion of the GP visit cards to an extra 400,000 or 500,000 people and to support general practices in hiring practice nurses, investing in IT systems and so on. The GP out-of-hours coverage is a part of that.

I thank the Minister.

I thank the Minister and his colleagues for their attendance. The exchanges we have at these meetings are very important. I will try to be as quick as possible. I have four or five questions to ask.

On the annual funding of €495 million being allocated to the enhanced community care programme, of the 96 planned community health networks, 94 have established. In addition, 21 of the 30 community specialist teams have been established. To what degree has this affected the delivery of services in a positive way?

It is going really well. I opened three primary care centres last Friday. We now have 167 primary care centres around the country. There are a lot more in construction, with more to be opened. There are 13 centres in construction, with another five in advanced planning and 29 in early planning. There are many primary care centres. As the Deputy stated and as colleagues will be aware, they are not like the community health centres of old; they are like small hospitals. Many of them have diagnostics and big GP practices. They have mental health teams, disability teams and primary care teams, and there is an energy and passion within the centres and these teams. They have the older person specialist teams and chronic disease management teams. The energy is incredible. It is a very exciting innovation and development.

I accept that. What I am trying to get at is what evidence has emerged to show how improved the service is in terms of dealing with all of the issues we have been discussing this morning, such as crowding at accident and emergency departments, the loss and lack of GPs and so on? The net impact is the important thing I am looking for in this particular situation. Can we state emphatically that we can show evidence to the effect that this is much better than what was done previously?

There is a lot of anecdotal evidence. We have some reviews. For example, the Irish College of General Practitioners has done a review of GP access to diagnostics which shows that a very high number of those people would have ended up in accident and emergency departments instead of ending up back with their GPs. Anecdotally, I can tell the Deputy that patients are saying that they no longer have to go into hospital to manage their chronic diseases. The doctors and the healthcare professionals are saying that they are now actively managing patients who otherwise would definitely have ended up in hospital. They are also saying that they are able to take patients out of hospital much quicker. This is really new. We have some 2,500 staff of the 3,500 now in place. Really we only started this in mid-2021, which was less than two years ago. It is very early for us to have the kind of data that the Deputy is looking for, and which we would like to have. Anecdotally, it is going very well. Perhaps Dr. Henry can add some detail on this as well.

Dr. Colm Henry

We have been gathering some metrics to demonstrate exactly what the Deputy has asked about. Some of the early results are coming through. When we consider the service being provided to older people in 21 of the 30 hubs in respect of dementia, falls and deterioration in circumstances where they would otherwise have been referred directly to hospital, for example, we know that 10% of patients are being seen on the same or the next day. One could certainly conclude that if the care had not been provided in so timely a manner, these patients may have ended up in emergency departments.

We also look at the frailty index, which is a measure of exactly what it says. It is about the proportion of people going there who are frail and who would otherwise be in hospital. It not just a new service for people who would not have needed a hospital service or who would otherwise might have ended up in hospital. The figure in this regard is 40%. It is providing a service that was not there before. It is also providing services to a cohort of patients, in the context of timeliness and need, that was not there before outside a hospital setting. The work is in progress. What we will be doing in order to answer that question for ourselves is-----

I thank Dr. Henry. I will move on to my next question. At previous meetings, in front of the Minister and every official, I have raised the question of hardship grounds for the granting of full medical cards. I have raised this as a Topical Issue twice or three times. I received very nice and respectful replies, but no action was taken. There was no action whatsoever. In fact, I can honestly say that my questions were treated with contempt. Hopefully, it is not a case of somebody being in a position to say "We will shut that guy up because we are not going to do anything, ever." Who suffers? It is the patients. These are not isolated incidents. There is an increasing number of incidents where somebody takes a decision on income grounds. This is not about income grounds; it this is about hardship grounds whereby the condition of the patient relates to a series of issues that have a significant impact on a person's general health. In some cases where accidents may have taken place or things may have gone wrong in hospital, they were treated the same way. As a result, because of their life-threatening and life-changing conditions, they were ignored altogether. The time has come for an awakening of the people who are responsible in that area. I mean real awakening. If there is not such an awakening, I will have to find other means of highlighting the issue, and I will do so. I do not want to do not without giving adequate warning to the people concerned. This issue is there and it needs to be dealt with.

I acknowledge and appreciate the Deputy's adequate warning. Let us find a resolution to this before whatever dire events the Deputy alludes to might unfold. Can I suggest this? The Deputy has advocated for this for some time. The Deputy and I have discussed the matter previously. I acknowledge that the system can probably be improved. A lot of the time, the patients and the people looking for this access are already dealing with very serious health issues as well as other issues in their lives because of their health issues. The Deputy has referenced cases several times that sound very worthy of review. By all means anonymise them. If the Deputy was willing to work up these as examples of the system not working, I can certainly undertake to take those and ask the Department and the HSE to use them as an example of times when the system is not working as it must do for patients and we can see what learnings and improvements could be made.

I would be glad to do that, but the kernel of the matter is simply that this is not a qualification on income grounds. Each time, those responsible come back and ask the same questions on the income of the patient. It is not about the income of the patient; it is about the emergency nature of the request, which has always been provided for but which is slipping away. I thank the Minister for the reply. I would like to see a very fairly urgent response on that for the people who are suffering. I am only talking about those of whom I am aware. I am sure there are many more people affected.

I also want to bring to people's attention again the home care waiting list, which was referred to by my colleague some time ago. There is a serious problem in this regard. We need to resolve it as quickly as possible. Patients are being told that they may not have services for a week or two weeks. A patient who requires a service does not go away. The need for the service does not go away just because there is nobody to meet the demand that exists at a particular time. Somebody needs to emphasise the necessity to look after patients who are caught up in the logjam in this regard.

The final point I want to make, while trying to stay within time, as is my wont, is about Naas General Hospital. I have referred to the latter on a number of occasions at meetings of the committee. I have a long history in this regard.

The curtain seems to have come down in recent times. It is kind of a wall of silence. From past experience in the business we are in, I know that to be decision-making time, which is usually negative from the point of view of constituents' values, concerns and worries. Planning permission has been granted for upgrades and extensions to endoscopy and oncology units and so on for years. It may be that the planning permission has expired. There is no excuse for the long delay, however. It was going to be on the cards as soon as money became available. Well, there is plenty of money available now. I would not like this project to be relegated to the substitutes' bench for the foreseeable future. That will not happen. It is in an area with intense population growth. The hospital provides a critical service to the people of the area and will continue to do so. I know that some changes have been made in recent times. There was no great deal of consultation on the changes or how they affected the delivery of services. It was to meet the cause of something else. I am seeking a clear indication of the proposals in respect of the upgrading and extending of the hospital, as per previous repeated promises.

I ask the Cathaoirleach to allow me time to respond on this important issue of Naas General Hospital. It is interesting that the Deputy has asked the question today. Earlier this week I had discussions with several Deputies who raised concerns in respect of Naas. In essence, they are saying there is a concern locally that there is some secret plan to downgrade the hospital. That is the question that was put to me. I wish to reassure the Deputy and the committee that the absolute intention of the Government, implemented by the Department and the HSE, is to invest in Naas hospital and to grow it and services there. I wish to be clear in that regard. I will provide three examples of that happening. When Covid arrived in 2020, there were 759 people working in Naas General Hospital. Today, there are 945. Since Covid arrived, in the lifetime of this Dáil, there are an extra 186 people working there. That is a significant increase in the workforce. In terms of capital infrastructure, the 12-bed single-room occupancy modular unit is now complete. It is an important additional piece of capacity. Equipping and commissioning is now under way for that unit. As regards the emergency department, reconfiguration and refurbishment of the existing space to provide an 11-bed MAU is under way, in addition to emergency department admission and discharge lounges being created. That is at appraisal stage. It has to go through the process. That will give the Deputy a sense of the progress being made. The workforce has grown significantly, new beds are being commissioned and a significant investment in medical assessment and emergency care is under appraisal.

The population of the area is growing rapidly. The five or 12 additional beds or whatever the case may be were on the basis of an assessment done several years ago. That assessment is now outdated. There is a need to review the situation to ensure we can provide adequately for the future, otherwise it will fall by the wayside. It will be like the medical card issues and so on to which I referred. It gets put on the long finger. The problem is that we never know how long the finger is. There comes an end to one's patience when one is waiting to measure the long finger. We are on the Minister's side. We want to deliver quickly, efficiently and effectively. The time for speculation on how the hospital might be closed and all that kind of thing is gone, however. That nonsense arrives every so often, usually when an election, particularly a local election, is approaching.

Oireachtas representatives in the mid west have attended several meetings, rallies and protests in respect of the ongoing situation with public hospitals and, in particular, the overcrowding and emergency department problems at UHL. I am grateful for the interventions being made by the Minister, including investment, enhancements and recruitment. If he does not mind me saying so, he is cleaning up a legacy mess that arose through many years. I ask him to comment on the 2009 decision, which predates our involvement in national politics. I hope that gives him a certain latitude to comment on a decision over which he did not preside. The 2009 decision was to reconfigure the public hospitals in the mid west by downgrading Ennis, Nenagh and St. John's hospitals and creating a centre of excellence at the Dooradoyle hospital. That centre of excellence has never materialised. It is an insult to patients and staff that the term "centre of excellence" keeps getting bandied about. As I have stated many times in the Dáil, it would have been incredible a couple of years later to say we are striving towards it but we are now 14 years on from that decision, and I do not think that politically, clinically, medically or by means of any other metric or lens we can say it has been a success or has worked. It has been nothing short of a failure. It was a mistake. I would love to hear the views of the Minister in that regard. We will discuss some of the many improvements he is making but we have to admit that the 2009 decision was the problem that led us to the situation in which we are still wallowing.

That decision was made long before my time but I can provide my view, for what little that might be worth. My sense is that the sequencing could have been done differently. In other words, the changes were made and additional capacity was promised. My view is that the additional capacity should be put in place first. The Deputy will be aware that I intervened in Navan and Drogheda and said that although patient safety must always come first and we must listen to the doctors and be led by the clinical evidence and expert clinical opinion, we must also, if we believe additional capacity is required, as it has been agreed is the case in Drogheda, for example, put the beds and services in place and then make the move. I am not sufficiently familiar with everything that happened in 2009 but my best guess is that the sequencing of it might have been different. The outcome might have been different if the kind of additional capacity we are now putting in place in Ennis, Limerick and elsewhere had been put in place.

On the second part of the Deputy's question, that capacity is being put in place at a significant level. With regard to Limerick, the number of consultants has increased by approximately one quarter since Covid arrived, from 165 to 205. That is a big change and we are sanctioning more on top of that. The number of NCHDs has gone up by nearly one third, from 388 to 505. That is a big number of additional NCHDs and we will be going further. The number of nurses increased by approximately one quarter, from 1,600 or so up to approximately 2,100. That is just in the lifetime of this Government. It is from the end of 2019 to today. There has been a substantial increase in the workforce. I do not have the figure in front of me but, since Covid, we added approximately 130 beds into UHL. The Deputy will be aware that I turned the sod on a facility to provide an extra 96 beds. There is a second one, and a third block behind that, where there is space, and we are looking at accelerating additional beds-----

If the Minister does not mind, I will interject as I have other questions. One of the matters he did not address was the protocol change in respect of the medical assessment unit and the beefing-up of local injuries units in the mid-west region. The next logical step is to reverse what I have referred to as a failure.

The Minister has not quite gone to the same extent with his language but the 2009 reconfiguration has been a failure so I believe that the next logical step is, although it cannot be done in the hospitals in Ennis or Nenagh, or in St. John's Hospital, to strive to get a second 24-7 accident and emergency unit in the region. Where it goes I do not know. Obviously I have a certain bias for County Clare but it must be an ambition to have a second unit. That goal cannot be achieved overnight and requires investment. There is a whole lot of implications when it comes to staffing, and let us not be naive about that. A second unit should be the long-term aim for all of us here who serve the region both politically and, indeed, those who lead the Department, including the Minister. Will the Minister offer a commentary on the matter? In the interim period, does he envisage the medical assessment units moving to an "18 over 7" capacity because that would be key to unburdening some of the pressure at UHL?

I acknowledge the Deputy's ongoing advocacy for significant investment in Ennis hospital.

The very clear clinical advice that I have, and that my predecessors had, would not point towards reopening an ED in Ennis. Regardless of my view, the Deputy's view or anyone's view, the very clear clinical advice is that the consolidation of emergency care to the bigger hospitals was important in terms of patient safety. Also, that a hospital of the scale of Ennis, which I think has about 50 inpatient medical beds, it just would not be safe for it to accept emergency department patients because the requisite skills, diagnostics and all the things we now need in modern healthcare simply are not there. However, we cannot just stop there. The Deputy has advocated strongly, and I applaud his advocacy in terms of further investment in Ennis. He will be aware that €2 million went into the new injury unit, which is a unit that was opened last year. Can we expand the hours? Yes. Can we expand the range of people and ages who are seen? Yes. That is part of active consideration in Ennis and around the country of an expanded role for the injury units. To be honest, the units have been really successful so we can do more there.

As the Deputy will be aware, we have invested more in outpatients in terms of X-rays, other diagnostics and replacement theatres. We are investing in a medical assessment team. I think I said earlier that 20 of the more than 50 additional workforce for the medical assessment units - a full 20 of them - are going to Ennis and are being recruited.

While the clinical advice would not steer us towards an ED, the clear advice I have, which I fully support and I have no doubt the Deputy supports, is ongoing investment into Ennis hospital in terms of medical assessment units, injury units, diagnostics, elective care, medical care, beds and so forth.

Estates management is a key. The Minister has just spoken about building new 96-bed blocks. In the mid-west region, and this is probably replicated nationwide, there are a lot of public healthcare facilities lying idle. Inisgile is a 16-bed mental health facility located in my home parish of Parteen that briefly opened as a vaccination centre for Covid. In 2019, it was fully refitted and retrofitted but that fabulous facility is lying idle. The facility could be used as accommodation for nurses, a mental health facility, refugee accommodation or cater for our homeless population. I have repeatedly asked what is happening with the facility but we have not got a sufficient answer. There is a long-term plan for the facility and to have it sat idle in this day and age is quite unforgivable.

Also, from the State's point of view, it is wrong, which I have often said to the Minister, that the management of UHL and the hospital group are not based in the UHL campus. Instead, they are based in a beautiful office block in an industrial estate that is far removed from UHL. I firmly believe that you cannot manage a ship, hospital or school if you are not located on the premises. We have been given every reason why these staff cannot be located at the hospital. I ask the Minister to intervene and crack a whip and say to get back to the hospital environment because you cannot run a hospital from an office suite located at a distance of 2 km. Repeatedly front-line staff tell us that management are not based in the hospital and that is failure No. 1.

Finally, there is a plan to co-locate Limerick Maternity Hospital with the acute hospital in Dooradoyle. I would love to know how that stands. Last night, I had a heart-wrenching phone call with a woman from my constituency who, following the birth of her beautiful baby, struggled with postnatal depression and postpartum psychosis during Covid, itself a difficult time. It took her a while to get her head around what she was dealing with and to get professional and clinical help. She told me that she knew of no facility in the country for the treatment of postnatal and postpartum depression. She was sent to a mental health facility with padded walls beside people with addiction problems and a range of other mental health issues. Her point, which I accept and for which I am advocating today, is that there should be a facility somewhere regionally or nationally. This would allow the father or other family member to come in with the child, integrate the child back with the mother and support her more sensitively than putting her in a padded cell.

She mentioned another point, one that I experienced when our last child was born. When women check into the delivery ward of the maternity hospital, one of the first things that happens is their bloods are taken. However, there is no blood testing lab in the maternity hospital in Limerick. Blood has to be brought by motorcycle or taxi across the city. This seems illogical. If you have the good luck or bad luck – I do not know which to describe it as – to go into labour in the early hours of the morning, one is vying for taxi drivers who are bringing people to and from nightclubs versus taking a fare from the hospital to bring a blood sample. It is daft.

Will the Minister comment on estates management, maternity facilities, postpartum depression and psychosis and how we can more sensitively cater for people’s needs?

Regarding University Hospital Limerick, there are many good people doing their best with historically insufficient capacity in terms of beds, theatres and staffing. We are working on that. I have been clear with the hospital that changes are needed in how patients are cared for there. I am not sure the Deputy was present for it, but I cited the example of University Hospital Waterford, which has approximately half the staffing contingent that Limerick has in terms of emergency care and so on. It rosters its senior decision makers to be present for much longer than is the case in Limerick. One of the solutions is for senior decision makers to be on site in the evenings and at the weekends. We have to scale up and invest in order to make that sustainable. I find it unusual that the hospital management is not on site.

A letter from the Minister could sort out much of that.

To intervene, this matter has been raised a number of times. We received a reply from management at the hospital. It exited the hospital to allow it to be used for other facilities. Management has also denied the allegation that it is never there. It is on record as saying that is not true and that they are present at various times during the day. Therefore, it has been raised and discussed on numerous occasions. I need to intervene on behalf of those senior staff. They are in there and, as far as we are aware, they are doing their work. They have acknowledged that there are challenges in the hospital, but they are on site every day and it would be wrong for me to allow the impression to go out that they are not present and making those decisions. Part of the movement off site was to facilitate the greater expansion of services within the hospital.

I fully agree with that. They are working hard and have immense challenges. There has been a gap in terms of capacity. The Government, the HSE and my Department are working very hard to increase investment significantly while also insisting that the patient flow within the hospital be improved. That is the reality. I sent in a specialist team to examine the matter. The hospital has made a great deal of deal of progress, but things need to be better. That is the reality.

I thank the Deputy for the point about mental health supports for women in pregnancy. One of the important recommendations that we launched in the women's health plan related to perinatal mental health teams. Perinatal mental health teams are now being put in place right across the country. I met the team in Galway. It is multidisciplinary and covers social work, psychiatry and many different clinical groups. The conversations I have had with some patients have been very positive. That is a service that we need to continue to expand to make sure that women have it.

Regarding that Inisgile situation, it has 16 bedrooms, is fully en suite and fully kitted out. We have health, housing and refugee crises going on. It is unforgivable that it has been like this for three and a half years. It is not the Minister's fault because he would not be aware of all these accommodation everywhere in the country. I ask him please to intervene and speak with estates management. That has to be used somehow, whether for mental health, public healthcare, or accommodation for nurses. It has to be put to some use. Sitting idle for another week or month is not an option. This is a turnkey facility. Staff from the HSE estates management come out to cut the grass, spread weedkiller on the driveway and maintain it, but they will not open it and use it. It has to be repurposed. It might not be critical but the Minister could make a quick decision to put 16 nurses in it, each with individual en suite accommodation. I ask the Minister please to use it in some fashion.

We will take a look at it. I thank Deputy Crowe.

I welcome the Minister. I have been dipping in and out of the contributions over the last while. I listened to the Minister's opening contribution. He talked about the additional hospital beds that have been provided, which are certainly welcome. One of the challenges faced at the start of Covid was critical care capacity and how that compared with other countries across Europe. Three years later, how are we comparing with regard to critical care bed capacity?

I thank the Senator. I will get him the exact figures. Much progress is being made. When Covid arrived, we had 258 critical care beds. This is below the international levels that we would expect Ireland to be at. We all saw the deficit exposed by Covid. We should acknowledge the quite extraordinary response by our critical care teams across the country. I do not want to take up the Senator's time, but a conversation I will never forget is one I had with two critical care nurses. They are seasoned, hardened critical care nurses who have seen it all in critical care and they said they were traumatised by their time in critical care during Covid because of how vicious the disease was in how it attacked patients, made them very ill and sometimes killed them. I will never forget the isolation of those patients, sitting on their own without friends and family, surrounded by people covered head to foot in personal protective equipment. We owe the nurses an enormous debt of gratitude. Part of how we show that is money. It is a matter of money and beds.

We have added 65 beds, which is a 25% improvement. To put that into perspective, the total increase from 2017 to 2019 was 18 beds. Our objective is to go to 352, which is beyond what was called for in the 2018 capacity review. That includes nine beds funded in the 2023 capacity plan too. Phase 2 is essentially a new national strategy saying that we need sufficient mass. Is it five centres?

Mr. Derek Tierney

Five.

There will be five centres of excellence where an awful lot more critical care capacity is provided.

When does the Minister anticipate reaching the 350 beds? It is welcome progress from where we were.

We will have 352 by the end of this year. We will go on from that. What total are we going for?

Mr. Derek Tierney

Some 446.

Some 446 is the objective.

We will have gone from 258 up to 446. We are now getting the kind of critical care capacity that the country really needs.

That is excellent. Well done to everybody involved in that great progress. Getting back to more local issues, the feedback on the temporary emergency department in Galway is that it is a huge improvement on what was there. One issue is that the old emergency department is being used. It has ten beds, which assisted over the last winter. Will they be available for the coming winter? The plan is to demolish and clear the site and have it available for a planning application for a permanent emergency department and maternity and paediatric services. Does the Minister anticipate that those beds will be available this winter or will they be located elsewhere?

Mr. Damien McCallion

What was put in this winter is temporary. It helps Galway with some of the pressures. The hospital is looking at this depending on the timing of the construction. It is also looking at whether there is anywhere else on the campus to accommodate those. It is difficult. As the Senator probably knows, the campus at Galway is tight for other space that could be utilised. It will hinge on the timing of the development works, as the Senator said. We are looking at other things for Galway too to support it with beds on the community side and also with regard to the enhanced community care programme that we talked about earlier. It is one of the five busiest emergency departments in the country. We want to have as many people as possible not having to travel to the emergency department. That will involve the older persons programme that we talked about earlier and the chronic disease programme. They are also in place in the Galway area and the whole western area.

It is imperative for those beds to be maintained somewhere. There was obviously the physical space and the capacity to deal with patients who occupied those beds. It would be a backwards step if, for the coming winter, we were down ten beds when the system was able to cope with them last winter.

Mr. Damien McCallion

The resources are protected as a result of the investment that was put into getting those into place. There is a timing issue regarding when the development will happen. We will keep looking at that. Galway is also looking at whether there are any other areas in the hospital that we can reconfigure to have short-term capacity to assist while some of the longer-term work, which the Senator is probably aware of, is going on.

I thank Mr. McCallion. The Minister said he is fast-tracking the development of new elective surgical hubs in Cork, Dublin, Galway, Limerick and Waterford to address shorter-term capacity demands. What sort of timescales, locations and so on does the Minister have in mind for that? The elective hospitals have been decided on for Cork, Dublin and Galway. They are medium-term. For these surgical hubs, is it a case of going to the private market and seeing if there is an available place? Presumably one has to identify locations and go for planning and so on.

I will ask Mr. Tierney to speak on Galway specifically. I asked a few things. That included going to five areas very quickly. They would ideally not need environmental impact assessments. We would use rapid builds. The NHS, for example, is dropping these in all over the UK. We are looking at a similar approach. There are different timescales for the five regions, depending on local factors. I ask Mr. Tierney to give an update on where we are with Galway.

Mr. Derek Tierney

The most likely location in Galway is Merlin Park. There was previous planning consent for a similar activity in that area. That will be an easier engagement with the local authority. As the Minister said, we are pushing to do this as fast as we can, so it will be somewhere within a 12 to 18-month timeframe. Obviously 12 months is the optimum. We are driving for that at the moment.

Is Mr. Tierney talking about modular units?

Mr. Derek Tierney

Yes, that is part of it, whether it is a true modular unit or under the broad umbrella of manufactured for construction. A modular, off-site fabrication would come on-site, with no wet trade. Everything is assembled on site.

What kind of bed capacity is Mr. Tierney talking about?

Mr. Derek Tierney

Anywhere between two and four theatres and associated bays. That design has to be resolved.

Two and four theatres.

There are no overnight beds for day care.

Obviously there are day beds for recovery.

Staffing and recruitment is an ongoing issue.

Is there an improvement or a worsening? Is it more difficult compared to a year ago on the international scene? That is where the focus is in terms of recruitment.

Specifically with regard to the surgical hubs, we are sanctioning the staff now. We are finalising the complement. We do not need the surgeons, because surgeons will come from their existing work and use the facilities, but we do need administrative support. We obviously need theatre nurses, who are rare as hens' teeth in Ireland and across the world. We are sanctioning the recruitment of those now. The idea is that as they are hired, hopefully through this year and next year, they can work within the main hospitals and when the surgical hubs go live they will be transferred to provide those services.

Recruitment is broadly going well. There are two different lenses on this. There are some parts of the country, some hospitals and some specialties where it is really tough to recruit and we have significant shortages. Theatre nurses are one speciality where it is very difficult to recruit, ICU teams are another, as well as paediatrics or emergency department nursing. There are various specialties. There are various parts of the country where hospitals have found it quite difficult. In Letterkenny, for example, they are finding it very difficult to fill some of the consultant posts that are sanctioned there. It is early days but people are getting quite interested in the new consultant contract. I have heard of one or two examples of doctors coming from the NHS to take up the new contract. The hope is that, particularly for those hospitals that have struggled, the new consultant contract, which is a very attractive contract, will help. It is early days but that is the hope.

At a macro level, recruitment is going really well. We have nearly 20,000 more people working in the HSE than we had when Covid arrived. It is a vast increase in the workforce. This year we are targeting about 6,000. Last year the final figure was about 5,400 and we have funded another 6,000 this year. If the HSE hits that or comes close to it we will basically have had four years in a row of record recruitment into the public health service . It is very encouraging. We are making a lot of changes. We have the new consultant contract. We are investing heavily in safe staffing. We are investing heavily in advanced practice for nursing and midwifery and now for health and social care professionals. I am working with the Minister for Further and Higher Education, Research, Innovation and Science to double the number of healthcare college places in the country so we will have a sustainable pipeline into the future. There is a lot of work going on. The Senator will be aware of the NCHD situation, which I think we all agree is totally unacceptable and has been for many years. We now have a good team in place. It has come up with some recommendations which we are now putting in place. The HSE, to its great credit, is making changes to things like emergency tax. We will be looking at regional training rather than posting people all over the country, unless it is to a national centre of excellence. There is a lot of focus on workforce. In fairness to everybody involved, we are expanding our workforce in healthcare at a level that would be the envy of a lot of countries around the world.

The Minister might look into this. The special pandemic payment has still not been paid to a certain cohort employed through Aramark in University Hospital Galway, particularly those who provided meals to patients in the hospital during that period of time. They have gotten the forms and filled them out but it is a long process. I ask the Minister to intervene in any way he can with Aramark to try to push it along and get those payments out.

The committee has written to the company in relation to the pandemic stuff if the Minister wants to wait for that reply.

I will but I would just like to comment on this. I met some of those workers when I was in Galway and I gave a very clear commitment that they were eligible so long as they were in hospital during those dates. I did not realise that, Senator. It is frustrating to hear because I met them and told them and the hospital very clearly that they were eligible and that they needed to be paid like everybody else. We have paid out €208 million, which is fantastic. We do not hear from the people who have been paid, obviously. We hear from the people who have not been paid. I will take that back immediately as I gave a personal commitment to those workers when I met them in Galway.

They got the forms from Aramark earlier this year but they still have not been paid.

I have a couple of comments myself. At the start of the meeting we heard that there were 592 people on trolley beds yesterday with an average of 560 a day. There are huge challenges there. It was asked why people turn up at emergency departments. The reason people turn up is that they are not well and are looking for medical assistance. In a lot of cases the first port of call is the pharmacy. We talked about this before around minor injuries and so on. Maybe at some stage the Minister could come back to us on what he proposes to do in in that regard. It is an important element in medical care and medical support for people in the community. The next step is usually the GP. This depends on where people are living but based on anecdotal evidence from colleagues and so on people are waiting about a week to get a GP appointment. People probably turn up at accident and emergency departments because they cannot get an appointment. We know there are huge challenges there with GPs. The health system is many moving parts and if one of them is blocked or not working that creates a challenge. The Minister mentioned that there are more GPs in training. We have had plenty of nurses going through the system but not staying. That is the key. If we are training more medical staff and more GPs, the important thing is that there are jobs there for them and that they actually stay in Ireland

Deputy Gino Kenny asked what the Minister had seen in accident and emergency departments. I am aware that he was not always a Minister. He has probably been in accident and emergency when he was not the Minister for Health and what he saw was probably completely different as a person coming into accident and emergency for themselves or a loved one or whatever else. My experience has been that there is good and bad. I have been in a number of hospitals. Some were the difference between night and day because of where they are located and some of the challenges the staff in those hospitals are facing. I have been in some where the toilets or the hand-wash basins were not working. I have been in ones where there were people taking drugs outside, there were people selling drugs and there was drug-dealing going on. I am just giving a picture of the huge challenges. That is outside the place, before you go in. In those emergency departments, particularly at weekends, there can be an air of violence because of that. I am saying all this because I accept all the challenges staff are facing.

Years ago there was talk of separating those presenting at accident and emergency departments with drug, alcohol mental or health issues. Deputy Kenny asked about the images the Ministers had seen. I have an image of someone. I was in an accident and emergency department visiting a friend of mine and there was an elderly woman there dying. I always remember this day. All her family were around here and they were praying. She was in a corridor with the family standing around her. Just beside her, there was a guy who was handcuffed who was clearly out of his head on drugs. He must have been out of prison and he was shouting abuse and expletives and so on. I still have that memory in my head of what happened to that family. It was awful. What a way to say goodbye to your mother. I am just using that as an example.

We need to consider the issue of people with addiction who clearly have alcohol and drugs taken, particularly at weekends. We need to examine the hospital system and the dangers within it. People who have mental health issues or are suicidal turn up there, but the accident and emergency department is not suitable for them. We need to see if we can come up with a different approach.

The Minister referred to additional beds for those in the system. It would be fantastic if we could get those 1,500 beds, but where they will be located is key. The beds could be in particular areas, but we need to put them where they are required. The Minister has mentioned many times that there are areas where blockages in emergency departments are down to a lack of beds in the system, and we know that there are hospitals that have submitted applications and where planning permission and climate concerns are not problems. The committee has asked the Minister multiple times for the 1,500 beds to be fast-tracked. Will he revert to us at some point on the matter?

Regarding rehab, why do people stay in hospital for so long? Is rehab one of the areas where there will be additional beds?

I have probably gone way over my time, so I apologise to members who are looking to contribute. I have asked a number of questions. The system is not working. The Minister described primary care centres and community care. The system is fantastic where it works, but I know of many areas where we do not have a one-stop-shop or other facilities. The Minister is describing the ideal model. Unfortunately, though, we know it is not in place. There are major challenges in the community. We are getting older because people are living longer. Housing adaptation grants, community supports and so forth form part of the package of supports that keep people out of hospital and are clearly necessary. If there are no supports in an area, it causes a major problem.

I have gone on for too long. Those were comments, but there were also questions among them.

I agree with the Chair about pharmacies. The Department is working closely with the HSE and the Irish Pharmacy Union, IPU, to enhance pharmacy care. We are considering a number of approaches. One is the introduction of a minor ailments scheme, which is something that the IPU has rightly sought for a long time. Another is a medicines shortage protocol to allow pharmacists to substitute medicines more readily. A third has to do with contraception. There are others, but we need to get going. Pharmacists are trained and capable of providing more advanced care than they are currently allowed to provide. We are working on that.

I agree about GP access. We have shortages. There is a mismatch between capacity and demand in general practice. There are many reasons for that. Ultimately, we need more GPs and practice nurses, particularly in some parts of the country. We are tripling the number of training places. This will make a big difference in time, but not this year or next year. What we can do this year and next year is fund the hiring of many more practice nurses, investment in IT systems and additional supports for GPs and attract international GPs to Ireland. We are working on these matters.

The Chair's story from the emergency department was heartbreaking. That should never happen. No healthcare professional anywhere would stand over it as an appropriate level of care. It should never be experienced by patients and their families. It should not be experienced by our healthcare professionals either. It is deeply traumatic for everyone involved. There are actions under way. We have discussed many of the preventative measures we are putting in place to keep people out of hospital. I do not know the specifics of the elderly lady, but it might be the case that there was some advanced community-based care like our older persons teams that meant she might not have needed to go to hospital. We are putting a great deal more capacity into hospitals. There are emergency departments that are putting in place older persons pathways, whereby older persons are seen in separate areas and there is a focus on geriatricians, those skill sets and discharge options. None of us would ever stand over what happened. That is the world that we have to move on from. While I am reliably informed that a positive face might sometimes be put on things when I arrive into an emergency department, I have also visited emergency departments at midnight. On planned visits, I have seen situations as well. In my experience, the healthcare professionals working in emergency departments want me to see what their patients and they themselves have to deal with. In most cases, they do not hold back. Nor should they.

We are dealing with an historic underinvestment as well as a rapidly growing and ageing population. The demands on our care and health services are increasing rapidly. The goal that everyone in the Oireachtas agrees on is universal healthcare. We are making great progress on patients' costs and the services available to them. For the first time in a long while, we are making progress on waiting lists. There is a focus across my Department and the HSE on emergency departments. We are moving away from the idea that we will have a winter plan every year to the idea that we need a strategy for urgent care, with ambulance services, GP out-of-hours services, minor injury units, medical assessment units, emergency departments, discharge options and community care teams working together. Within that strategy, we ramp up resources in the winter for obvious reasons, but it moves us away from the idea that, since our services do not have the capacity they need during the winter, they get a bit more and try to struggle on. We need to approach this issue much more strategically in terms of prevention, community-based care, hospital care when necessary and discharge options. That is what we are trying to do. We cannot and will not be able to solve it all in a matter of months – it is taking time – but at least there is ongoing investment in capacity at a level that has not been seen in a long time.

What about national rehabilitation beds?

I agree. I was in Dún Laoghaire recently, where the National Rehabilitation Hospital, NRH, is looking to put in place a second phase. It is needed. The Chair will be aware that, for the first year, we have a fully funded national stroke strategy. Part of that involves neuro-rehabilitation in the community. We need significantly more acute rehab beds around the country. Much of the heavy lifting is being done by the NRH in Dublin. I have not received any reports on the matter, but for what it is worth, my view is that we need regional hubs. We cannot ask the NRH to do everything. There is funding for additional inpatient beds. At Peamount Healthcare, for example, we are putting in place an extra ten beds. We are moving on the matter, but I agree that much more is needed.

The trauma strategy is positive. Two major trauma centres are being built – one in the Mater, the other in Cork University Hospital. The Taoiseach and I launched what was essentially the start of the new trauma services in the Mater last week along with the opening of a new state-of-the-art block that has dedicated trauma beds. We are looking at a whole new building for the Mater. Those trauma facilities will help as well.

I thank the Minister for his engagement with the committee. It was slightly unfair of Deputy Cathal Crowe to expect him to comment on what happened in 2009. None us of in this room was in national politics at that time. I was a councillor back then. It is not fair to put that question to the Minister. It should be directed to the Tánaiste, who is the only person currently in the Cabinet who was also a Cabinet member at that time. I recall there being 30,000 people on the streets in Ennis protesting over the reconfiguration.

I have had correspondence from the Irish Wheelchair Association regarding the €1,000 pandemic payment. Will the Minister intervene in this matter? It is 14 or 15 months since people were told they would get the payment. While there are various reasons for the delay, it is now an undue delay. It is reasonable for the Minister to accept it is an undue delay, given we are almost into May and the Cabinet agreed to the payment in January last year.

That issue was addressed earlier.

My question relates specifically to the correspondence I had from the Irish Wheelchair Association.

Is there any initial feedback on how the new management structure that has been established by the new CEO of the HSE is bedding in? It is a significant change that was done very quickly. Has the Minister seen any stoppages being cleared or any other benefit from it?

I thank the Senator for his questions. I will make inquiries about the pandemic recognition payments to which he referred. The vast majority of payments have now been made but there is an outstanding number of section 39 organisations and private providers for which the moneys still need to be processed and paid to staff. I assume the Senator refers to residential services rather than day services. Staff in the latter are not included in the recognition payment.

On the Senator's second question, all I can say is that we have two of the management team here and I think they are exceptionally talented and hard-working individuals. They will no doubt be blushing at such praise. We have a serious team of people in place in the HSE. I have been very impressed with Bernard Gloster.

He and I have met on numerous occasions. The initial signals are all good.

Dr. Henry might be able to help with the next issue I want to raise. On 18 March 2021, the Minister met with representatives of the Irish Haemochromatosis Association. One of the things they asked for is to have a point of contact with whom they could engage. At one stage, Dr. Henry was their point of contact but I understand that is no longer the case. The association is not expecting somebody at that level to be a point of contact but, given nearly 200,000 Irish citizens are carriers or have haemochromatosis, there is a need for a national strategy. That has not happened. We also need a national screening programme and for haemochromatosis to be considered a long-term illness, which it is. I would like a comment on that.

Senator Conway is moving away from the subject we are discussing this morning. As he knows, we have written to the Minister for an update on the issue to which he referred. The Minister may reply if he wishes.

Perhaps he might come back to me with a note.

Dr. Colm Henry

I know Dr. Maurice Manning and the other advocates in this group well. I am more than happy to meet with them, as I have done before. We worked on a model of care with them. I will make it my business to make direct contact with them as a consequence of the Senator's request.

That is great. I thank Dr. Henry.

The next speaker is Deputy Gould. We are running out of time.

I will get through my questions as quickly as I can. There is a lot going on in the health service and I appreciate everybody's hard work. The Minister is aware of the tragic case of Vivienne Murphy, the young child in Cork who passed away from Strep A. One of the issues her parents raised was the lack of ICU facilities for children outside of Dublin. Has a decision been made to put a paediatric unit into Cork University Hospital, CUH and, if so, is there a timeline for that?

The Irish Nurses and Midwives Organisation, INMO, has described the situation in Mercy University Hospital, Cork and CUH as being out of control, with 132 patients on trolleys in the two hospitals last week. Will the Minister comment on that? The emergency department in Mercy hospital is based in Portakabins. I was there last January or February with my father. It is not good enough in this day and age to have people sitting in a Portakabin.

I have written to the Department and to Mercy hospital about a man who has had an operation cancelled three times. The first time was because of the Covid crisis. On the next two occasions, the doctor rescheduled the operation for different reasons. Most recently, this man got less than 24 hours' notice of the cancellation. He has an appointment next Tuesday. I met him one day recently and he can barely walk. He is a carer for his wife who is also sick. He is in constant pain and has been waiting three years for an operation that has been cancelled three times. What can be done for people like him? I thank Deputy Michael Collins for all the work he does in getting people up to Belfast for treatment. I was contacted by a woman in Farranree who needed eye surgery but did not want to go to Belfast for it. The South Infirmary Victoria University Hospital does cataract surgery but this woman has to go to Belfast. That does not make sense when there is a facility in Cork that could do the operation.

The time is running out. One of the issues I am most concerned about concerns the SouthDoc service in Cork city. There is a clinic on the Old Mallow Road and another at the Kinsale Road Roundabout. There is talk of having one facility in the city centre. When SouthDoc was closed before, more patients were going to emergency departments for treatment. We are trying to keep people out of hospital emergency departments.

Is there any timeline for the delivery of the new elective hospital in Cork? I have asked a lot of questions. If the Minister does not get through them all, he might give me a note or get back to me later.

I applaud the Deputy for getting half an hour's worth of questions in right at the end. His experience is showing.

The most serious of the issues he raised concerns the tragic death of Vivienne Murphy. I express my heartbreak and my condolences with her family and friends. The Deputy asked about paediatric ICU services in Cork. The current clinical view is that paediatric ICU patients are to be transferred to one of the two Children's Health Ireland, CHI, sites in Dublin, that is, Crumlin or Temple Street. There is a significant investment under way in paediatrics in CUH, as the Deputy will know. We are building a new paediatric wing. Critically, it will offer single-room occupancy and it will go all the way up to high-dependency care. The advice we have at the moment is not to include ICU facilities but to include high-dependency care. Dr. Henry, my Department and the HSE will keep under review the best deployment of paediatric ICU services from a patient safety perspective.

The number of people on trolleys in Mercy hospital and CUH is a problem. Both hospitals are under sustained pressure. In preparation for this meeting, I asked for the cumulative number of patients on trolleys. The daily figure as of yesterday shows CUH was second in the country and Mercy hospital was third, which aligns exactly with the Deputy's point. I also asked for the cumulative figure for the year to date, which shows CUH is second to Galway, which had the most patients on trolleys. Mercy hospital is further down the list but I know there have been serious issues with patients and healthcare professionals there. We are investing a lot of extra resources in Mercy hospital's emergency department. My figures might be slightly wrong but, from memory, it previously had an allocation of half an emergency medicine consultant, who I understand came over from CUH to manage the Mercy hospital side. I understand that allocation has now gone up to three full-time consultants.

I will check, but it has gone up a lot. That is going to make a difference, and there have been a lot of additional, refurbished and new beds put into the Mercy University Hospital, but I fully accept that there is more that can be done.

On the long waiters, part of what we are doing in the waiting list action plan, and what the team is doing, is systematically going hospital by hospital. There will be a relatively small number of patients waiting for years, that is, waiting four, three or two years, and we are systematically going through that with the clinical teams. I know Mr. McCallion is involved in that, going through it with the clinical teams to say that unless there is some clinical reason, we have got to have nobody waiting for those periods of time. I fully share the concerns around those long waiters, and we are moving as quickly as we can to get them the care that they clearly should have had several years ago.

I thank the Minister.

Again, I thank the Minister for assisting the committee in its consideration of the challenges in hospitals, including emergency departments, bed shortages and overcrowding. It is a matter, no doubt, that will continue to be monitored and considered by the committee. I believe the Minister is back again with the Select Committee on Health next week.

Am I? What are we doing next week, Chair?

Committee Stage of the Regulated Professions (Health and Social Care) (Amendment) Bill 2022.

Oh good, yes, we are. I will see members again next week.

The Minister has a permanent seat there.

The joint committee adjourned at 12.31 p.m. sine die.
Top
Share