JOINT COMMITTEE ON HEALTH AND CHILDREN debate

Role and Functions: Discussion with Health Information and Quality Authority

Chairman

I remind Members, guests and those in the Gallery to ensure that mobile telephones are switched off for the duration of the meeting, as they interfere with the recording equipment even when in silent mode.

I welcome Dr. Tracey Cooper, chief executive of the Health Information and Quality Authority, HIQA, and Mr. Marty Whelan, head of communications and stakeholder engagement, in HIQA. This is the first time during the current Dáil that HIQA has visited this committee. The creation of HIQA in 2007 was to drive continuous improvement in Ireland's health and social care services. It is an independent organisation. The authority is committed to an open and transparent relationship with everyone. To that end, I look forward to today's first meeting with HIQA and to our engagement with the authority.

Before I invite our guests to make their presentations, Members are reminded of the long-standing parliamentary practice to the effect that members 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. By virtue of section 17(2)(l) of the Defamation Act 2009, witnesses are protected by absolute privilege in respect of their evidence to this committee. If a witness is directed by the committee to cease giving evidence in relation to a particular matter and the witness continues to so do, the witness is entitled thereafter only to a qualified privilege in respect of his or her evidence. Witnesses are directed that only evidence connected with the subject matter of these proceedings is to be given and witnesses are asked to respect the parliamentary practice to the effect that, where possible, they should not criticise or make charges against any person, persons or entity by name or in such a way as to make him, her or it identifiable.

I ask Dr. Cooper to make her opening remarks.

Dr. Tracey Cooper

Thank you, Chairman, and I thank committee members.

On behalf of the Health Information and Quality Authority, I thank the Oireachtas Joint Committee on Health and Children for giving me the opportunity to discuss the overall work of the authority. I am joined today by Marty Whelan, our head of communications and stakeholder engagement.

We very much welcome the opportunity to appear before the committee and engage with it. This is our first opportunity to appear before the current committee and we appreciate the opportunity to engage with it on its work, today and in the future. The authority was established in May 2007 and we are very conscious of our responsibilities to Government, the Oireachtas and the public. We look forward to hearing the committee's views and working with it today and over the coming years.

HIQA was established as an independent authority reporting to the Minister for Health with a wide range of regulatory and non-regulatory functions, most of which are set out in the Health Act 2007. All of our functions contribute towards driving continuous improvement in the safety and quality of care and support for people using our health and social care services. While many of the members may be familiar with many aspects of our work, I would like to describe briefly the functions of the authority and then focus on the specific areas that members of the committee have asked us to address today.

The authority was established on 15 May 2007. We report to the Minister for Health and the role of the authority is to promote safety and quality in the provision of health and personal social services for the benefit of the health and welfare of the public. This means the authority has responsibility for setting standards on safety and quality for people using our health and social care services, with the exception of mental health services; monitoring compliance against these standards; and regulating social care services for adults and children, including inspecting and registering designated centres for older and dependent people, such as nursing homes, and inspecting children's services. We have responsibility for supporting providers and staff in bringing about improvements in the safety and quality of services for service users; undertaking investigations where there is a serious risk to the health and-or welfare of a person, or people, using services; and evaluating and providing advice on the cost and clinical effectiveness of health technologies, for example, drugs, medical equipment and cancer screening programmes. More generally, and most importantly in the current climate, we are responsible for promoting the better use of resources in our health system. We also have a function for setting standards in relation to health information and, most importantly for us, publicly reporting on our work in a transparent way and providing information on the performance of health and social care services.

I would now like to focus on the specific areas that members of the committee have asked us to address today. First, I will cover how we assess the safety and quality of hospital services in general. In our assessment of performance of any given service, we focus primarily on the experience, safety and quality of the service for the patient. Our approach in assessing services always aims to be proportionate and risk-based. We are fully cognisant of the economic and fiscal challenges that our health system, and the country, are facing at the moment and what, as a regulator, our reasonable expectation of providers should be as a result. In recognition of this, and increasingly over the past number of months, the emphasis for us, and providers, must be on getting a service safe and keeping it safe. There is no excuse for unsafe care. We can then build quality from this basic platform.

The authority's current powers in health care are derived from the Health Act 2007 and differ from our powers in social care. We may talk about that later. Currently, and in advance of the licensing of health care services, the authority's main functions for assessing the safety and quality of health care services are undertaken through a range of different responsibilities. The first is for setting evidence-based standards on safety and quality which, when approved by the Minister for Health, service providers are required to implement. Currently, the health care standards that have been approved include national standards for hygiene services, prevention and control of health care associated infections and symptomatic breast disease services. We then monitor the compliance of providers against the standards, using a variety of different assessment tools, making recommendations for improvement where required and publicly reporting on the performance of a provider against those standards. Importantly, we also set to monitor key performance indicators which are measures of the quality of the service and which focus on significant and specific aspects of safety and quality for patients receiving those services. We also undertake statutory investigations, instigated by the authority or at the request of the Minister for Health, where there are serious risks to the health and or welfare of people using those services. To date, we have completed four statutory investigations across a range of aspects of the health service and we are currently concluding our fifth. One inquiry has also been conducted.

The members of the committee may not be aware that we have a variety of regular different interactions with parts of the system, specifically to do with elements of safety and quality in the provision of the services. This may or may not be reported in the public domain. In undertaking this work, we work closely with professionals, providers, service-users and professional bodies, both nationally and internationally, where required. This is important and we actively engage with them by means of advisory groups for setting standards, by accessing their advice in monitoring compliance against standards as necessary, and in relation to all of our statutory investigations. They perform as authorised members of investigation teams and in the provision of professional expert up-to-date advice to ensure that our findings and recommendations are appropriate to Ireland, up to date and evidence-based.

We use a number of well-established assessment tools to monitor our standards and to assess the quality and safety of services, which is most important. These range from self-assessment by the provider and which we subsequently validate and also focused assessment where particular issues of concern require a follow-up or where new information comes to light giving rise to a concern relating to mandated standards, up to and including a full review of a service against a full set of standards. This is an open and transparent process and each of these approaches involves ongoing assessment and consideration of information; specific information relating to the how the business is carried out; and an on-site monitoring visit during which we interview people, patients, staff and we observe the areas in which care is provided. If any immediate risks are identified, which is the aim, these are brought to the attention of a provider at the time and action is required. All elements of information from different sources are considered and verified. A report is compiled which is issued to interested parties for the purpose of factual accuracy and, on completion, recommendations are made and the report is made public.

Our approach in monitoring the performance of providers against standards is to enable continuous and sustainable improvement to be embedded in services in order for providers to ensure and to be able to demonstrate that they are providing good quality, safe and reliable care in similar services right across the country.

The new draft national standards for safer better health careare awaiting approval by the Minister for Health. These standards, when implemented, will drive substantial improvements in the safety, quality, governance and reliability of health care services. Based on national and international best practice, there are eight quality themes focusing on what is important for the administration of a good quality, safe health care business. These are person-centred care; safe care; effective care; and the health and well-being of the people receiving those services. They also focus on the building blocks to keep it safer, such as governance, leadership and management; how information is used; the most appropriate use of resources; and the workforce. Subject to approval by the Minister, the authority will commence a national monitoring programme which will radically and substantially drive improvements in quality nationally.

It is anticipated that these standards will be the underpinning standards for the licensing of designated health care services in Ireland. All existing and new designated health care services will be required to meet the regulations for licensing and these standards, in a proportionate and objective way, in order to operate. Only designated services that are well governed and managed, that provide the appropriate types and range of services that can be safely provided by them and that are of a high quality will be licensed to do so.

I will now refer to a number of statutory investigations. These are held where the authority believes on reasonable grounds that there is a serious risk to the health or welfare of a person or people receiving those services. Alternatively, the Minister for Health may request the authority to undertake an investigation. Each investigation has clearly defined terms of reference agreed and published by the board of the authority. These terms reflect the scope of the investigation and the range of the risks and areas that need to be investigated. The process for each investigation is open and transparent. Guidance is issued to the relevant provider, to all individuals who are interviewed and is published on the authority's website. As part of this process, clear lines of inquiry are identified to provide a clear framework for the hospital under investigation, the people being interviewed and the patients receiving care and the investigation team. This framework assesses whether there are satisfactory arrangements in place for the provision of high quality, safe services.

An investigation team is established for the investigation which typically comprises members of the authority and key national and international experts, as required. These experts relate to the types of services being investigated. The views of patients are represented by a lay person who is also a member of the team. Each member of an investigation team has statutory powers to investigate through a process of authorisation by two Ministers. In addition to having authorised experts on the investigation team, the authority establishes in every investigation a formal arrangement with the respective professional colleges in Ireland for the provision of professional expert advice pertaining to each investigation to ensure that we have access to additional advice as required, to inform our recommendations and to ensure that they are appropriate, up to date and evidence-based.

The lines of inquiry for the last two investigations have reflected the authority's draft national standards for safer better health care, the findings of previous reviews and investigations carried out by the authority and the recommendations of the report of the Commission on Patient Safety and Quality Assurance. Generally speaking, the lines of inquiry are framed around themes as follows: governance, leadership and management; safe and effective care; the workforce; and the use of information. Where relevant and in previous investigations, we also investigate the measures put in place by the provider and-or the HSE to implement recommendations of previous reports and investigations issued by the authority and other relevant bodies for the purpose of furthering knowledge.

Our approach involves the review and evaluation of information derived from multiple sources, including documentation, data and observations in the hospital. In addition, interviews may take place with clinical and non-clinical staff, those involved in the management of the service, patients and their family members and the board members of the facility and wider HSE managers, where appropriate. Information pertaining to the investigation may be sought from the hospital or the HSE.

It is important to note that every investigation undertaken involves recommendations for improvement specifically for the hospital that has been investigated, and also, as important, recommendations for improvements on a national basis as a result of the findings of the investigation. It is the responsibility of the provider of the service to implement the recommendations. On behalf of patients, the authority requires periodic assurances from those providers that the recommendations have been implemented and sustained. It is important to us that the recommendations made by the authority are developed with the expertise of the authority and with leading professional expert advice. Where recommendations regarding patient safety risks in services provided at the hospital being investigated have been made, and where they relate to similar services that may be provided elsewhere in the country, the HSE and other relevant providers are required to consider and apply those recommendations to the relevant services in order to implement and learn from them.

Investigations have an extremely important role to play in driving and shaping safer, better care for patients in Ireland. Our investigation reports to date have had important patient safety implications. We publish all our inspection and investigation reports at the earliest opportunity so that the lessons learned are in the public domain for the information of patients and also to allow the HSE and other providers to begin to address our findings and recommendations. The authority will continue to evaluate the HSE's implementation of the recommendations of all our investigations, alongside its compliance with the new national standards for safer better health care when mandated.

The Health Information and Quality Authority's statutory investigations into Ennis, published in April 2009, and Mallow, published in April 2011, identified serious concerns for patient safety at these and, potentially, other similarly-sized hospitals, particularly in regard to the range and scope of patients requiring emergency care who were being treated in the hospitals. The reports contain a series of recommendations aimed at improving patient safety across the health system which should be implemented in full where appropriate.

The authority has not recommended the closure of any hospital. However, it has advised and made recommendations, and will continue to do so, where it believes that changes need to be made to services provided, including the types and range of services, if they are not safe for patients. In all of our investigations we have made recommendations on how to improve the quality and safety of services for patients. The investigations into Ennis and Mallow hospitals identified that these smaller, often stand-alone, hospitals have a pivotal role in providing a wide range of services to their communities, provided those services can be delivered safely. However, our investigations showed that they were not able safely to provide the full range of emergency care for patients. This was due to their lack of capacity to provide the underpinning services needed to treat all types of patients who may arrive and require emergency care. In addition, certain types of acutely ill patients achieve better outcomes when treated at centres that are used to treating higher volumes of such patients.

HIQA made several recommendations in the Ennis report on what was required to ensure the range and scope of services provided at these types of hospitals are delivered safely and optimally. The authority required the HSE to identify all similarly-sized hospitals that face these types of challenges and to put in place the appropriate risk management actions and service changes to protect patients. That was in 2009. The Mallow investigation was instigated following a further patient safety event that took place in a model of care that was reflected as being unsafe in the Ennis report. Sufficient mitigating clinical risks for patients had not been disseminated across the system or implemented sufficiently by the HSE in similarly-sized hospitals at that time.

The findings of our investigation clearly show that these hospitals should not be providing services which they cannot safely provide. It was clear from a HSE report provided to the authority during our Mallow investigation and published as an appendix to the Mallow report that a number of smaller hospitals had continued to provide 24-hour, full emergency care despite insufficient measures having been put in place to safeguard patients or outline how clinical risks were being identified and managed. There has been ongoing progress in the past year or so by the HSE in addressing these issues.

We outlined in the Ennis report that the types of medical patients who can safely be cared for in small hospitals are dependent on the ability of a hospital safely to provide suitable acute surgical, anaesthetic and critical care services 24 hours a day, seven days a week. Where this cannot be provided, acutely ill medical patients with all types of conditions cannot safely be cared for in such hospitals. However, many other types of patients can be safely cared for. As such, we recommended that the HSE establish a model for medical care in order to ensure that as broad as possible a range of less acute cases, including outpatients, day procedures, day patients and inpatients, can be safely cared for in such hospitals.

Following persistent requests by HIQA to outline how it was managing clinical risks for patients in small hospitals of a similar type to Ennis and Mallow since April 2009, the HSE confirmed to the authority in June 2011 that it had serious concerns regarding the range and types of services provided at Roscommon hospital. This reflected the risks to patients in small hospitals that had previously been identified in the Ennis and Mallow reports. Moreover, these risks were being compounded by the shortage of non-consultant hospital doctors, NCHDs, at that time. The HSE also informed the authority that it had made the decision to change services at Roscommon in order to address the patient safety issues. These changes are fully consistent with the recommendations of the Ennis report of April 2009 and the subsequent Mallow report. HIQA supports the new model of services that was implemented by the HSE in Roscommon last year.

At a corporate level, it is the responsibility of the board of the HSE to oversee the implementation of the quality and safety recommendations set out in the reports and to ensure that the necessary, often difficult, decisions are made in respect of services at a local level. These decisions should be informed by the recommendations of the authority and the professional experts nationally. HIQA will continue to hold the HSE to account in implementing these recommendations throughout the State.

Those responsible for providing services in a health system have a duty to be responsive in applying system-wide learning from adverse patient safety events. Where these events occur in one part of the system, the learning must be applied wherever similar services are provided. This is a fundamental tenet of a modern, reliable health system. In its absence we may be exposing staff and patients to unnecessarily unsafe care. HIQA will continue to highlight patient safety concerns as they arise and to evaluate and monitor the HSE and other providers' implementation of recommendations and future compliance with national standards.

HIQA has been in existence for more than four years. We are absolutely committed to discharging the responsibilities bestowed on us by the Oireachtas in a person-centred, robust, professional, objective and independent manner. In so doing our focus is, and always will be, on driving high-quality and safe care for patients accessing our health and social services. We are conscious that the well-being of some of the most vulnerable people in our communities depends on our capacity to set appropriate and high standards, follow through on their delivery, work in effective partnership with all involved in the delivery of care and be a resource of knowledge and experience for the future. I thank the committee for the opportunity to make this presentation and look forward to working closely with members in achieving our shared purpose.

Chairman

I thank Dr. Cooper for her presentation. I now invite questions and observations from members and ask them to be as brief as possible.

Senator Marc MacSharry

I hope the Chairman will afford me some leeway as my two Fianna Fáil Party colleagues are engaged in other business and are unable to attend the meeting. I thank Dr. Cooper for her informative presentation. One of the issues I am interested in, which I am sure she will reflect throughout her responses, is how the committee can be of assistance to HIQA in its work.

In regard to the moratorium on the recruitment of staff in the public service, does Dr. Cooper see this as a particularly blunt instrument? We see the effects of that moratorium on services throughout the country. In the north west, for example, Sligo General Hospital, an acute facility which works very well and is trying its best to cope with austerity measures, there is a near dangerous scenario on the wards. In this and other facilities we are depending on the good will of staff to go that extra yard in doing their work. If an unforeseen event arises such as member of staff being taken ill, are we depending on luck to protect against catastrophe? Will HIQA examine acute hospitals throughout the State which are being forced to cut back for reasons that are specifically to do with budgets and then decide that hospital A or B is unsafe and must be closed down? I will return to that point presently.

Has HIQA any role or does it take a view on strategies being implemented by the HSE? We have spoken ad nauseam about the national cancer control programme in the past. The committee may have a review of that in the coming months.

The recommendations contained in a report on cardiology and cardio catheterisation laboratories by Professor Kieran Daly are being implemented. What is being done mirrors the approach being taken in the national cancer control programme. The basis of that approach appears to be that as 80% of the population live in certain areas, the other 20% do not matter. As part of the recommendations in Professor Daly's report and in line with international best practice, people who have a heart attack will have stents inserted within the recommended period of two hours. However, this will only happen in 80% of cases. As a result of the approach being taken, we appear to be saying the 20% of the population who live north of the infamous line from Dublin to Galway should move closer to that line or die.

Does HIQA have a view on the need to provide services? I am not stating services should be provided in every locality. However, we must cater for those who do not live adjacent to large population centres. It is all very well for those in various authorities and Members of the Oireachtas to sit in their ivory towers and harbour the view that because 80% of people are being catered for, everything is fine and that the other 20% can either move closer to large population centres in which services are provided or die. As Senator Imelda Henry and others from the region to which I refer will testify, this is an important issue for those who live there. What is HIQA's view?

Is it the responsibility of HIQA to make decisions regarding the carrying out of statutory investigations? Does it decide, on a random basis, to investigate matters in Roscommon on one day, in Bandon the next and in St. John's Hospital, Sligo, on the day after that? Is the level of proximity between HIQA and the HSE such that the HSE may suggest matters which the former might investigate or examine?

I have no wish to open old wounds, but I must again mention the national cancer control programme. In 2009 the debate on the move from Sligo to Galway, etc., was at its height. The minutes of an internal HIQA meeting which took place on 3 June of that year and which was attended by John Billings appear to indicate that a report on symptomatic breast cancer services in Galway was being rigged to ensure the success of Galway in the move to which I refer. The relevant notes state:

Other members of the team are nervous about the review. HIQA will construct something that will allow the reviewers to dip into details on certain aspects but will not aim to catch the centres out. Surgeon is concerned that HIQA may fail a centre on a technicality. JB [presumably John Billings] advised that that will not be the case.

I accept that this is an historical issue, but the notes to which I refer indicate a level of proximity and behind the scenes engagement between HIQA and the HSE in following a set of policies which, it appears, are being jointly determined by the two organisations. I obtained the minutes of the meeting of 3 June 2009 through freedom of information requests. The offices of the Ombudsman, Ms Emily O'Reilly, were required to secure the minutes. What happened in this instance is a cause for concern.

On the moratorium, what reassurances can our guests give to all Members of the Oireachtas that HIQA will not, for want of a better term, be doing the dirty work of the HSE's finance department which it appears is directing HIQA on how to proceed? For example, it seems to be saying, "Go to Lifford next and compile a report. We know the hospital there is understaffed." It is able to do so because, as outlined, the process has been rigged, as it was in the case of Galway and UCHD, in the context of it becoming a centre of excellence for cancer treatment. To what degree can our guests assure us that what I have said is not the case?

I hope I have not taken up too much time. I thank the Chairman for indulging me and support him in the work he is trying to do. However, he will appreciate that I have a number of concerns and that I wish to have them allayed.

Deputy Michael Colreavy

I welcome the representatives of HIQA. This is an important meeting and I hope the committee and the authority will maintain a continuous and productive relationship. I apologise for the fact that Deputy Caoimhghín Ó Caoláin is not present. Unfortunately, he was obliged to attend a funeral this morning.

HIQA performs a hugely important function, namely, working to ensure the safety and quality of health and social services for all those who avail of them. Its role is going to be increasingly vital because cutbacks in health are beginning to cause damage to the very fabric of the public health service.

I wish to pose a number of questions relating to specific matters about which I am concerned. Do our guests share the concerns of many members regarding the use to which some of HIQA's reports have been put by the Health Service Executive? On a number of occasions HIQA has reported instances where improvements need to be made to public nursing homes but where it has not recommended closure. The HSE has seized on such reports and used them as a rationale to either close or threaten to close the facilities in question. Two examples in this regard are Loughloe House, Athlone, which was closed, and St. Bridgid's, Crooksling, County Dublin, which is threatened with closure. I understand a great deal of work was carried out at St. Bridgid's in order to bring it up to standard but that the HSE has persisted with its decision to close it. I understand, however, that the Minister has given the home a temporary reprieve. Did officials from HIQA engage in a further visit to St. Brigid's when the work to which I refer was carried out following the initial report?

The Minister has implied that there is a question mark against the viability of public care units for older people with fewer than 50 beds. Is HIQA in a position to confirm that there is no safety issue in respect of homes with fewer than 50 beds as long as the various standards and requirements which obtain are met? I am concerned about the process of reducing the number of beds available because of financial constraints and then using such reductions as a rationale to justify closure. In effect, this is similar to a self-fulfilling prophecy and constitutes a planned process of closures - possibly under the banner of HIQA.

When will the report on Tallaght hospital be published? Why is HIQA investigating certain hospitals and not others? In the context of Roscommon County Hospital and smaller general hospitals, there are many facilities which are not classed as regional hospitals but which could provide appropriate and safe services. I reject the mantra that big hospitals are safe, while small hospitals are not. This mantra is used as an excuse to remove services - not just emergency services - from smaller hospitals and centralise everything at a handful of regional centres. There is a risk that decisions which are based on economic considerations are being made under the flag of convenience of the need to take cognisance of quality and safety issues. Has anyone examined the safety and quality of services provided at overcrowded accident and emergency departments in larger regional hospitals?

It is sometimes stated politicians want a general hospital at every crossroads. That is not the case. However, account must be taken of people's level of access to services. In that context, I refer to the reality for those who live in the west and other outlying regions with regard to the distances they must travel to access services. A clear pattern has been established. Either the Minister or the HSE is allowing services at smaller hospitals to be starved of resources and they are then being declared unsafe. This, again, is similar to what one would expect with a self-fulfilling prophecy. Does HIQA have a brief to look at the position of patients on long waiting lists for certain specialty services because a failure to deliver services can be as damaging?

My final question is what is HIQA's role in respect of private acute hospitals? It was interesting to note, for example, that when breast cancer services were being removed from Sligo General Hospital, patient throughput was one of the key determinants of the decision, yet breast cancer services are being provided in private acute hospitals with a considerably smaller throughput.

Deputy Denis Naughten

I welcome Dr. Cooper and Mr. Whelan. My first question relates to the new HIQA standards for ambulance response times. The first set of data published by the HSE shows that up to last July 70% of all ambulance call-outs failed to meet the HIQA standard. Will someone explain to me how HIQA considers its standard which has resulted in a 70% failure rate offers a safer option than having a local accident and emergency department with a clear bypass protocol in place for particular patients?

Following on from the previous question, perhaps HIQA might clarify the position. The Minister has agreed that there should be regulation of the public, private and voluntary ambulance services. HIQA agrees. Therefore, when will it happen?

When were HIQA representatives last in University Hospital, Galway? This week we again had a full capacity protocol implemented there. It is where, based on the HIQA formula, critical patients from County Roscommon are supposed to go. As one patient described to me today, conditions in University Hospital, Galway are Third World and there is genuine fear that people will be dumped there. People have refused to get into ambulances when they have been told they are going to the hospital.

The emergency transport service is an issue I flagged with Dr. Cooper when we met last July. As she is aware, the accident and emergency department in Roscommon was one of the most isolated in the country up to July last year. Currently, when an ambulance eventually arrives at a patient's door, he or she has to be put into the back of it. The ambulance crew then have to ring the ambulance control centre to find out which accident and emergency department has the capacity to take the patient, which runs contrary to the indication given by HIQA that patients be taken to the most appropriate centre. That is not happening to our patients. I have provided particular instances when trauma patients were taken to Portiuncula Hospital when they should not have been. One trauma patient was diverted to University Hospital, Galway en route because Portiuncula Hospital was not in a position to cater for them. Sadly, the family arrived in Galway before the ambulance. In that context, has HIQA reviewed the fall-out from the closure of the service in Roscommon County Hospital and the failure to transport patients to the most appropriate centre? Has it looked at the ambulance service in Roscommon, and response and transport times? What assessment has been made of the knock-on impact on patients in Ennis and Mallow on foot of the closures?

It has been stated HIQA supports the new model of care being implemented in Roscommon. If anyone has looked at the situation in Roscommon one could not make the comment that has been made in that regard. I have given specific examples to show what is not happening. Patients who have had a heart attack and should be admitted to CAT labs are not being so admitted.

On the comments made about smaller hospitals, as the delegates are aware, Professor Jon Nicholl, head of Sheffield University's medical research unit, was in the country at the weekend when he made the point that claims that lives would be saved if patients were taken to large specialist emergency departments did not factor in dealing with a large cohort of patients. He went on to say this country needed both local accident and emergency departments and centres of speciality, something that has not been acknowledged to date by HIQA.

Dr. Ronan Collins, director of stroke services at Tallaght hospital, has again contradicted the Minister and HIQA on the issue of the golden hour. He has pointed out that it is not accurate to suggest patients in rural areas have up to four and a half hours to receive appropriate treatment if they suffer a stroke. In fact, research published in the Irish Medical Journal regarding the Midland Regional Hospital in Mullingar, indicates that each minute a person is delayed in receiving treatment has an impact on his or her subsequent quality of life. How does one square the circle in terms of a small cohort of patients who need to get to a regional centre and the vast majority who need treatment quickly which they are not receiving?

Dr. Tracey Cooper

I apologise in advance if I do not cover all the questions asked. Members should let me know if that is the case, as I am keen to answer all of the questions asked. They should remind me of the hard questions.

Senator Marc MacSharry spoke about how the committee could work with us and vice versa. As far as we are concerned, we do business for the country. The organisation and I are interested in having regular meetings with the committee to discuss any matters members wish to raise. We would also welcome an opportunity to hear their views on developments. Perhaps we might discuss the matter later with the Chairman, as we are keen to be more involved. We see it as being part of the ongoing discussions we need to have.

Reference was made to the moratorium on staff recruitment, how it was impacting and how it would continue to impact. In February and coming months, when another large group will retire, there will be a potential impact on the provision of services. It will be hugely challenging for all organisations, in particular service providers. What we are finding in our work, particularly in the past year or so, is that opportunities arise in terms of how health care services are organised, for example, in providing shift cover in respect of the opening hours of radiology departments. Many practices in a number of hospitals, although not all, are very much based on an historical model of care and organising waiting times for patients. We are looking to provide a system of care that will make the best use of the staff available, with the appropriate skills and based on the opening hours available to the public, and ensure the most appropriate person is able to do the maximum of jobs. What I mean by this is that in work we did previously, about which we have not talked much today, on our health technology assessment function, we looked at how colonoscopy services were provided across the country. To enable us to introduce a cancer screening programme to save up to 290 lives a year, we examined what we needed to do more efficiently. The answer was not to add a lot more staff - doctors and nurses. One of the main solutions was to develop nurse practitioners who were skilled and competent, perhaps more so than a junior doctor at performing such procedures.

In the current climate - the Senator and I agree on this - there comes a point when there are not enough staff available. There are only so many efficiencies that can be incorporated, but if I was a manager of a service, the first question I would ask is whether I was organising the service for patients in the most effective way and there was a major way for us to reach the most efficient way. I have been involved in many discussions not only on how we provide emergency models of service across the country in hospitals of different size but also on how we should address issues such as the provision of the preventive care services we need and how we help to build primary and community care services. Many patients are seen in hospital, but many services can be provided in primary care settings, whether it is having to queue for a blood test because there are not enough staff available to take blood, undergo minor procedures, see a consultant cardiologist or a consultant diabetologist when they could see a general practitioner who is capable and skilled. There is much to be done in examining how we organise care services and make the best use of staff, but I agree there comes a point when it is difficult and challenging.

The Senator asked whether we would use this as a stick to say if there were not enough staff available, we would close a facility. I will say this only once and ask members to read it into many of my answers to the questions asked. We have not recommended the closure of services. It is about the services that can be safely provided, not stopping a service. We are living in a world in which it is as much incumbent on us to ensure what is expected in terms of safety and quality is reasonable in what can be provided in an increasingly challenging environment. I made the point in the presentation - I hope I did not come across as a little puritanical - that it was important to emphasise that safety had to be the primary consideration for everybody. That includes staff and the organisation of care. We will encourage, support and help to drive developments, using our staff in the system better in organising services, but if there comes a point when it is unsafe and a service must be enhanced, we will also make that point. That is not an easy answer and we must be dutiful and proportionate in the way we approach our work.

The Senator asked about Health Service Executive policies. I apologise, but I am not familiar with what is being proposed in respect of cardiology services. I am familiar with some of the evidence in respect of rapid access to stents for particular patients who have suffered an acute heart attack. My approach has always been to ensure decisions are made in a way that is informed by the evidence nationally and internationally and by examining the demographics of the country. It must always be what is appropriate for Ireland. How and where should we provide tertiary and specialist services? The matter must be looked at nationally before we ask what would it mean in different parts of the country. Decision-making has been difficult for understandable reasons, but when we come to actively design and provide care at local and regional level in terms of unique specialist services, as a country, we must take active decisions and then look at the issue from a regional perspective. I agree with the Senator, but my view is that it must be an informed process, rather than looking at the issue sporadically. Travel times, distance and population density must be part of these conversations.

The Senator talked about symptomatic breast disease. I refer to his comment about rigging and the excerpts he read. I will say this once and forcefully. We are adamant that the only way we can do our job is independently. I cannot see us doing it any other way. Much of what we have to say is difficult for people to hear. The messages are difficult, but it is about safety. However difficult it is, it must be managed. There are other challenges about the way we manage the changes to be made.

On our relationship with the service providers we regulate, we regulate the HSE, voluntary hospitals, private and voluntary nursing home providers. One of the Senator's colleagues asked about private hospitals. I will deal with that issue shortly, but I am not into cosy club relationships. Members should, please, take that comment in the way it is meant. We cannot fulfil our duty and do our work that way, but we are not about catching people out. When I first came here five years ago - people have had to put up with me for that length of time - I said - I will continue to say it - that it was about helping people to provide better, safer services. It is not about the regulator trying to catch people out. If we have done this, we have failed. We try to be very open. We are not trying to make good people who go to work to do a good job feel demoralised in what they do. We become frustrated when the communication of advice and recommendations is misinterpreted or badly communicated. This is not fair on staff and patients.

Chairman

Is Dr. Cooper saying she is not in a cosy cartel with the HSE?

Dr. Tracey Cooper

Absolutely. For us, it is a regulated entity; therefore, when we come to monitor standards or investigate it, there must be clear lines of responsibility. From our perspective, the HSE and other providers have responsibility for managing the provision of services. Our responsibility is to monitor whether they are providing services to the required standards for patients.

At a strategic level, when we talk about the current reform system, how we move towards self-governed trusts, free primary care services for all or changes being mooted around the HSE, as an organisation which sees gaps in quality across the system, we have discussions with the Department and, at times, the HSE on how we can help through our work to get the country to where it needs to be, but when we inspect services specifically provided by the providers we regulate, we have to do it independently. It is not about catching out staff.

The Senator used the word "rigging". Rigging benefits no one. For as long as I have been in the organisation, we have worked with people. We have strong powers that we do not wield unless we have to do so. However, we have had to do so on a number of occasions when we had to seize information from providers, including the HSE, because it is about the patient, not the provider.

It includes HSE management. Let me outline the process when HIQA comes to decide whether there should be an investigation. Let me refer to the example of Mallow hospital, as we outline in the report. Information of significant concern came to us on someone who had died. It was confidential and, to safeguard the family, we did not publish it in the press. When there is such concern, we contact the provider - in the case in question, Mallow hospital and the regional director of operations of the HSE in the area. We outlined in a non-attributable and anonymous way the kind of care the patient in question received. The patient had had an operation and died subsequently. In such cases, we ask what services were provided and how risks were managed. We asked whether there had been adverse events in Mallow and what had been done about them.

From approximately April to July - forgive me if I get the timeline wrong – we persisted in seeking assurances from the HSE that it was identifying the risks and that the risks for patients were being managed. Over two months we reached the point where we failed continually to be satisfied and assured that safe services, related in particular to complex surgery still being undertaken in the hospital, were managed sufficiently. Consequently, we believed patients were being exposed to dangerous care.

In considering our findings, it is always as an escalation and never on the basis of one piece of information that comes through. The Tallaght hospital case was the same as the other. The benefit of the doubt was given with regard to the hospital's assurance that it was managing risks for patients. We balanced the information and considered all the correspondence received. We also considered the fact that had the recommendations in regard to the risks identified in the Ennis hospital report been implemented, we might not have been led into carrying out the Mallow hospital investigation. Rightly, it was the view of the authority and its board on that occasion that there were reasonable grounds for believing there were serious risks for patients.

As with every item of information that comes to us, we engage with the facility in question. It is a big issue considering our powers. With regard to Ennis hospital, we were requested to carry out the investigation by the Minister. There were ongoing discussions with the hospital. Committee members may remember that a number of patients had died. There were approximately ten items of additional information on adverse events of which we were made aware. We engaged with the HSE. We wanted assurances and to know how its services were being provided. There were a number of specific services that we regarded as inappropriate for examination. We were concerned about how the organisation, as a hospital, was managing patient care. On that basis and on foot of discussions with the Minister, we were asked to instigate an investigation.

The Tallaght hospital case involved ongoing engagement in regard to the accident and emergency department for a number of months on identified risks. Action and improvement plans and ongoing assurances on how patient risks were managed were requested. We were then informed a patient safety event had taken place. We considered the information and were not assured the service was safe. We then made the decision on the investigation. There is a very deliberate process, as there must be, to decide when we should investigate.

There are a number of additional engagements throughout the country, in respect of which we have not made a decision to instigate an investigation but in respect of which we are concerned and want to keep a monitoring eye on the quality and safety of the services provided. I refer to two places, one in the north east and the other in the mid-west. Periodically, normally every other month, we meet a large team in the two hospitals. We go to the sites, walk around the accident and emergency departments and the rest of the hospitals. We have worked with the special delivery unit on how it is helping the hospitals to try to improve systems and safety for patients. We have a number of deliberate processes in place, which as a regulator we must have.

Have I answered all of the Senator's questions?

Senator Marc MacSharry

Yes.

Dr. Tracey Cooper

I thank Deputy Colreavy for his questions. He is absolutely right. In the current climate of health cutbacks, it is imperative that we ensure services that may be curtailed are safe. He asked about our reports and HSE's interpretation thereof. To be honest with him, it has been the cause of frustration. However, our reports speak for themselves. As the Deputy will know, we publish a report on every inspection we undertake. If there is a legal process, however, we publish at the end of that process, within a reasonable timeframe. It is purely a matter for the provider, as the regulated entity, be it public or voluntary or the HSE, to close a service.

There are centres which are providing safe services. They may not be gold or platinum, but they are safe and continue to improve. Some of these centres may have challenges associated with the building, but that does not mean patients are not receiving good quality care. Every provider has until 2014 to address some of the institutional building issues in the light of the regulations. We must ask whether the people running a centre are fit to care for vulnerable patients and whether the standards and regulations in law are being met when making a decision on registration. We must be pragmatic, but we must also ensure a service is safe. If the HSE decides to close a centre, it must inform us. However, it is its decision. We continue to inspect an investigated centre and publish our results on the quality of services provided.

Regarding the service plan and the challenges associated with nursing home provision, we will be meeting the Department and the Minister to have conversations on how HIQA, as a regulator, can help to provide some stability in the sector. Deputy Colreavy referred to where there were fewer than 50 beds in a nursing home or centre for older people. From my experience of regulating nursing homes and community hospitals caring for the elderly, particularly in the past 18 months, there are significant differences to be considered. There are different services in public centres because of the nature of how they have been established. Sometimes psychiatry for old age is provided in such centres, as well as long-term care, rehabilitation services, etc. The private providers tend to provide long-term care and tend not to receive such support. I am not informed enough to make a comment on where is the point of viability, as in general it is different for each centre. For instance, a number of very small private services have chosen to close. In addition, HIQA has entered into a process in which it has not been sufficiently satisfied on the quality of care provided or the fitness of providers and has closed them through a legal process. As for the trend in this regard, we are talking about 20 or so people. Consequently, there is a challenge, particularly regarding the level of viability, but I do not know what a specific level would be in respect of financial viability. It depends very much on the totality of services provided in a particular centre and we would expect a decision to be made taking this into account.

Deputy Michael Colreavy has asked when the Tallaght hospital report will be published. We have concluded the investigation proper, that is, we have concluded all the interviews and received all the information and data we have considered. We have met people from many parts of the system that relate specifically and indirectly to Tallaght hospital and are in the process of concluding the draft report. This is a big destination and when completed, the draft report will be subject to a process to ensure accuracy. This means that those who have been interviewed in respect of a particular service will be provided with the relevant excerpts pertaining to them, as interested parties, to revert with comments. In other words, if HIQA has written a figure as 22 when it should be 18, we need to correct it. This process will take a few weeks to complete. We will consider everything that comes back to us and then finalise the report which will be approved by the board of the authority and published shortly thereafter. Realistically, the timescale may move somewhat, but it is likely the process to ensure accuracy will take up the greater part of February to complete. Being realistic, I hope we will publish the report at the end of February or, at the latest, in early March.

I consider this report to be of significant and substantial importance to the health system. As in every investigation to which I referred in the presentation, HIQA makes recommendations that do not merely relate to the relevant hospital and its services. In the case of Tallaght hospital, we have considered governance issues, the board and how patients requiring acute care are cared for across the hospital. Consequently, it is a major report. In addition, HIQA will make national recommendations that will have an impact on how large hospitals are run. Again, were the joint committee to consider it appropriate, we would be delighted to come before it at some time after the report's publication to provide advice or comments or to hear members' views in this regard.

Deputy Robert Dowds

I would be interested in doing this.

Chairman

We would be happy to arrange it.

Dr. Tracey Cooper

Deputy Michael Colreavy asked about patients on long waiting lists and he is absolutely right. The draft standards to ensure safer and better health care outline a number of elements in respect of quality which include waiting time. The Deputy is absolutely right in that were one to wait for a long time for a hip replacement, by the time one has had one's hip replaced one might now have a problem with one's knee or other hip. Consequently, this is a quality and a safety issue and the standards outline those elements of quality HIQA would expect to be managed. At the very least, we would expect prioritisation of patients waiting on a list in order that it was not tackled purely by chronology but that there would be an informed decision as to whether a patient's case was urgent and what was that timeframe or whether there was an acceptable waiting time. We have had a number of discussions with the special delivery unit on the quality elements of performance and waiting times. As the Deputy may be aware, the unit is focusing on certain patient conditions for which there are waiting lists to try to address those about which there is most concern.

The Deputy asked about private acute hospitals. In picking up on Senator Marc MacSharry's point, I absolutely agree. The standards should apply to every facility providing such services, regardless of whether they are private, public or voluntary. While it is different for social care, I refer to the position on health care under the Health Act 2007, under which HIQA was established. Our statutory function applies solely to the HSE and providers that provide services on behalf of the HSE, most typically the voluntary hospitals.

I refer to the introduction of licensing. We are having a number of real-time discussions with the Department about the standards being mandated and implemented and about HIQA monitoring these standards. Then, I hope in the relatively near future, licensing will mean all providers, public, private and voluntary, will come under such a licensing regime. We have regular discussions and meetings with the Independent Hospital Association of Ireland. I note the majority of larger private hospitals which come under that association's auspices have engaged openly with us and are keen to have the standards applied to them. However, at this time, HIQA does not have statutory jurisdiction.

In response to Deputy Michael Colreavy's comments about volumes and outcomes in small private hospitals, I agree this should not be the case. Does that cover his questions?

Deputy Michael Colreavy

It does. I thank Dr. Cooper.

Chairman

Dr. Cooper should respond to Deputy Denis Naughten's questions. I am conscious that other members are waiting to contribute.

Dr. Tracey Cooper

I will try to be brief. Deputy Denis Naughten spoke about ambulance service key performance indicators. As there is much on which to engage with the Deputy, I apologise and will try to be brief.

HIQA has been involved for the last two and a half or three years - again, not everything we do gets into the public domain - with the Department and the HSE to try to strategically improve the provision of ambulance services. This has involved looking at the number of paramedics and advanced paramedics. It has also involved introducing a call prioritisation system for patients who dial 999 and includes ensuring we do not have too many ambulance control centres but just as many as we need. This is because wherever there is a control centre, there is a boundary, which is unsafe. Much has been input incrementally to try to move the service to where it needs to be. Certain items of information are fundamental to knowing how good is one's service. In an ambulance service, this is the case with response times, particularly for patients with immediately life-threatening conditions. The evidence is that for certain conditions, particularly heart attacks, the longer it takes to provide definitive care, the less likely the patient is to have a good outcome.

Consequently, the Deputy may be familiar with the ambulance service key performance indicator, that one has seven minutes and 59 seconds to get to all patients with immediately life-threatening conditions. In order to achieve this single indicator, the ambulance service must change radically the manner in which it provides services. Frankly, this means practices such as having people on a pager and working from home when out of hours who, when they receive a call, must then travel to an ambulance station to pick up an ambulance to go to a patient, have no part to play in a modern-day ambulance service. We are no different from many other countries that face population density challenges. A number of counties have progressed the concept, based on evidence, that when a person has an immediately life-threatening condition, particularly if one's heart has stopped or one's breathing is troubled or has stopped, the most effective thing to do is to get to that person someone who is appropriately qualified with good life support equipment, including a defibrillator. Moreover, as soon as possible, if this assistance is not available in an ambulance, one needs a patient-carrying vehicle to collect the person and take him or her to the right place. While much work has been done in this regard, I agree there is still much to be done.

As for HIQA's engagement with the ambulance service on this performance indicator, when we started out, we knew it did not have in place the information systems necessary to even carry out measurements. Consequently, we agreed to work with the ambulance service, but told it that it was obliged to continually improve in this regard. We indicated that we wanted it to engage in performance managing at local level, that it needed to collect the information required and ensure its collection because it could not manage without it and that it then needed to progress it. We have periodic meetings with them to look at that. We have also made recommendations in relation to the arrival of an ambulance for less immediately life-threatened patients because sometimes the wrong information is given by phone and what one may think is not an immediately life-threatening condition turns out to be one when an ambulance arrives. That is the next suite of indicators on which we have made recommendations to the Minister to approve. It is not going to be perfection overnight; it is about getting us to the place where we need to be over a sensible period of time.

I am concerned to hear from Deputy Naughten that an ambulance then rang control. I would be interested in that information.

Deputy Denis Naughten

I can send it on to Dr. Cooper.

Dr. Tracey Cooper

Please let us know. Obviously, we are keeping an overview. Even up until yesterday we were having discussions with Mr. John Hennessy about how things were progressing. It is the same with Mallow, Ennis and all the smaller hospitals at the moment.

Chairman

Perhaps Deputy Naughten can correspond with Dr. Cooper on that particular issue.

Dr. Tracey Cooper

Please do. We would be happy to hear that. Deputy Naughten talked about when we were last in Galway. We have had a number of discussions with the HSE concerning changes to all the smaller hospitals and, most importantly to me, the management of the changing flow into larger units. The next meeting is in the coming weeks, while the last one was before Christmas. That has to be managed on the basis that one cannot shift the risk for patients from one place to another by changing services. Back in 2009, we made clear recommendations in the Ennis report that said changes to the model of services have to be managed. Where additional capacity is needed in a larger receiving centre, appropriate risk mitigation needs to be taken in such a centre while they bring about those changes. We have had discussions about Galway and Limerick. I mentioned that we have a formal arrangement with Limerick. I would be keen to hear Deputy Naughten's concerns about Galway. We quietly visited a number of hospitals in the country where we have concerns about emergency departments. We would be keen to hear of specific details the Deputy may have. While I am not saying we will or will not do so, if we believe it to be appropriate we will visit those hospitals to see for ourselves what is going on.

Apart from the ongoing engagement with the HSE, there have been occasions where we have arrived at hospitals to see what is happening because we have been concerned. That is our challenge until the standards are in place. When the standards are in place, it will give us the ability to do something in hospitals about which we have concerns. Because of the legal nature of the standards at the moment, on what is or is not in place, it is difficult for us to enforce change other than the recommendations we make and that we expect to be implemented around system learning, investigations that are undertaken and current standards. However, I would like to know about the Deputy's concerns and would be keen to hear them today.

Deputy Naughten spoke about closures. As I mentioned earlier, we have not closed hospitals, nor have we made recommendations to do so. We have and will continue to make recommendations where we think the type and range of services that are provided in a large or small hospital are not safe for patients who are relying upon them. It is not about the people but the organisation, infrastructure and what can safely be provided in those hospitals. If we do not consider that to be safe then we will make clear recommendations about it.

It is not a case of hospitals being downgraded or shut. We have repeatedly made strong recommendations in investigation reports and also in press releases we have issued that these type of hospitals must - there is no option - play the role they can play exceptionally well in providing access to care for people in the community in the safest and most accessible way, as well as ensuring that the type of services provided can fulfil that. I apologise for taking up time, Chairman, but it is important to note that point.

Last summer, and in the Ennis and Mallow reports, we repeatedly articulated the type of challenges we are talking about here. An emergency department by definition is one that provides 24/7 care for all types of patients who turn up. That means whatever level of seriousness and medical trauma patients may incur - including burst aortas, and anything else - an emergency department should be able to do that. However, the emergency department is often seen as being the hospital's front door, as we all know so well. The range of services that can be provided there is purely and solely as a result of the type and range of services that can be safely provided by the hospital in its totality. It is only when one looks at that that one can say what can be safely provided at the hospital's front door.

There is a range of different elements, some of which the Deputy has alluded to. One concerns volumes of certain types of patients who are acutely ill, although not all. The international evidence clearly outlines these patients as suffering from major trauma, those with particular medical conditions, including certain types of acute heart attacks, as well as pneumonia and congestive heart failure, but not all. The international evidence outlines that these type of patients do better when they are treated at centres that are used to treating higher volumes of these patients.

When we want a hospital to provide a range of services so that if someone goes in with a ruptured aorta, major trauma, or is extremely ill with an overwhelming infection and their body is shutting down, there needs to be appropriate senior on-site clinical cover. Such a person needs to have access to a surgeon so that if the aorta has burst someone will provide appropriate treatment. The person will also need to have access to an anaesthetist or someone who can put a tube down the airway to ventilate the person so he or she will survive in such circumstances. They also need to have access to on-site medics who can treat them appropriately in such circumstances.

The other area is critical care. If a hospital is providing an emergency department, that means that everything goes anywhere. When my heart stops or when I have kidney failure and am deteriorating rapidly, and have major trauma, I need to know not only that a person can anaesthetise me, but also that the total body supports required to give me intensive support can be provided. We start to look at that model and ask what services can be, and are being, provided at that hospital. If there is not on-site senior surgical cover to treat me at 2 o'clock in the morning, and if there is not an on-site anaesthetist or someone trained to manage my airway, that reflects on what the front-door really can do in that hospital. That is the key element.

The final element is about skills and relates to my first point. Regardless of the evidence around outcomes, that is just one element of this. For certain procedures we know there is a minimum number of operations, both emergency and elective, that a surgeon should be doing on a regular basis. They could be excellent surgeons but must ensure that when I need that treatment I will get it done to an appropriate standard. It does not make them bad people, but it is the reality of activity. Putting in a lot of services, resources, doctors and nurses can - and has done in other countries - dilute that number further because there are more people to operate on fewer patients pro rata. We have to know where the evidence is, what the hospital can safely provide on site and maintain skills. There is not one issue that answers the question. However, if it is added up, it shows different types of services that should be, must be and can be provided at a hospital while certain types cannot.

In our investigations we have had Ireland's and other countries' experts assisting us. The medical colleges are the professional experts to which we refer and defer. They have been involved in all the recommendations HIQA has made.

In the Ennis report, we examined those different elements I referred to but it did not mean medical services should stop. Actually, many medical patients who attend small hospitals can be safely cared for there and should continue to be cared for there. It is about identifying the minority of patients who cannot be cared for. We made a clear recommendation that the Health Service Executive, HSE, needed to review Ennis and the medical programme came out of that. We are talking about hospitals which are not safe for a minority of patients. These hospitals must ensure diagnostics, endoscopy, rehab, consultant-led clinics, day care surgery and inpatient surgery is provided.

Deputy Denis Naughten

Is it correct that there has not been any formal follow-up on the hospitals in question in Ennis, Mallow and Roscommon other than discussions with the HSE regional director of operations, RDOs?

Dr. Tracey Cooper

I was in Limerick in October last year for three and a half hours going through how the hospital was managing to change inpatient flow. We made it clear it is about two-way flow. We have done the same with St. John's Hospital in Nenagh, County Tipperary. We have had ongoing engagement on Mallow and we are deciding when the time is right to revisit those hospitals.

Deputy Ciara Conway

While most of the big ticket issues have already been dealt with, I want to raise a matter which some may consider mundane but which I believe is significant, that of hospital hygiene. The last in-depth analysis of hygiene standards was in 2009. When HIQA was first established, its primary function was to focus on hygiene. I was interested to hear that HIQA's approach is not about catching people out but setting standards and allowing hospitals and service providers to work up to them. However, is there a need for unannounced spot-checks when it comes to hospital hygiene?

When hospitals are inspected for hygiene in the UK's National Health Service, NHS, service users accompany the inspectors. This may be a good development here because many people do not believe hygiene spot-checks occur. Such a move would reassure people on this issue. I am horrified about the stories I hear at my constituency clinics about the state of public toilets in hospitals and doctors and nurses leaving hospitals with their scrubs on. It is a disgrace that sick people go into our hospitals and come out worse because of the lack of hygiene standards and the simple action of hospital staff not washing their hands. As a mother of a nine year old girl, I am always asking her has she washed her hands. Yet in some hospitals there is an epidemic of MRSA because staff simply do not wash their hands.

I have been informed of a new system being introduced where nurses will be monitors of hand hygiene. While it is welcome, I urge some caution. We all know there is a hierarchy in hospitals. I am not entirely convinced that a newly qualified nurse with the best intentions would be able to face down a senior consultant about not washing his hands.

I have met many patients and their families who were affected by MRSA infection and they have told me how their physical and emotional quality of life has been impacted.

I find social services gets pushed aside as a topic at this committee. HIQA's remit covers inspection of children's homes and foster care services. Has it had any engagement with the Department of Children and Youth Affairs on the establishment of standards for the proposed child protection agency? I worked as a child protection social worker prior to my election and I know how difficult it is. I also worked in an auditing capacity and people need to see standards implemented. We saw how standards were not met at the Gleann Álainn high-support unit for children in County Cork. If we do not get it right with foster care services at an early age — say with two year olds — we will have problems with them later at 15 and 16 years.

Deputy Robert Dowds

As Deputy Ciara Conway stated, many of the issues have already been covered. I refer to the question of whether HIQA will do spot checks on hospitals and other institutions for which it is responsible. When reports are done, are they followed up? What happens if the standards are not met at that stage, irrespective of the institution? I do not regularly seek the dismissal of staff but if the failures point to particular individuals, can action be taken?

I represent west Dublin and, therefore, I am interested in the Tallaght hospital report. Anecdotally, I have heard considerable changes have been made in the hospital with improved throughputs in the accident and emergency department, which is welcome.

Deputy Conway and I attended a meeting yesterday where the issue of nursing home standards was raised. The authority has high standards. For example, single ensuite rooms must be provided for patients but would a more flexible approach be appropriate in order that three or four patients could be in the same room getting good care? Could this be regarded as acceptable? I am interested in Dr. Cooper's comments on that.

More than a year ago, I raised an issue relating to the ambulance service in the greater Dublin area in the media. I was approached by one or two ambulance drivers who were greatly frustrated that they often had to wait for hours at hospitals for the trolley on which they brought a patient in. One told me he had to wait on occasion for up to eight hours to get the trolley back, which meant the ambulance crew was tied up and doing nothing of value because they had to hang around. I do not know whether that is still a problem or whether the authority can do anything to address it. At the time, the problem was worst at Beaumont Hospital but there was a general problem.

Senator Colm Burke

I apologise for being late but I had to attend another committee meeting. I refer to the number of medical procedures carried out, particularly those in which advances have been made in recent years. For instance, a few year ago a hysterectomy was the procedure to deal with a particular problem but developments have taken place and the number of these procedures has reduced dramatically. If a small hospital only carries out two such procedures a year, must it transfer the patients to a larger unit where the number of procedures has also reduced dramatically?

I refer to a national policy on treatment for a condition for which advances had been made. The treatment is not provided by the public health system and a person in a clinic made patients aware of alternatives to the current procedure but the person was reprimanded at national level because the person had no right to give the information to the patients. The person has resigned the position and the clinic will close as a result. The person was only giving information and making sure patients were aware of all the alternatives available as opposed to requesting patients to avail of them. What is the authority's view on that? At national level, someone is telling medical professionals that they cannot give this information to patients.

Deputy Peter Fitzpatrick

I apologise for being late. I spent the past two hours with the Minister for Health discussing two nursing homes in County Louth - St. Joseph's in Ardee and the college hospital, Drogheda. There are many angry people and all they seem to hear is the acronym, HIQA. The authority is being blamed for closing all the nursing homes in the country. The Minister asked first what standards the authority is applying to both nursing homes. I was informed that its new standards will come into force in 2015. I am seeking clarity. When HIQA staff enter a nursing home, what are they looking for to ensure it complies with the regulations? Most nursing homes in my area are in listed buildings. Are they a problem or can the staff be a problem? I need more clarity because this issue is ongoing.

Before a nursing home is closed, there should be a 12-week consultation with everyone affected, particularly the patients. Many people are fearful. Can HIQA give Oireachtas Members information to feed back to the people running nursing homes? The population of Ardee is 7,000 and if the nursing home is closed, people will have to travel 14 miles to Dundalk to avail of such a service.

Dr. Tracey Cooper

It is good to have a conversation with Deputy Conway, given her background in social work. She asked about hygiene. We inherited a suite of hygiene standards and we did a number of national hygiene inspections. The standards were fine but they were even somewhat out of date at that point so we invested a lot of time bringing them up to date and producing standards which are a combination of handwashing and hygiene meeting microbiology as the two come together. We have national standards that have been approved for the prevention and control of health care associated infections, which include MRSA and a number of others. They were approved the year before last. We have had ongoing engagement with the HSE around MRSA rates and about clostridium difficile in particular parts of the country. We had meetings about one particular outbreak of clostridium difficile in the north east and we had intended to undertake some inspections against those standards last year. We found that most of our staff were doing investigations to develop standards and, therefore, our intention this year is to do a number of unannounced inspections around those standards.

When the Safer Better Health Care standards I referred to are in, we will be in the first wave of a formal monitoring programme. We will also examine in every hospital we go into the management of health care associated infections. I share the concerns of members. We had intended to do another wave of inspections last year. Our experience is that if we do a number of unannounced inspections, they have just as much impact as covering everybody in a short period and publishing the results. I want us to have more of a presence around health care associated infections this year.

While I said we do not catch people out, we still go unannounced to these places but what I mean by not catching them out is that they have no excuse about not being clear about what is expected of them, whether it is announced or unannounced. There is a place for both on the basis that if they cannot get it right when they know we are coming, that is a concern. So we carry out unannounced inspections of nursing homes and a number of hospitals. We will continue to do unannounced inspections as our functions grow. Having family members and other people joining inspection teams is a fantastic idea. When we inspected against the symptomatic breast disease standards, we had a delightful lady, Christina Murphy Whyte of Europa Donna, who has sadly since passed away. She was on all of our inspections as a layperson. We always have laypeople on our investigation teams. When we turn up to do inspections or investigations we put signs up to let people and family members know. I would be very interested in having a conversation with the committee about having such people involved and we are very keen to do that.

I would like to pose a question to the committee if I may. I believe we have not tapped into the power of the patient regarding everyday activities in health and social care where the risk of healthcare-associated infections could be reduced. What I mean by that is people safeguarding themselves. We have talked about the cultural stuff. I would be very keen to have a discussion with the committee at some point to ascertain if we could do something jointly to try to get some communications out there. I feel that now is the time for that.

Deputy Conway asked about children and youth affairs. We have a function regarding monitoring children's services. We meet the Minister for Children and Youth Affairs, Deputy Fitzgerald, reasonably regularly. On a monthly basis we meet Gordon Jeyes and the Minister's Secretary General. We are about to appoint 11 new staff as inspectors of children's services. We are coming towards the end of developing the first sets of standards to protect children in Ireland. An advisory group has been established to do that and it will go out to consultation, I hope, in approximately a month. We have recruited people in the current challenging environment because we advised the previous Government last year that we needed to start inspecting child protection services. By the middle of the year we will commence a formal inspection programme monitoring the HSE's delegated duty for the provision of protection and the safeguarding of children and young people.

Chairman

Would that include adults and children with disabilities, which was promised?

Dr. Tracey Cooper

Chairman

----- of service providers.

Dr. Tracey Cooper

To be honest, we do not know what we do not know at this point in time. We know of services providers which have invested considerable money in accreditation programmes - normally from the United States - in order to improve. We know there are many very small providers and until we start regulating them we do not know what the quality of the service will be.

I believe I have covered Deputy Conway's points. Deputy Dowds asked about spot-checks and I hope I have confirmed that. We do a combination of announced and unannounced checks. Depending on the purpose it is important to do both. He asked what happens if people do not implement the standards. From a legal perspective regarding standards, we have powers of entry and requiring information. We do not have powers to enforce. We provide considerable advice and guidance as to how to implement actions. We would publish the reports of everything we have done. The publication is an important means of progressing, and we then follow up, go and revisit. We publish the progress made against the actions plan the providers set in train. We cannot enforce and make but would rather them improve themselves. So publication, ongoing monitoring and ongoing liaison at the moment are what we do and can do. When licensing - as we have discussed - comes in, it will apply to the health care, the same legal approach as we have at the moment for the older persons' centres.

The words "registration" and "licensing" are actually the same in this regard. We do not look at registering and licensing for the good of centres. We publish and report on good practice, because it is about learning. It is really about the providers about which we have significant ongoing persistent concerns, and which are not appropriate to provide services for people. When licensing comes in, we have separate powers. Really for sustainable improvement if we get to the point of making people do things, we have lost the plot and the game. So we are limited in what we can do. On the whole regarding standards-----

Deputy Robert Dowds

Do HIQA's counterpart bodies in other countries have powers of enforcement?

Dr. Tracey Cooper

It depends on the legal basis. I will give examples from Australia and the UK. Here the Act gives us different powers for different functions. For our standards monitoring and our investigations functions, our powers are really more about getting access to information, requiring people to be interviewed and making recommendations. We cannot go and take action if somebody has not done that. We register providers of social care, meaning that those not fit to be registered to provide a service are out of the market. We have powers of prosecution which we have not yet used. At the moment we have a variety of different powers. In Australia, for example, our counterpart dealing with older people services, the Aged Care Standards and Accreditation Agency, does not have any powers. However, in Australia the government will not pay state money to a provider of older people services unless it is accredited so it is done through the financial flow. The UK has introduced changes in its legislation on regulation and has completed restructures in the organisations that are regulating. For many years they did not have enforcement powers and they monitored against the British Government's standards. Now they have moved into licensing of public providers as well as private providers and they have those powers. We will get there, but we are doing it in an incremental way. Our responsibility is to discharge the powers we currently have and inform the ones for the future.

Deputy Dowds also spoke about nursing home standards and single rooms, which also follow up on Deputy Fitzpatrick's questions. I would like to clear up some misnomers and misinterpretation by outlining the process. There are a number of different levels here. The Act that established HIQA outlines very clearly what is expected of service providers. There are regulations to support the Act, which link into the standards. The regulations are the most important area for decisions on whether a provider is fit or compliant. The regulations specify the build and how long a provider has to address structural issues - I will come back to Deputy Fitzpatrick's question to cover that. They also outline what is required when appointing a person in charge, etc.

We also have the standards, with which people will be familiar. The standard statement should link with everything and should be about reasonable expectation of good safe care for older people. The particular elements that are being played out at the moment seem to be about premises and not so much about the quality. Just because a building is 200 years old does not mean that good safe care is not being provided in that centre. In fact some of the highest quality of care, I would say, in that sector is being provided in very old buildings. On the contrary there can be the most up-to-date, pristine and beautiful centres that are dangerous. Quality is one element of it.

As far as the structure is concerned, the legislation made it clear when the function was commenced in July 2009 that the older institutions have up to seven years to address reasonably some of the challenges they have to ensure that they were compliant not with the regulations, which established HIQA including going to the en-suites, but with the older regulations of 1995 because it was more reasonable and manageable. Centres have up to 2014 to address that.

We work with all providers and certainly the very rare occasion where we have required a provider to do something structurally in advance of waiting for their seven years to get planning permission and money - obviously the world is changing and we need to consider that - actually has been issues like eight people on a second floor who were somewhat debilitated and there is no lift or stair lift. There would be structural concerns in the case of a fire and we would want them to put in a stair lift. If, for example, 49 people are sharing one shower, one bath and one toilet, we would expect them to do something about that. There is a long run-in time for them to address the particular issues. We have registered a number of centres that are institutions - they are still within the law. There are registered centres which have six or seven people sharing a room because they still have a number of years to address that. Where we do not register a centre, which is exceptionally rare - we have not closed any centre based on structure - it is where the provision of face-to-face care for residents is unsafe.

The final challenge relates to fire safety compliance for providers. Every provider of services must meet the fire regulations of the country and not our fire regulations. Some of those are challenges around what is required. Those are not our requests, but are by law what is expected of them. Our approach has been and continues to be - in this climate it cannot be anything more - an enabling and facilitative one to ensure we can enable people within the law to be cared for safely in those difficult and challenging environments. We are progressing registration decisions with centres, which will continue until the end of June. It is worth noting - this came up previously - a number of centres that are proposed to be closed by the HSE are providing good safe services. I mentioned earlier that the decision making for that will be important. Other than where there are blatant unsafe services we are being as enabling, facilitative and pragmatic as we can because we certainly do not want to be putting older people out.

Deputy Catherine Byrne

I apologise for having to leave the meeting and thank the Chairman for allowing me to contribute at short notice. I was taken aback when a member mentioned a constituent who refused to get into an ambulance because the person did not want to go to a certain location. I hope it was the location that put the person off and not the practice.

I welcome Dr. Cooper and Mr. Whelan. It is good to see them again. All of us with family members who have ended up in hospitals or homes want a safe service, a friendly environment and a home away from home. In recent years, most of us have recognised that situations are not always as we had hoped. Not only have we seen this to be the case on television programmes, but with our own eyes. For this reason, I hope HIQA is where it is.

I thank our guests for their presentation, for which I was present. I have attended many meetings and it is rare for a presentation to give us so much information. I compliment our guests on breaking the details down.

If my questions have already been asked, the Chairman can stop me. I support the delegation's comments on older nursing homes. Cherry Orchard in my area is one of Dublin's largest nursing homes. Many people telephone me to try to get their parents or ill family members into that home. While the building matters, what really matters is the care provided. Cherry Orchard houses some of the longest serving nurses and doctors in Dublin and they provide a treatment that people want. The service given and compassion shown to the loved ones of people with whom I speak regularly are unmatched. It is for this reason that the list is so long.

If our guests cannot answer now, they might revert to me, but what is HIQA's cost to the State? Everything has to do with value for money now. How many staff has HIQA? What is the average cost of employing the experts who were mentioned? A few minutes ago, our guests announced that HIQA will employ 11 new inspectors of children's services.

It is important that HIQA is the public's eyes and ears. For too long, many nursing homes and hospitals were run without someone regularly knocking on their doors and asking the serious questions that needed to be asked.

Senator John Crown

I apologise for not arriving earlier. A pathology of working in one of the lowest quality health systems in western Europe due to our grotesque levels of understaffing is that jiggling the schedule a bit is difficult. What is HIQA's annual budget?

Chairman

We will take the questions together.

Senator John Crown

Most of HIQA's staff are moderately paid professionals who do quite a job toiling in the fields of inspection, often in circumstances in which their lives are made difficult. How much is spent on public relations, communications and stakeholder engagement? Has HIQA contracts with PR companies and what else is used?

I studied quality in health care to postgraduate level and I came away with the impression that the professional quality movement had a fundamental weakness, in that it did not measure quality, but compliance to whatever standards were decided by the people who set them. I will not personalise the issue or name specific hospitals, but I have heard accounts of particular hospitals that are held up as models for the rest of the country, given their stellar quality audit records. The truth is that nearly no doctor I know would ever let a family member attend those hospitals with a serious illness. It is a reality of life that, if one sets certain standards, one can measure compliance to them.

Is there an inherent tension between HIQA having a justifiable and primarily inspectorate role and being the entity that appears to be becoming the arbiter of health economics and health technology assessment? This conflict of interest needs to be addressed urgently.

The real problem in the health system has been an extraordinary concentration of power in a few hands. Contrary to the opinions of those whose knowledge of the health system is based on seeing an old episode of "Doctor in the House", people who study the health service will realise that power is heavily concentrated in the hands of bureaucrats, not politicians or health care professionals. With few exceptions, those bureaucrats will not use that health system because they have private insurance.

When one concentrates too much power, the inspectorate function and the health technology assessment function in the same hands, it causes problems. I am concerned about some of the specifics that might be coming down the line. I am not blaming our guests or their organisation, as the specifics relate to different parts of the bureaucracy.

I wish to bring a matter to my colleagues' attention. In terms of the classic quality audit, the most audited health system in the world is the UK's. The British more or less invented the modern health quality audit movement. Routinely, they also deliver the worst outcomes in international comparisons. Merely auditing what one is doing in terms of complying with an arbitrarily low standard does not imply that one's system will function to a high standard. This is a problem. When one considers access to health care indices in OECD studies, the British routinely come second last. The only people that keep them from being in the embarrassing last position are - guess who - our good selves.

We need a strong and robust inspectorate, but I partly believe that a separate entity from the one that sets standards for acute health care in hospital facilities should inspect nursing homes. I am not sure that leaving both tasks to the same bureaucracy makes sense.

My next two questions seek to clarify some troubling facts that have been put into the public domain in recent years. Our guests may have addressed one of them already. Did HIQA ever inspect Roscommon hospital? Albeit not officially in the Seanad, the Houses were led to believe that HIQA-generated figures suggested a serious signal of adverse outcomes for patients admitted with myocardial infarctions in Roscommon. These figures were not used prospectively to justify the unit's closure, but they were partly used to explain retrospectively why the decision could not be reversed. Were there such figures?

I will have to communicate with the Senator on that matter.

While I am CEO of HIQA, I also wear a different hat in terms of my work in other parts of the world, including in developing and antipodean countries. Interestingly, I probably work less with colleagues in the UK than in any other part of the globe.

As regards quality, unless there is clarity in terms of what is expected of people, quality can become the most nebulous of aspirational achievements. That clarity must be a process of evolution. I agree to a point with Senator Crown's remarks in this regard. During my many years doing this work, I have come across people who get involved in clubs which focus on quality rather than engage in hardcore support for continual improvement in the delivery of health care. I believe that standards are important but more important is how standards are developed. A framework is important for a country and service to attain and to then continually improve. In our development of standards we work with an advisory group of experts which includes patient and lay representatives and occasionally people from other countries in Europe. We have also had input from Australia. We also engage in a process of public consultation in order that the public is afforded an opportunity to comment on standards for the country. However, they must be reasonable and appropriate. Standards are put in place to ensure a clear expectation of what is required.

I am not into auditing. There is a misunderstanding of monitoring and auditing. Monitoring includes considering information that comes into our domain and indicates a tangible concern about a service. Consideration of that information, in terms of how we relate to a provider, could include a series of conversations with staff, residents and patients to get their experience. We do not have a checklist which we go through when monitoring quality of a service. Without a framework of standards, it is difficult for a provider and patient to know first what is expected of them and second what they can expect.

Senator Crown referred to the HTA and raised an interesting question in that regard. We are most similar to France in terms of the diversity of our functions. The system in France has an accreditation type quality improvement assessment function. Our function is to monitor against standards and registration in this respect. The Senator may also be aware that the French system is more about comparative effectiveness. It takes a mini cost effectiveness-clinical effectiveness approach, which involves looking at drugs or a series of steps in a guideline for a patient and considering whether it will make a difference to the quality of care, outcome and experience of the person and how much it will cost to do that if spending €10 million per annum for potentially a handful of patients. They are the type of questions that must be asked. I believe the functions complement each other.

The joint committee adjourned at 2.25 p.m. until 11 a.m. on Thursday, 26 January 2012.

JOINT COMMITTEE ON HEALTH AND CHILDREN debate - Thursday, 19 Jan 2012

Role and Functions: Discussion with Health Information and Quality Authority

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JOINT COMMITTEE ON HEALTH AND CHILDREN debate -
Thursday, 19 Jan 2012