Use of Private Hospitals

We are joined in the Chamber by Mr. Martin Varley, secretary general of the Irish Hospital Consultants Association, IHCA, and Mr. Maurice Neligan, consultant orthopaedic surgeon. From committee room 1 we are joined by Professor Alan Irvine, consultant dermatologist, IHCA, and from the Irish Medical Organisation, IMO, Ms Susan Clyne, CEO, Dr. Anthony O'Connor, and Dr. Matthew Sadlier. Can we be heard in committee room 1? Yes.

I wish to advise the witnesses that 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 they are directed by the committee to cease giving evidence in relation to a particular matter and continue to do so, they are entitled thereafter only to a qualified privilege in respect of their evidence. They are directed that only evidence connected with the subject matter of these proceedings is to be given and they are asked to respect the parliamentary practice to the effect that, where possible, they should not criticise or make charges against any person or persons or entity by name or in such a way as to make him, her or it identifiable.

Members are reminded of the provisions in Standing Order 186 that the committee should also refrain from inquiring into the merits of a policy or policies of the Government or a Minister of the Government or the merits of the objectives of such policies. We expect witnesses to answer questions asked by the committee clearly and with candour. Nevertheless, witnesses should expect to be treated fairly and with respect and consideration at all times and if they have a concern in that regard, I invite them to raises that concern immediately. I remind members that witnesses should be treated in accordance with the witness protocol.

I ask, finally, that all witnesses confine their opening statements to five minutes - these have been circulated in advance. We are under very tight time constraints. I ask Mr. Varley for his opening statement.

Mr. Martin Varley

Good morning, Chairman and committee members. I will read through the statement as quickly as possible.

I thank the committee for the invitation to join in its discussions on the use of private hospital capacity and the impact of the agreement on the continuity of care and healthcare delivery.

The IHCA is the representative body for more than 3,200 hospital consultants practising in public and independent hospitals. The association represents approximately 95% of all hospital consultants in Ireland. This submission outlines our views at the time of writing on Friday morning, prior to the outcome on the Cabinet discussions on the private hospital agreement, which was scheduled to take place during the day.

The association's members have been front and centre in treating Covid-19 infected patients throughout our acute hospitals since early March, in addition to providing emergency, trauma and urgent care to patients with non-COVID illnesses. This includes consultants in essentially all specialties across the full spectrum of acute hospital care. Whole-time private practice, WTPP, consultants have demonstrated their commitment by continuing to treat patients with urgent care needs on a voluntary basis in private hospitals throughout Ireland in the absence of a suitable contract and in the face of other significant constraints. We have sought agreement on practical and workable contractual arrangements that would properly enable WTPPs in treating Covid-19 and non-Covid-19 patients while also continuing to treat their existing and new patients who rely on them for urgent medical and surgical care.

This includes patients across all ages and demographics from the 46% of the population that has maintained health insurance over the years. For a relatively high proportion it includes older people who have maintained health insurance at all costs, going without in other aspects of their life, so that they could afford timely care when needed. This is driven by the access problems that exist in our public health service, a problem which has been caused by the failure of successive Governments to ensure adequate capacity in our public hospitals. This is not the fault of any patient, but it is patients who are now being penalised because of the failings in our health service.

Independent hospitals carry out 250,000 theatre procedures annually, accounting for approximately 40% of the total number of procedures requiring anaesthesia in acute hospitals. Those figures relate to 2015 and I expect that today the figures are even higher. Consultants in private practice also provide care for medical patients and are responsible for a significant proportion of outpatient consultations.

The IHCA working group engaged with HSE and Department of Health officials in early March and over the past two months on contractual proposals to be offered to WTPPs to enable the provision of care to patients in private hospitals and consultant outpatient clinics.

The proposals of health service management are preventing and restricting whole-time private practice consultants providing continuity of care to their patients. The contract being offered does not provide for the practical workable approach required to facilitate the optimum engagement of the maximum number of WTPPs. This is despite months of constructive efforts and collaborative engagement with officials by the IHCA working group. This has resulted in large numbers of existing and new patients of private practice consultants being deprived of the continuity of care they urgently require. The failure to resolve these matters is seriously impacting on the provision of care to patients across private hospitals and in private consultant outpatient clinics. As a consequence, large numbers of patients requiring urgent care are being added to waiting lists unnecessarily. In addition, it is adversely impacting on the effective use of private hospitals and the clinic capacity of WTPPs.

In March, on a precautionary basis, the State entered into arrangements to have access to the private hospital capacity to cater for the expected steep surge of infected patients requiring acute hospital care along the lines of the experience of Lombardy and Madrid. The steep surge did not occur because of the mitigating actions taken and at this time it appears it is unlikely to occur in the months ahead given the success of the public health measures implemented thus far. The test of time has confirmed that the private hospital agreement, which is costing approximately €115 million per month, represents poor value for money from patient care and taxpayer perspectives. The experience is that of very low private hospital bed capacity occupancy, at approximately one third on average, and low utilisation of theatre and other ancillary facilities. Furthermore, the private hospital contract is prohibiting the provision of urgent care required by patients with non-Covid illnesses. This is leading to the accumulation on waiting lists of a large number of patients who require urgent care. There is now the additional risk that these patients will deteriorate clinically and will increasingly evolve into emergency cases if they are not treated without delay.

I will conclude with one or two final comments. We are basically calling for the contract to be brought to an end. I know decisions to that effect were taken last Friday. The most important thing is to utilise the savings that will be achieved through ending the contract to put in place increased capacity for our public hospitals. The Government and Dáil have already decided that there should be significant investment in additional acute hospital beds and step-down beds. This is provided for in the national development plan. We would certainly welcome these additional beds being put in place in an accelerated manner in the context of the current crisis.

Ms Susan Clyne

I thank the committee for the invitation. In light of the Government announcement that the current agreement with private hospitals will not be renewed, we would like to focus on the urgent measures required to enable our public health services to deliver care for both Covid and non-Covid patients. It is important that we remember our hospitals have been overwhelmed and operating at dangerous levels of capacity for many years and Covid has exposed the underlying fragility of our services. It is untenable that we continue with historic deficits in manpower and bed capacity in the context of increasing waiting lists.

We would like to begin with our recommendations. The HSE is due to publish its clinical roadmap for the reopening of services shortly. This roadmap must allow for a gradual reopening of both public and private care in tandem, prioritising patients based on clinical need. An urgent assessment of current capacity and how that capacity will be affected as we deliver care under new social distancing arrangements and infection control guidelines is needed. Given that the current agreement with the private hospitals will not be renewed, Government must support immediate investment through temporary builds while investing at the same time in long-term projects such as stand-alone public hospitals for elective care. There must be immediate investment to recruit and retain doctors to work in the health service, including targeted measures to address our unprecedented number of consultant vacancies, which now stands at more than 500. Successive reports and studies have demonstrated that the two-tier consultant pay issue is a major barrier to recruitment. We must appropriately resource diagnostic, radiology and laboratory departments to allow timely access to investigations for both hospital doctors and GPs in the community.

We also need clear referral pathways for all patients into secondary care.

At the forefront of this national effort to deal with Covid-19, and notwithstanding the long-standing contractual issues and inequities, doctors across the health system have stepped up, working long hours in their normal work locations and being redeployed to other sites to deliver specialist care. Many doctors have worked without leave since the pandemic began. We should acknowledge in particular our non-consultant hospital doctors, NCHDs, who have been at the front line of care for Covid-19 patients, and our public health specialists who play an invaluable role in health protection and who should be awarded consultant status in line with the recommendations of Dr. Gabriel Scally. Fortunately, due to measures taken by the public, we have so far avoided the worst-case scenarios. It is very likely, however, that low numbers of the population have been infected and we are not yet out of danger. Until we have effective treatment options and a vaccine, we face continued uncertainty as to the impact of a second and subsequent waves, particularly as respiratory illnesses begin to circulate again as early as September.

Due to neglect by successive Governments our health system has huge deficits in bed capacity and manpower. Ireland has one of the lowest number of public hospital beds per population and our hospitals operate on average at 97% occupancy. Some 5,000 additional beds will be required to meet future demand and with more than 500 vacant posts, Ireland has one of the lowest number of consultant specialists in the EU. An additional 1,600 consultants are required to provide a consultant-delivered service.

Due to the cancellation of all non-urgent care across the public and private systems, 570,000 people are on public waiting lists for an outpatient appointment and a further 230,000 people are on a waiting list for inpatient or day-case procedures. Cancer screening programmes have been put on hold and GP access to diagnostics and referral pathways for all patients effectively have been closed down. The HSE and its staff now face significant challenges as it seeks to reopen services for elective, outpatients and other programmes. In this context we must ensure sufficient spare capacity for current needs and for a future surge. We will need to reconfigure the physical space and hygiene practices in our hospital facilities to maintain infection control to protect patients and staff. The rate of infection in healthcare staff is a matter of extreme concern. There will be an inherent reduction in capacity in our public services of up to 50% when new measures are put in place for delivering care in safe settings.

We know from our persistent lengthy public waiting lists that long delays in accessing diagnostics and specialist care can impact negatively on patient outcomes. Often the only way to access care is through the emergency department. As we emerge from lockdown and into a new normal, we simply cannot revert to a situation where additional beds are being added to wards and hundreds of patients are boarded on trolleys. Overcrowded waiting rooms at outpatient clinics cannot be a feature in our health services.

The Irish Medical Organisation, IMO, has repeatedly called for investment in acute bed capacity and manpower, but successive Governments have failed to provide the necessary resources. Instead of investing in additional beds and staff Government policy has been to purchase capacity from the private sector through the National Treatment Purchase Fund, NTPF. The NTPF, which was originally a short-term solution, has become a long-term measure thus depriving the public system of investment and enabling the continued neglect of our health services. A policy that consistently diverts funding to the NTPF in the absence of funding for our public health services will not address the problems of capacity and will not be a long-term solution to waiting lists.

While the agreement was the correct measure to take at the time, we must now recognise the need for urgent investment in our public health system and not revert to continuing the all-year crises that beset our services prior to Covid-19. We appeal to the committee and the incoming Government to put health first in terms of sustained investment and to value those front-line workers with meaningful support to enable them to deliver care.

I thank Ms Clyne. Before moving on I remind members that we have only five minutes per person, or a maximum of ten minutes if using another member's time. The order will be Sinn Féin, Fine Gael and then Fianna Fáil. Will Deputy O'Reilly be taking five or ten minutes?

I will take ten minutes.

I thank our witnesses and their members, and all our healthcare workers who do a phenomenal job day in and day out. We have said many times that while it is very nice to get a round of applause in this House at 8 p.m. on a Thursday, it would be even nicer to have the decent pay and conditions, and the equipment needed to do their job. That must be our focus. The appreciation is there but it needs to have very serious follow-up.

I thank the witnesses for their statements. I suppose it is fair to say that we came into the pandemic in very poor condition in terms of our health service, not just in the length of our waiting lists but also in the level of overcrowding which existed. Into that breach stepped healthcare workers who proved themselves capable of changing their own work practices and adapting to the new environment in a way that was breathtaking. The IMO makes the correct point that in the deal that was done, the capacity was made very necessary due to the neglect by successive Governments over many years, as the IMO statement put it. We know why we were in that condition. That said, there was a very real and pressing need for the additional capacity to be sought. I want to concentrate on the value-for-money element of this deal of €115 million a month for a minimum of three months. Is it likely in the opinion of our witnesses that the private hospitals would have seen a huge downturn in business because of Covid-19 in any event? I do not think there is any question that the private hospitals were going to be full. The evidence suggests that people were staying away from hospital, that they did not want to be putting themselves in harm's way. We were purchasing from the private hospitals on the basis of the capacity that we needed, but we never achieved that capacity in the private hospitals and those beds were never utilised. Could the witnesses comment on what the likely activity would have been in the private hospital sector? Would it have experienced a similar fall-off in attendances for procedures? I hesitate to use the word "business."

Mr. Martin Varley

I will make an initial comment in response and will hand over to Mr. Maurice Neligan. He works in a private hospital as a private practice consultant. The first point about value is extremely relevant in a number of respects. I would link back to the Deputy's comment about ensuring we can recruit and retain an adequate number of hospital consultants in our public hospitals. It is a long-standing issue which the current Government has looked at. One fifth of our permanent posts are vacant and have been for some time. This Government commissioned a Public Service Pay Commission report on the matter, which recommended in September 2018 that parity should be restored to ensure we can recruit and retain staff. In fact, some of our figures suggest that we could do that on a cost-neutral basis. However, if we have savings arising now, a small part of those savings will go a long way to rectifying the recruitment and retention problem among our younger hospital consultants, who are very much front and centre in dealing with the crisis.

Going on to the Deputy's main point, value for money in the contract is obviously in question. We would regard it as being poor value for money with the passage time. Of course, when the deal was being agreed and struck initially, we would all agree based on what we were seeing playing out in Italy and Spain, that we absolutely had to bring on board any capacity we had in the country. Our members practising in private hospitals were fully committed to that. As a working group, we invested a great many hours with the officials to that effect. With the passage of time, we can now see that we did not need the capacity. We must also allow for the fact that the population who depend on private practice consultants for care, often in their outpatient clinic and often requiring follow-on care in hospitals, would have returned to those hospitals in greater numbers than we have seen. We have lost the opportunity to use the capacity at a vital time and we have paid dearly for that. I would now like to hand over to Mr. Neligan.

I thank Mr. Varley for his input. Unfortunately we are on a really tight schedule. Mr. Varley can see the clock; we have five minutes left. If I could bring in a speaker from the IMO, I have other questions I want to ask.

Mr. Martin Varley

Sure.

Ms Susan Clyne

Across the system, both public and private, attendance has dropped off. Appeals were made from emergency departments, GPs, consultants in various specialties and the Irish Cancer Society for patients to come back. Patients were not coming in.

In terms of value for money, had we had the surge and had we required those ICU beds and ventilation spaces, we would not be querying the value for money. The decision had to be made. It is only now, as we move out of that time and phase from having the surge, that we can see what value for money could have been delivered in the context of the agreement with the private hospitals. We had not been able to test that.

I take that point but given that value for money has to be a factor - maybe not the only factor - it was necessary to get the capacity. As for a plan, we knew that the capacity was in case the surge happened. Was there a plan B? In the event the surge did not happen, was there a plan to ensure we would get some value for money out of those beds? Was there ever a plan B by the HSE, the Department of Health or the Minister that Ms Clyne is aware of?

Ms Susan Clyne

No, the consultant representative bodies were not involved in the discussions with the hospital associations to take over the capacity. I anticipate that the HSE will now want to use that capacity for elective care.

That time, however, has been lost. The surge did not happen and we paid for the beds, but there was never a plan to utilise them in the event that the surge did not happen.

Ms Susan Clyne

No, but in fairness, and it is different throughout the country, many oncology services were moved into the private hospitals. My colleague, Dr. Anthony O'Connor, might comment further on this. Endoscopy services were carried out in the private facilities. Work was ongoing, but it was stepping up and we did not get to the phase where it had stepped up.

It had not stepped up, according to our information, to beyond a maximum of 50% capacity in some instances, which does not-----

Ms Susan Clyne

I think that is across the system.

-----represent good value for money in anyone's mind.

On the waiting lists, which were described as running at 800,000 cases, what is the likely impact of this deal on them? Will we see higher numbers and longer waits in the post-Covid environment? I will put that to Mr. Varley before Ms Clyne, if she does not mind.

Mr. Martin Varley

For two very significant reasons, we will see higher waiting lists. First and foremost, the impact of providing care to Covid-infected patients has changed the situation in hospitals, and we saw the drop-off we have referred to in both public and private. That will give rise to very significant increases in the public waiting lists, but in addition, we now have hidden waiting lists in private hospital settings that we would never have had before. Some of them are urgent non-Covid cases, such as cardiac cases, oncology cases and ophthalmic cases - the list goes on. We have not been flexible, agile or innovative enough in dealing with this agreement to allow us to treat more patients. We have seen a great deal of flexibility coming from consultants throughout our acute hospitals to cater with the surge and everything that has given rise to, but we have not seen flexibility in terms of this contract.

We wrote to the Minister, having dialogued with the officials over a lengthy period, suggesting there were ways to introduce a more practical, flexible contract arrangement that would have optimised the use of the private hospitals' capacity and of the outpatient clinics, which were effectively shut. Consultants in private practices had a Hobson's choice. They either signed a type A contract that stated everything had to be public, which meant they could not feasibly maintain their outpatient clinic for thousands of patients-----

I am sorry to cut across Mr. Varley but that was the point I was making. There was no plan B-----

Mr. Martin Varley

There was no plan B.

In the event that the capacity was not needed for the surge, there was no plan B. No attempt was made to get some value for money, however small it would have been, from the additional capacity. It was based on making preparation for a surge but there was no plan B in the event that the surge did not happen.

Mr. Martin Varley

Regrettably, that is correct. Despite much effort at engagement on our behalf and that of our consultants, that was not reciprocated-----

There are only a few moments remaining so I will turn to Ms Clyne. On the issue of waiting lists, what will be the likely impact of this?

Ms Susan Clyne

Dr. O'Connor will answer that.

Dr. Anthony O'Connor

We started with 700,000 people on the waiting lists for hospital care. By the time we get back to work, we will be dealing with at least six months' pent-up demand and less capacity to deal with it than ever before. We have heard a great deal about patients being locked out of care in recent weeks, but what has not been stressed enough is that public patients have been completely locked out of care and are likely to remain so for the foreseeable future. We need to see a roadmap by which that care can open as soon as possible for everybody, not just for private patients but for public patients too.

We have been told for the past three months that we are in it together and to hold firm. We cannot continue to lock public patients out of the service any longer. We need a good and robust plan for how we are going to get public outpatient and inpatient services up and running.

That should include the utilisation of the last month left of this contract and for as long as we are paying for it to have some sort of impact, meaningful or even small, on the waiting lists.

Dr. Anthony O'Connor

I agree.

I thank the witnesses for their attendance. We agree there was a need for additional capacity but at the end of March and the beginning of April, attendance was low and people were not turning up for many different reasons. The contract will not be extended beyond June. What can we do now to use June well to maximum capacity?

Dr. Anthony O'Connor

Utilising the pathways already there is one point. I do much of my elective endoscopy work now in a private hospital with which we partnered. That can certainly improve the day case waiting lists.

There is also the potential of an inpatient surge. Our members and many of my colleagues have reported certain resistance when trying to transfer patients from public hospitals to private hospitals. That needs to be worked on a bit better because there are patients who we in the public hospitals would have felt should have gone across but they met with barriers. That has to be looked into. If we get a surge of any activity, Covid or otherwise, in our emergency departments and we are back to having 70 to 80 people on trolleys at night, then we need to have that pressure valve and utilise it for June.

Mr. Varley commented on the State taking over on a precautionary basis. He stated that this was an essential measure at that time. The passage of time, of course, gives us a different perspective. Does Mr. Varley’s organisation agree that we are going to need to maintain some additional capacity in the medium term?

Mr. Martin Varley

There are important issues to be assessed in the context of what capacity we will need to provide for a potential second wave or a surge. We also need to allow for the fact that the patients who have not been in a position to get follow-on care from their private hospital consultants are actually catered for. There is the wider issue of waiting lists in general.

The primary lesson I have learned from this particular exercise is that we need engagement on a tripartite basis. We need engagement with health service management, the private hospital associations and the private practice consultants. It is difficult actually to design the most effective way to do something if one does not engage with all three in a round-table setting. That was the big failure. Looking back on it, we can see why and the rush that did not happen. However, as we go forward, it is hugely important that there is tripartite engagement to optimise the use of our capacity in our public and in our private hospitals.

It is hard to disagree with that but Mr. Varley's organisation is open to the fact that there is going to be a need for ongoing capacity and flexibility from that side.

Mr. Martin Varley

There is. We need to be always available to provide surge capacity if there is a second wave. Indeed, we must optimise thereafter in order that we do not have the capacity to be underutilised as we have experienced over the past two months.

That was for several different reasons, however. That was not just about a contract or otherwise. That was about the rate of presentations as well as everything else.

Mr. Martin Varley

Yes. There is always a danger it will continue because inflexibility in contracts and arrangements can actually be the devil in the detail. We have observed that with our whole-time private practice consultants, who are more than willing to look after Covid and non-Covid patients. In fact, a large number of them actually did so on a pro bono basis until the bank holiday weekend in May when the provision for clinical indemnity for them in that respect was removed. That was extremely surprising for consultants who wanted to look after patients.

That was clarified fairly quickly, however.

Mr. Martin Varley

It took a week or two to reverse it. We have never really found out why it happened. It was quite bizarre in the extreme.

Mr. Maurice Neligan has been operating within this system. Will he give the committee a flavour by way of example of the sort of work that has moved between the hospitals?

Mr. Maurice Neligan

I have worked in both public and private sector as a consultant in Tallaght for eight years before I moved into whole-time private practice. I have a view of the positives and the negatives of both sides.

The hospitals did work very well and stepped up, especially in my experience at the Beacon Hospital.

In the Beacon Hospital, we had consultants who moved over from St. James's and Tallaght hospitals to provide non-urgent Covid care to cancer patients. My colleague, Dr. John Reynolds, did many oesophagectomies and Dr. Terry Boyle brought a lot of public cancer patients over to deal with significant breast cancer issues. That seemed to work very well. That was the majority of the work going on within the hospital. I spoke to both consultants and they said it was a very good operation for them. I cannot speak on behalf of the private hospitals.

Mr. Maurice Neligan

I completely agree with Mr. Varley that the real failure here was the inability to have the three groups, the three legs of the stool - the Government, the consultants and hospitals - in one room. It might have been a little more fluid if that had been the case.

There is certainly an opportunity to do that for the next phase. I thank Mr. Neligan.

We shall move to Fianna Fáil.

Last week, I asked a question about the various samples that were taken and we were told that if someone did not sign the contract A documents, samples would not be processed. What was the fallout from that?

Mr. Martin Varley

The fallout was very significant. It put consultants in an invidious position. If a consultant was providing care to his or her patients and could not sign the contract because rooms facilities were not provided for, he or she found that the consultant pathologist in a particular laboratory to whom samples were sent in good faith was being told the specimens could not be reported on. We could have been talking about cancer specimens. It left both sets of consultants in an extremely difficult position. It got rectified after a week or so but we had similar circumstances, as I said, with pro bono-----

How many patients were affected by that decision?

Mr. Martin Varley

Unfortunately, I do not have that detail but there could be a significant number, allowing for the fact that approximately half of the private practice consultants had not signed a contract. I am not in a position to guesstimate but it could be significant.

Who issued that instruction?

Mr. Martin Varley

To my understanding, the instructions in relation to indemnity cover by the State and the State Claims Agency were being issued by the State Claims Agency on the advices of the health service management. It was, therefore, a joint effort to provide the cover for indemnity. I do not know who exactly took the decision. Obviously, the State Claims Agency issued it but I expect it did so after consultation.

Consultation with whom?

Mr. Martin Varley

It would have to be the health service management. That would include, in my view, the departmental officials, HSE officials and, potentially, individuals at ministerial level.

In reaching an agreement regarding the private hospitals, did the Department of Health or HSE take into consideration the debt that was being serviced arising from consultants investing in the services they were delivering? Was that question ever dealt with in the context of these negotiations?

Mr. Martin Varley

We had raised it quite early on in the discussions; I would say in or around the early days in April when it became clear to us that the type of contract being offered was type A only. If a less costly contract had been offered, the cost of rooms would not have been an issue. However, when it became quite clear nothing was going to be offered other than type A, we raised the issue of rooms costs. We put it to the health service management that certain specific cost headings should be agreed as being eligible. We did not get definitive agreement even on specific cost headings. Following on from that, we got commitments that further engagement, involving the national director of finance and an independent accountancy firm, would arise to work on that on the following Monday. I have had no communications in the interim despite seeking engagement to agree the broad headings. Even today, I am not aware of any private practice consultant who has signed the contract who has had his or her significant rooms outpatient costs covered.

Does Mr. Varley believe that is an issue that has to be addressed? Is it an outstanding issue as far as consultants are concerned? Will they approach the HSE or the Department to find a resolution and compensation?

Mr. Martin Varley

It is an issue on which we have had some commitments, which will be addressed. However, the detail has never been progressed, to the extent that, following a meeting with the Minister and his senior officials in the first week in May, we sought such commitments and a number of our consultants emailed their costs in a very transparent manner to the senior officials in the Department to ask them to confirm if these costs are eligible, and they have not had any response in the affirmative or otherwise. The general response has been that the CEOs of the private hospitals should now address these issues but I am led to believe that the CEOs of private hospitals are encountering similar difficulties to those that we have encountered in trying to get agreement on even the cost headings and the particular costs.

With regard to cancellations of procedures or ongoing treatment and care of patients, what does the waiting list look like now? How many were cancelled? How many are likely to now form a new queue to receive the care that they were getting from a private consultant?

Mr. Martin Varley

It is difficult to estimate. Two or three things are happening at the same time. Some consultants would have seen their patients on a pro bono basis in their rooms but could not refer them and guarantee continuity of care. There is an aspect of care not being followed through. There is no doubt also about the aspect that some outpatient clinics could not continue in the uncertain environment that exists vis-à-vis covering costs and keeping clinics going at the normal rate. I am not on the front line so unfortunately I do not have all that detail.

Has Mr. Varley any idea about cancellations? Is there a way to establish the number of cancellations across the hospitals?

Mr. Martin Varley

There is but one would have to survey consultants individually. I was trying to guesstimate the total number of outpatient clinic appointments where outpatients would be seen in private practice consultants' rooms. Even if one allowed for 33 patients to be seen in a week across two clinics, in two half days, there could be in excess of 1 million such outpatient appointments per year. I am guesstimating that 20,000 outpatient clinic appointments would normally take place in a week but it could be a lot higher. I do not know how many of those are lost.

Some consultants have complained to members of the committee that in the context of that new arrangement, where private hospitals were taken in charge by the HSE, the output was very low because there was no working arrangement. Instead of covering a number of patients, as with the figures Mr. Varley has just given us, they were not able to do that number. As a result, there was little value for money.

Mr. Martin Varley

Yes. There were other contributory factors. For example, we sought a lot of clarity about indemnity. Clinical indemnity is multifactorial and multidimensional. A private practice consultant has clinical indemnity for outpatient consulting rooms and for the private hospital. It is only in the last week or two that we have had absolute clarity that a private practice consultant who has signed the contract is also indemnified for treating public patients in his or her outpatient clinic. As I referred to earlier, many variables were not discussed or provided for. We flagged those quite early. The frustration that private practice consultants had was that we were not getting answers, decisions or practical approaches.

As many as 1 million patients suffered from this.

Mr. Martin Varley

This is the real problem. Many patients have suffered and care has unfortunately been delayed.

I am deputising at short notice for our health spokesperson, Deputy Ossian Smyth. I apologise if there is crossover with previous questions and answers. My first question relates to the transfer of patients for consultants who did not sign the new contract. Was a mechanism in place for those patients to be transferred onto the public list? If so, and if that has happened, is there a mechanism to deal with those patients now that the deal is coming to an end?

Mr. Martin Varley

It is a valid question. I am not aware of a mechanism, other than a general indication that patients can be transferred to a public list. I have spoken to many consultants who wanted to know how to go about this and transfer a large number of patients to a public list. Where do they go on that list? The aspect of continuity of care gets fractured once we start talking about transferring a cardiac or cancer care patient, for example, in the middle of care, or when a person has an event and needs to be looked after. It does not make sense to transfer somebody in a critical stage of care into a public system that is already overwhelmed with very long waiting lists. This has been a major problem for private practice consultants. Many of them have said to me they have ethical and medical responsibilities to their patients that they could not ignore.

How many cases might we be talking about in this kind of scenario? Mr. Varley has indicated there is no existing mechanism to deal with that movement if it happened.

Mr. Martin Varley

There has never been a mechanism to deal with that as the two systems operated quite well independently with some integration. There was not a mechanism to that effect. We must also allow for the fact that in a crisis, the time and management availability to deal with this was quite limited. I am not saying this is an excuse for not doing it but the reality is it did not need to be done if a practical arrangement was put in place for WTPPs to look after their patients. That was quite feasible and doable in the circumstances.

The Government states the deal is ending but in the eventuality of another surge, as we know is extremely likely, it is likely private hospitals might be needed again to provide capacity. How has the engagement of the organisation been with the Department of Health on the matter? Does the witness have recommendations, although we should be more prepared now than we were? Are provisions in place in the event of another surge so we can continue the general operation of services like BreastCheck, for example? We should not be surprised in the same way if there is a resurgence of the coronavirus. Have a system been put in place whereby normal service like BreastCheck can be continued?

Mr. Martin Varley

Much work must be done on that, which is all quite feasible. The association and its private practice consultant members are willing and able to engage. As was said earlier, we need a tripartite approach to this, in all likelihood, to ensure it is effective.

There are witnesses in the committee room if the Deputy wishes to direct any of his questions to them.

I will ask the questions generally and whoever is best placed might provide the answers.

If any of the representatives in the committee wish to contribute, they may raise their hand.

Ms Susan Clyne

I will speak to the cancer screening services. The IMO is currently in discussion with the HSE about how screening will come back into place, particularly cervical screening through general practice, as well as other screening services. The screening services were not cancelled on the basis of any agreement with the Government. It is important to remember all non-urgent care, as well as private care, was cancelled across the system. This was right across the system and it did not just affect appointments for private patients.

I thank Ms Clyne. I have a quick final question. Since services began to resume on 5 May, is there a number for the private consultants treating public patients in that timeframe?

Mr. Martin Varley

The numbers of public patients being treated by consultants in private hospitals is possibly part of a submission on which I have seen reports from the health service management, representatives of which are joining the committee in the afternoon. I have not had the opportunity to look at those figures aside from a fleeting look this morning so perhaps they would be in a better position to provide the data to the committee.

My first couple of questions are for Mr. Varley. Dr. O'Connor spoke to the backlogs of up to six months for public patients. What are the views of the IHCA on the reconfiguration of any new deal with a specific focus on clearing the backlog of public patients?

Has Mr. Varley formed a view on that? How can he help, and how would that influence any new deal?

Second, Mr. Varley mentioned in his opening statement that the original rationale for the hospital deal no longer pertains. None of us are prognosticators in terms of what will happen in the future but given what has happened in the past and the data we have on the winter flu, we all agree that the winter flu and any re-emergence of Covid-19 will not be able to exist side by side in our health service. Does Mr. Varley believe that whatever deal comes next will have to take cognisance of the fact that capacity will be needed this winter across both spheres?

Mr. Martin Varley

Dealing with the latter part of the Deputy's question, which I think is the proper place to start, the big question is how we can now configure in our hospital structure, both public and private, the optimum use of capacity. We have possibly lost sight of an element of that in the context of the expansion of bed capacity provided for in the capacity review and in the national development plan, but I am aware also from discussions with the HSE that there are fairly advanced plans to put in place substantial intermediary step-down care beds - something of the order of 1,600 across the country - which are hugely important. In addition, beds had been opened on a temporary basis during the crisis that need to be opened on a sustained basis. That is vitally important in terms of ensuring we have a capacity footprint that is greater than the one we started out with. In particular, opening the approximately 1,600 integrated beds is vitally important to allow us to decant patients from hospitals once their clinical treatment is completed and they need to go on to further care before returning home. There are difficulties there to my knowledge but there are substantial bed numbers in that regard.

The same applies to ICU bed capacity in our public hospitals. Trojan work has been done by everybody to ramp up our public hospital ICU capacity. A lot of extremely good work has been done by consultants on the front line. We need now to put that on a sustainable basis. Let us not forget that about a decade ago the then Government commissioned a report that recommended we should double the number of ICU beds by 2020. We are probably there but only there on an improvised basis. The concerns I am hearing from our public hospital doctors in ICU in particular is that we could lose sight of that. That was the critical exposure we had in terms of dealing with a pandemic and a crisis. We always knew it was a problem in terms of trying to deliver scheduled care and unscheduled care together in a stretched environment. We would like to see us going back to our tripartite discussions. We need to engage with the other parties: health service management, private hospitals, private practice and other consultants.

I have a question for Ms Clyne. She mentioned that an urgent assessment is needed of current capacity and how that capacity will be affected as we deliver care under new social distancing arrangements. Has the IMO formed a view on the two metre versus one metre debate and how that would impact us in being able to meet the capacity and address the backlogs in outpatient departments and every other element of our health service?

Ms Susan Clyne

The IMO would fully support NPHET and its recommendations. If two metres is recommended by NPHET, we want to operate our health services in the safest way possible. It is not a place to take additional risks to sort out the infection in our health services. The two metre rule is in place at the moment and we would fully support that.

It is not a question of two metres or one metres in the health services because given the lack of capacity and the growing waiting lists, we need much more fundamental investment in temporary builds, staff coming on board and staff getting engaged with management and plans. Consultants, nurses and management in every hospital are looking at this and they are all very worried about how we continue to provide essential services to patients with so little capacity.

Dr. Sadlier, did you have your hand up to answer a question? No.

Professor Alan Irvine

I appreciate this is to do with the review of the private hospital deal. There are certainly many learnings we can take from this but we should not be focused entirely on what we will do with the next private hospital deal. We have massive restrictions in capacity. We need to be bold, imaginative and local. We need to look at where good local solutions have worked and how we can get extra capacity for outpatient and inpatient procedures in the public sector also.

That has to be an absolute priority rather than seeing how we can do things better in a narrow way with the independent sector. That might be important in the short term, but let us also be bold and imaginative. We are in a special place-----

Does Professor Irvine have any concrete, bold or imaginative proposal?

Professor Alan Irvine

Yes, there are imaginative solutions - for example, what Citywest is doing-----

I will give some of my own time at the end rather than take somebody else's. I look forward to your contribution. I am sorry to cut across you, but we do not have time.

Deputy Shortall has five minutes.

I want to thank both groups for their presentations .

Does Mr. Varley accept, in the context of the Covid-19 crisis and the general atmosphere of everybody needing to put their shoulder to the wheel, it was regrettable that more private patients did not sign up to the local contract?

Mr. Martin Varley

Is that in the context of private practice consultants?

Mr. Martin Varley

We have to see this through the prism of the situation the private practice consultants found themselves in. As I said earlier, they had a Hobson's choice. Would one sign a contract that constrained or prohibited one from providing continuity of care in one's outpatient clinics? I have spoken to many consultants in those circumstances. I should add that private practice consultants in different specialties found themselves in different situations. If one was an anaesthetist the same circumstances did not apply as would to a cardiologist, medical oncologist and others. This explains why some were in a position to sign up and others were not. I have seen some of the room costs of medical and respiratory consultants in private practice. The lowest is €6,000 per month increasing to €10,000, €15,000 and €20,000. In my view the failure was not, in fact, that private practice consultants were not engaging. I estimate I have spent 80 to 100 hours a week on issues trying to unblock the obstacles, together with our private practice consultants, so they could sign up.

Nevertheless, there was a massive national effort under way and in that context it might have been better if more people had signed up.

Mr. Martin Varley

Could I finish on one point? The vast majority who could not sign up offered pro bono services in their hospitals to treat public patients. We should not lose sight of that.

I wish to raise some questions with Ms Clyne and the IMO. I note the comments Ms Clyne made with regard to the NTPF diverting important funding away from the public health service. I very much agree with those points, and that should be taken on board by people involved in negotiations at the moment.

It is regrettable the decision was taken by Government to end the arrangement at the end of June, because there was huge potential. In the context of no distinction being made between public and private patients in the treatment of Covid-19 patients, it would be great to see that same kind of effort made on non-Covid care, with single lists being operated and all of the capacity within the public and private hospital systems being used at least until the end of the year. If we avoided a second surge or wave, real progress could have been made through the waiting lists for all patients. It is regrettable that did not happen. There is a strong argument for the State to retain the use of at least a few private hospitals in order to operate them as elective-only hospitals. There is commitment to developing elective-only hospitals at some point. Would Ms Clyne accept there is a strong case for retaining some private hospitals for use as elective-only hospitals, as happened in Scotland where a private hospital was bought for that purpose?

Ms Susan Clyne

Yes, we would like to see some elective-only hospitals in place. I do not think we spent long enough on the arrangement with the private hospitals in terms of deciding what everyone wanted from the system. The Government is going to end the agreement. We do not know what the new agreement will be.

The HSE, I suspect, had a vision or a plan to use these hospitals for elective work. We must do something rapidly about our waiting lists. However, even with the private hospitals, it is not a long-term or even a medium-term solution. There is still not enough capacity or consultants in the country when one adds the capacity in the public hospitals together with the private hospitals. We really have to invest in acute hospitals, in beds, and in consultants to deliver care to patients.

I thank Ms Clyne. I am going to have to reduce each slot to four minutes from now on to get everybody in.

Deputy Paul Murphy has four minutes.

I suggest in future that we should do that throughout, rather than those who are at the end getting cut off.

I appreciate that. I am sorry. There was much procedural discussion at the start.

As general comment first of all, it is unfortunate the discussion happens in the context of the horse having bolted, with the Minister and the Government having taken the decision to effectively return to what looks like a two-tier health service, combined with a supercharged NTPF. That looks like where they are going. It seems to suggest that it is not okay to treat people according to wealth when they have the coronavirus, but it is okay to do so when they have cancer, heart disease, or depression. Instead of going backwards, we should be going forwards to a national one-tier public health service.

I refer to the details of the deal with the private hospitals. I was a critic of it, and I thought it appeared extremely expensive. I agree when Mr. Varley says that it represents very poor value for money. His basis for that is primarily based on usage, that is, there is a huge amount of excess capacity and we are only using a certain number of beds, therefore it is very expensive per bed used. However, according to the figures published in Britain on the deal between the NHS and private hospitals, even on a per-bed basis, regardless of usage, the deal looks very expensive. In Britain, the average cost per bed is about €10,000 per month, whereas in Ireland it is about €44,000 per month. Has Mr. Varley any insight into why the deal appears, on a per-bed basis, appears to be so expensive?

Mr. Martin Varley

I do not have full detail on that, but I recall commentary on it at the time, in the early stages. My understanding, and this is subject to verification, is that the agreement entered into with the private hospitals in the UK effectively allowed more flexibility in terms of what was being purchased and taken over, so to speak. As such the private hospital deal in the UK allowed the possibility for capacity that was not required to be used to treat the patients in those hospitals that would otherwise require urgent care. That in some respects would account for the fact that in the UK, they were probably - I stress probably because I do not have all the detail - paying for the capacity they sought, but it not being all the capacity in the hospital, or else the capacity being used. In the private hospital agreement here, however, I think it was covering all the capacity. That is the sort of detail that becomes problematic in trying to optimise capacity and getting good use of it.

To follow up on that, I have been trying to get access to both the April cost provided by the private hospitals, and a full breakdown of the costs from the Government. They are refusing to give me any of the figures, which makes it very difficult for us, as public representatives, and the public in general to make a decision on whether or not it is good value for money because we do not have any figures to go on. Would Mr. Varley agree we need to have more transparency in terms of the costs, the deal, etc., so that people can make an informed decision about it?

Mr. Martin Varley

In particular in circumstances like this, transparency is hugely important, so I can only agree with the Deputy's suggestion.

I thank Mr. Varley. Does the IMO have any comments to make on that? In particular, I note its comments about the NTPF. It seems that is what the Government is gearing up for, a more extreme NTPF with all the inequalities, and so on, which go from that.

Dr. Anthony O'Connor

Our position would have been that it was premature to abandon this deal before there was a proper roadmap for reopening the service for public patients as well, because their lives matter too.

People talk about a second surge and what might happen. They say we could have hundreds of people lying on trolleys, overburdened intensive care unit capacity and operating theatres closed for a month. That is January every year in the Irish health service. What could be coming if we do not address it could be apocalyptic. We need to find a solution. If we say the NTPF might be the solution, then we will have to use it in a way that we have never used it before, and we had better get started with it.

Deputy Shortall made the suggestion about putting some of this on a more permanent footing. That is another option but whatever we do we need to set about it fairly quickly.

I thank Dr. O'Connor and Deputy Murphy. I call Deputy Shanahan for the Regional Group. He has four minutes. I am sorry but we are reducing slots to get everybody in.

On the deal done in early March, how soon does Mr. Varley think the alarm bells started to ring for his organisation that the capacity there was not going to be utilised? When did the IHCA bring that to the Department's attention forcefully?

Mr. Martin Varley

We brought it to the Department's attention quite early on in our discussions with officials. We did that for the simple reason that we were very concerned about continuity of care for patients of private practice consultants. We could see that the contract being offered to our members was cutting across that and our members were concerned about events happening for cardiac patients, oncology patients and others that would be detrimental to their health. We flagged it quite early on and because we were making so little progress we wrote to the Minister on 30 April outlining that this arrangement was going to prove extremely poor value for money, poor value for patients and there was a very high risk we would not be able to utilise the capacity to the extent that we should.

Given that there was a lack of activity in the public and private hospitals and understanding the efficiencies that were available in the private sector, does Mr. Varley think there was an ideological component to the Department's arrangements vis-à-vis the full-time private consultants?

Mr. Martin Varley

I struggled to understand the reasoning behind many of the exchanges I have had with the officials. I recall at one point saying to an official that we had 600 consulting rooms that provide very valuable outpatient clinic care to patients. I said it was like cutting off one's nose to spite one's face to ignore this vital capacity that we need more than ever during a crisis. I was pleading with the officials to understand that what we were doing was not going to be optimum.

With respect to where we go from here, we have heard the doctors and the IMO speak about the dangers of a surge later in the year. I do not agree with my colleague, Deputy Murphy, about the NTPF. What we know about the present model, whatever the future model might be, is that if one incentivises activity, one gets increases. At the moment, the only way to do that is within the private hospital sector. Where does Mr. Varley think we are going in terms of the NTPF? Can we streamline patients through the NTPF to get more elective procedures done?

Some of the private hospitals have already invested in polymerase chain reaction, PCR, testing, which gives results within 20 minutes. This should allow a far safer movement of patients, and potentially care staff, through the hospital. Is this something the IHCA would try to progress as quickly as possible? That seems to be a way to speed up efficiency and to counter some of our capacity issues.

Mr. Martin Varley

As mentioned by Professor Alan Irvine earlier, we have to optimise the use of our capacities across all aspects of our healthcare delivery. We are in a very challenging environment and we should do so.

It is very important that we advance the 1,600 or so intermediary care beds so that we can streamline the stepdown care for patients coming from public hospitals. Otherwise, many beds in public hospitals will not be available to provide scheduled and unscheduled care to patients. There are 12,000 to 13,000 beds in our public hospitals and 2,000 beds in our private hospitals. The bigger opportunity is in our public hospitals and in putting in place additional capacity for public care. Our members on the ground, in public and private hospitals, have demonstrated much agility and innovation during this crisis.

They brought things in very quickly. They are more than happy to engage, as we go into the winter, to avoid problems that would otherwise arise.

I now call Deputy Michael Collins. He has four minutes. I apologise but we have had to reduce time.

I welcome the witnesses. Do they think the takeover of private hospitals was done in a hasty and poorly thought-out manner?

Mr. Martin Varley

Everyone can understand the circumstances that we were in in March. Everyone was fearful as to what was coming our way. The agreement was entered into in those circumstances with the best possible intentions to protect the population and to protect our front-line workers. The agreement was hasty, but probably necessarily so. Where it probably fell down is that there was not enough engagement with the hospital consultants who would be critical in delivering the care in those private hospitals. The analogy has been drawn that the agreement effectively rented the aircrafts but did not enter into appropriate consultation with the pilots who were necessary to deliver the service. That is probably the main failure and the main lesson that we must learn as we go forward. Engagement across all spectrums with all the stakeholder groups is hugely important.

Was the decision seriously damaging to public health?

Mr. Martin Varley

We are in an environment where the health service and health services generally had been hugely challenged because of the crisis. Yes, some damage has been done because we have not optimised what could have been done in private hospitals. Care to urgent non-Covid patients has been prohibited and frustrated and care for non-Covid urgent patients in public hospitals has also been delayed. This is anything but an ideal environment. We could have done better, as we have alluded to, by putting more practical arrangements in place to allow private practice consultants to operate their suites and outpatient clinics to give timely care to their patients. They were more than happy to do that, together with providing care in the private hospitals, as had been requested. That was not facilitated and that was the huge problem we had.

Was the decision correct to deny 2.2 million people their legal rights to gain access to what they paid for?

Mr. Martin Varley

There is another broader discussion there. As I outlined in my opening statement, 46% of the population had maintained their health insurance. They rely on the private hospitals to a large degree and the private practice consultants provide that care. That is good for public hospitals because we do not have sufficient public hospital capacity. As I said, there are 12,000 beds in the public and 2,000 in the private; we must use them to the optimum degree. I am sure those who had health insurance will look forward to a situation where, if they have a requirement for urgent care, they can access it with their consultants and that will give continuity.

Was there much inaccuracy in statements issued by the HSE on this issue?

Mr. Martin Varley

We would have seen that and been concerned about that. Much of our engagement has been absolutely collaborative. I have all my communications with me. They have also been constructive. That has been our approach as an association and has been the approach of our members. However, it has not been reciprocated in a similar manner which I regret hugely, especially during a crisis. We have operated with absolute integrity in these matters. On occasions, it has been portrayed otherwise, which I find extremely regrettable.

I am conscious that Dr. Sadlier in committee room 1 wishes to contribute.

Dr. Matthew Sadlier

The answer to the Deputy's question is that we must ask ourselves why we needed to do this. Why, in a public hospital system, did we need to look for extra capacity in the private system? It is because we have had so many years of under investment into the public hospital system. We talk about beds in the public hospital system but there are other things we could have done that would have helped and facilitated the move to the private hospitals.

We cannot let today's meeting finish without making sure that three things are clearly stated. First, is the investment that we urgently require in the IT systems within the hospitals. Within mental health, where I work, we have been asked to move to telemedicine, but that is not possible unless one has computers with cameras and microphones, which almost none of the primary care centres and mental health teams is facilitated with.

Second, the private hospital spread around the country does not reflect the geographical spread of the population. There was, and still is, a possibility with some of the money that was being spent on this deal to introduce generational changes, whether it is through modular builds or temporary builds to expand bed capacity in areas of the country where due to population spread there is no private hospital alternative.

Third, we cannot under any circumstances leave today without emphasising the damage that the 30% cut to consultants' salaries in 2012 has done to the recruitment and retention of specialist staff within the public healthcare service. We can talk about capacity in terms of beds and buildings as much as we like, but if we do not have the specialists within those buildings to provide the care for the patients the buildings are fundamentally useless. Ultimately, what is going to happen in the coming months is that there will be an unprecedented demand for medical expertise across the world. Within the English-speaking medical world we have always been the country that has paid the least and has been the least competitive in terms of being able to recruit specialist staff. If we do not address the 30% cut urgently, we could be in a far worse place when the autumn and winter comes. As my colleague Dr. O'Connor said, we will have an apocalyptic situation if we get hit with flu and Covid at the same time.

I thank Dr. Sadlier very much. The next Sinn Féin speaker has seven minutes and there are also two four-minute slots. Deputy O'Reilly went over. I am just doing the best I can to be fair to everybody.

We will talk about that another time, a Chathaoirligh. I thank the witnesses for their contributions today and for their frank responses so far.

Could any of the witnesses give an indication as to how many Covid-19 cases have been treated in private hospitals since the deal was negotiated and agreed?

Mr. Martin Varley

I do not have those figures. I suspect the number of Covid-19 patients in private hospitals is relatively low. I think some cases presented in the early days in one of the private hospitals in Cork and I am sure there were occasions elsewhere where similar presentations would have occurred but, in the main, the intention was that the Covid-19 patients would be treated in the public hospitals.

Is that view shared by the IMO or does anyone in the committee room have additional information?

Ms Susan Clyne

We do not have those numbers but I think it is true to say that the public hospitals, in the main, have dealt with the Covid issue.

We have been paying €115 million per month for the use of private hospitals during this period. The corresponding figure we were given for the deal that was done with private hospitals by the NHS in Britain is €82.5 million. I accept there will always be distinctions between different healthcare systems but according to the figures I have – I am open to contradiction – it works out roughly that our deal equated to €44,000 per bed per month while the equivalent deal in Britain was closer to €10,000 per bed per month. Dealing with the issue from a staffing point of view, our deal worked out at €14,000 per staff, per month compared to the British figure of about €4,000 per staff, per month. Could any of the witnesses shed light on why there would be such divergence in those figures?

Mr. Martin Varley

Unfortunately, I do not have visibility of the detail and I have not had an opportunity to examine it.

Does Mr. Varley see any reason we would be paying over three times the amount?

Mr. Martin Varley

As I alluded earlier, I do not have all the facts, but it is quite possible that the agreements differ in terms of the basics of the agreements. The agreement here was to acquire access to all the capacity and pay for it, as such, whereas I think - subject to verifying this - the UK agreement may be around payment for capacity used or sought but not all of it.

Therefore, it allowed the private hospitals in the UK to also continue to provide care to private patients in terms of continuity of care as well.

The agreement was entered into in a very extremely difficult and challenging circumstance whereby most of us were of the view we were going to be overwhelmed with patients infected with the Covid virus and everybody approached that with the best possible intentions. Where we have slightly gone wrong is that there has not been flexibility in terms of how the agreement works in practice.

Mr. Irvine is in the committee room and would like to comment.

Mr. Irvine is welcome.

Professor Alan Irvine

To give a brief description, the deal we did here was to take over the complete command and control of all of the running costs of the Private Hospitals Association, PHA, hospitals, whereas the British deal was more titrated towards activity delivered and it did not take over the entire operation of the hospitals. That is going to account for quite a big discrepancy in the per-bed costs when one reduces it down to that. Obviously if one buys 100% capacity but use 20%, 30% or 50% yet still pay for 100% then that will skew the costs per unit item.

Two questions flow from that. Clearly, the understanding we have from media reports of the Government's intentions is that it is moving towards that model. Is there any particular advice that we need to give? Either set of speakers are welcome to answer my question. Was the Government in a poor negotiating position for the original deal considering it had essentially announced the deal before negotiations had started? Therefore, it needed to bring the deal over the line because of the additional pressures that were placed on it. In other words, did the private hospitals manage to get an incredibly good deal in return for what was actually delivered over the past number of months?

Ms Susan Clyne

The reason this or any Government would be in a poor negotiating position is because the public health system has been so underfunded, has too few beds, too few doctors and increasing demand.

On the detail of the negotiations or the deal with the private hospitals, we were not involved in any of those negotiations. We really do not want the committee to lose sight of the following fact. Whatever arrangement the Government now enters into with the public hospitals - and it will need to enter into some kind of an arrangement with them - needs to be based on prioritising clinical need while at the same time investing in public services. This cannot be another excuse to say, "we are doing this, we have this capacity so we don't need to do anything in the public service". The public service is crying out for beds and manpower, and we need to do that now.

I agree with all of that. Issues were raised at the end of the last round of questions. What level of investment is required for IT systems? Are there particular areas of practice where the IT systems are frustrating the provision of a healthcare system within the public system?

I noted the comments and very strong focus that was put on the salaries for consultants. Does the IMO have an equal position on salaries for other front-line workers, particularly nurses, doctors, primary healthcare providers and others?

Ms Susan Clyne

I will deal with the salaries for consultant posts and then my colleague, Dr. Sadlier, will deal with the IT staff. All healthcare workers should be rewarded appropriately for their post. The issue of the salary for consultants is regarding a specific and unique cut that was imposed in 2012 on consultants only that was on top of all of the other financial emergency measures in the public interest, FEMPI, cuts that all healthcare workers suffered. It is an extra 30% cut that was targeted - and politically targeted - at consultants. It saved the State hardly any amount of money but destroyed the health service and destroyed the recruitment of consultants into the public system and we are still suffering from that cut now.

I thank Ms Clyne. Does Dr. Sadlier wish to say something?

Dr. Matthew Sadlier

To answer Deputy Carthy's questions on information technology, the IT systems in Irish healthcare are abysmal. That is the only word one can use. Anyone walking in to most Irish hospitals will see we are using the same methods - paper and pen and cardboard charts that get filed - as were used in 1890. When patients come in to the emergency department, the only records we have of them are in a cardboard file that has to be dragged up from a basement. In the era of information technology, we could use collaborative working platforms. When we try to attend remote team meetings, as we all had to do overnight, we are not able to do so. There are information systems available that work very well.

Could we ask the IMO to prepare us a paper on that? That would be very useful.

I thank Deputy Carthy for that constructive suggestion. Would Dr. Sadlier be happy to provide a written reply?

Dr. Matthew Sadlier

Yes, we can do so.

I thank Dr. Sadlier for his understanding.

I thank both the IMO and the Irish Hospital Consultants Association for their presentations. On the agreement between the Department and the private hospitals, I note Mr. Varley makes no reference in his presentation to any contact between the IHCA and the private hospitals. In view of the fact that the private hospitals were the places where the IHCA's members worked, was there at any stage over the past two months ongoing consultation with the private hospitals?

The agreement will not be renewed after 30 June, although there will be a new agreement. Has the IHCA set out its stall with the private hospitals as regards how an agreement can be reached between all parties as opposed to having the Department and HSE reach an agreement with the private hospitals and leaving the consultants out? I am wondering about the communication the IHCA had. The same question applies to the IMO as regards the consultation it had with the private hospitals.

Mr. Martin Varley

We had discussions with the private hospital associations, in terms of their executive and CEOs, at an early stage when we became aware of what was being proposed. We outlined all of our concerns vis-à-vis the need for a contract that would be practical and workable from a consultant point of view. That was during the latter half of March. If we cast our minds back to that time, the overwhelming view I got from those discussions was that there was a shortage of time and a lot of pressure, and people were trying to get an agreement. Members will have seen that in the media. We highlighted and flagged the problems, which become more apparent as the agreement went on. In particular, we stressed the need to deal with those problems.

In relation to the type of contract, it seems that health service management presented only one option and was absolutely inflexible therein. There was no room for us as an association to get a hearing on what were reasonable points. Even though we engaged with health service management from mid-March onwards, a significant hiatus arose between those discussions and follow-on discussions whereby there was not enough feedback and engagement from the officials until after the agreement was signed with the private hospitals. Unfortunately, an opportunity was lost in that period.

Mr. Varley's main criticism seems to be with the Department and the HSE. Does he not accept that there should also be criticism of the private hospitals given that the IHCA was excluded and the private hospitals did not seem to respond to its concerns?

Mr. Martin Varley

The Deputy has summed it up well. The main criticism was with the officials who have a responsibility to engage and to ensure whatever arrangements the Government puts in place work well. As I said in our earlier discussions, on matters such as this, we need tripartite discussions between health service management, representatives of private hospital and representatives of private practice consultants.

When one of these is neglected, one ends up with a situation such as was described earlier in which it is as if one pays a lot of money to hire aircraft without engaging with the pilots. That is extremely regrettable. Our members wanted to commit to this huge national challenge and did so despite a suitable contract not being available. As a result, not all of them could sign the contract. We need to make sure any future engagement is carried out on the basis of the necessary considerations being taken into account in shaping any future arrangements.

The IMO may want to come in on my next point. With regard to future arrangements, if there were to be 80% or 90% occupancy in a private hospital and the Department suddenly concluded that a surge was on the way, how many days would it take to make beds available?

Ms Susan Clyne

I am afraid we do not know the answer to that. If hospitals are operating at 80% or 90% capacity while we are waiting for a surge, we will be in real trouble.

If one was to take the average stay of a private patient in a private hospital into account, surely one could estimate how long it would take. Should we now estimate the capacity above which private hospitals should not operate?

Ms Susan Clyne

We make the point that the public services and the private services should open in tandem, based on patient clinical need, so that we will know where we are across the system at any one time. In designing the new agreement, we will have to consider what exactly we now want from the private hospitals. Is it to be like the UK model, in which some targeted purchasing is negotiated? We hope it will not be based on the National Treatment Purchase Fund system but are greatly concerned that it will be.

Dr. Matthew Sadlier

Ultimately, one of the main arguments raised here is a little false. In normal times, the public hospital system operates at near 100% of capacity, as does the private hospital system. While in an emergency period of a number of months the capacity for elective care in one or both of those systems can be reduced, the demand ultimately builds up and will come into the system. The overall system ultimately needs more capacity. We need more beds than the public and private systems combined can provide. That is the ultimate problem. If we were to go back to using the private system for public patients or for surge capacity, all we would be doing is causing a build-up of patients which will leak into either the public system or the private system. Ultimately, we need more capacity in the country, regardless of the system it is in.

To return to the issue of capacity, do the witnesses have experience of modular hospitals? Have they been successful?

Dr. Anthony O'Connor

We had modular builds in Tallaght University Hospital for quite some time. They helped us with our capacity. It is now on a more permanent footing. It was also tried to good effect in South Tipperary General Hospital. We know it can be done; we have seen it happen all over the world in the past three months.

How long do such buildings take to construct from start to finish?

Dr. Anthony O'Connor

When the urgency is there, things can happen very quickly. That is an important thing we have learned in recent months. I cannot stress enough that what we consider a surge is the norm in our hospitals every winter, so we need to get ready now. There is plenty of time before winter for us to get modular capacity if that is what is needed. There is loads of time right now.

With regard to the IT system, I understand that maternity services have been computerised and that this is progressing section by section within the health system. What progress has been made over the past two years?

Dr. Matthew Sadlier

It depends on the section. I could provide a very long answer to this question but I will be very quick. Ultimately, we need a single integrated system across all hospital sites. Individual hospitals with individual systems that do not integrate do not provide value for the overall system. By the nature of our health system, most patients go to more than one institution for their healthcare, depending on the specialty they require or the problem they have. The maternity hospitals are a great example, particularly in Dublin which has stand-alone maternity hospitals.

There is a very good point to those maternity hospitals having a system for themselves, but when those patients have another health problem that is not related to their pregnancy or childbirth and they go to one of the public hospitals, if the information digitally recorded in the maternity hospital cannot follow the patient to the other hospital, it is underutilisation of a system.

I understand that over the past three years, this system of computerisation of patient records has been developed across all the maternity hospitals.

Dr. Matthew Sadlier

It needs to integrate into the other general hospitals. Patients may have other health problems that are potentially not related to their pregnancy or childbirth and they may attend a general hospital where information from the maternity system is not feeding back into the general hospital. The computerised system is good for one health journey the patient has had, but a life is full of multiple health journeys. The information technology system should follow us through that.

Professor Alan Irvine

The individual health identifier has been on the statutes in various committees for 16 or 18 years. It would make a huge difference. It rests here in the Legislature, not on the operations side.

I thank all of the witnesses for coming to the committee. I thank their respective members for the Trojan work they have done over the past months. It has been quite extraordinary to see the level of skill and dedication as an entire clinical system geared up for a disease we had no idea how to treat when we did not know what it would do to our population. It has been an incredible show of skill, professionalism and dedication across the clinical community. I thank all of the witnesses' association members for everything they have done and continue to do.

I believe that taking over the private hospitals was the absolutely the right thing to do. It was a bold, brave decision to deal with the surge. Once the surge did not happen, however, they should have been given back pretty much straight away. It is my sense that the new rationale for holding on to them to use as additional capacity has been an implementation disaster. It was always going to be very difficult. For June, I do not understand why the contract was not ended last week. I cannot find anybody who believes that the contract makes any sense now for patients, be they public or private or anyone else. In his opening statement, Mr. Varley stated that some 250,000 operations under general anaesthetic are done per year in the private system. That is approximately 21,000 per month, which is a lot. It is two in every five surgeries performed under general anaesthetic in the State in any given month. Given that this deal means we are getting about half of what we should be getting from the private system, does Mr. Varley believe it reasonable to say that continuing this contract for June means that approximately 10,000 patients - which is a ballpark figure - who need surgery under general anaesthetic will now not get that surgery?

Mr. Martin Varley

The Deputy's broad analysis is correct. If we are operating at 30% of 40% capacity in bed utilisation, and if we allow that some of the patients who had been transferred to private hospitals are at the end of their clinical care, then perhaps the real impact is somewhat lower. At 30% or 40%, and even allowing for Covid-19 restrictions, it is quite possible we could have used our private hospitals to the extent of 60% or 80%, depending on circumstances. We are aware from our private practice consultants that care has been delayed at outpatients clinics and for follow-on care that may be required in hospitals.

Is it Mr. Varley's understanding, and I put this question also to the clinicians here today, that some of this delayed care as a result of lower capacity is cancer patients and urgent care including diagnostics, outpatient clinics or surgery?

Mr. Martin Varley

Yes, unfortunately. I have spoken to many consultants, medical oncologists, urologists and other specialists who treat cancer patients. They have been extremely frustrated. They cannot get the contract to work to provide the timely care they want to provide for their patients.

I thank Mr. Varley. Do any of the representatives from the Irish Medical Organisation, IMO, want to respond on the care that is being missed at the moment?

Dr. Anthony O'Connor

It is a huge concern. If we cancel the contract immediately, it would mean that those 10,000 operations can happen but it bears no relation to need or urgency.

One could have a situation where the private sector is allowed to operate as it normally does but the public patients are still completely locked out of all elective care and all cancer care. That is why this organisation was calling for both arms of the service to be opened up in tandem according to clinical need, with urgent time-sensitive stuff first, maybe something like chronic non-malignant disease after that and then opening up more gradually while seeing if there is any more benefit we can wring out of this deal for however long is left, be it a month or whatever.

I will come to that and I agree. When I advocate for the ending of this contract, it is not to go back to the status quo where public patients cannot access it. I am just trying to get a sense for the total quantum of care that we can now deliver to people in this country. I do not really care if they are public or private; they are people who need care. If there are 10,000 fewer of them having surgery this month because of what I think everyone knows is a bad deal, that is worth putting on the record. I have a quick question and would like a general response. In terms of value for money, am I right in thinking that under this contract, for the last few months and for this month, public money will be used to have private patients as well as some public patients treated in private hospitals by private doctors? Essentially, operations and procedures that would normally be paid for by the insurance companies are being paid for out of the public purse.

Mr. Martin Varley

That is the situation. On the basis of the contract that was drawn up, the normal billing that could have arisen for privately insured patients was not provided for. Therefore, the State is paying for the use of that capacity whereas the private health insurers could have funded it and would have been happy to do so.

Ms Susan Clyne

Under the legislation, all private patients became public patients.

We understand but essentially they were private patients. Their insurance companies were going to pay for their care and treatment and we stepped in and said we would pay for it instead, if they can get it. My final question is probably more for the IMO but also for the IHCA. It is about solutions. We now have a perfect storm. We have lost 20% of beds in our public hospitals by going from about 100% to 80%. In her opening statement, Ms Clyne referred to a loss in capacity of up to 50%. Be it diagnostics or outpatients, a lot of doctors are saying that is what is going on. We need solutions and we need them for this year. That reduced capacity is going to stay with us. There is a fear that our entire healthcare system is going to be overwhelmed by an increased level of demand at the same time as a massive reduction takes place in capacity and huge additional expenditure needs arise around PPE, testing and tracing. A new care area, namely Covid-19, has also arisen along with a €30 billion deficit in our finances. We need solutions to increase capacity now. As we know, building hospitals takes a very long time. Have the witnesses solutions for what we can do to increase capacity immediately?

Ms Susan Clyne

Yes, and we have outlined some of them in our submission. We need an assessment of what is available now. For example, Citywest Hotel was set up with a number of beds to be used for Covid. It is now not being used for Covid but we have rented it so we can use it for something. We have to use temporary modular builds. We have to help hospitals located outside of the big regions, like Wexford, and put in extra beds there. We accept that the building of a hospital takes a long time but it will take longer if we do not get it started. Temporary modular builds have to start taking place. We have to be innovative and work with GP colleagues to see how we can streamline services between general practice and the secondary care system. We have to recruit doctors. We have significant number of non-consultant hospital doctors, NCHDs, in the system who are due to finish their specialist registrar, SpR, training posts in July. They should be offered an acting-up consultant post immediately. It is possible to do that. We also have NCHDs who are due to finish various contracts in July who have not been guaranteed any posts to stay in the Irish system. While we are saying we need all these doctors and more, we are allowing another generation of doctors to leave the country.

Professor Alan Irvine

We need to massively increase the workforce. We talked earlier about correcting the 30% pay cut, which is really important in recruiting the next generation of consultants, a point we cannot emphasise enough. If looking for solutions in a broader system, one will find them mostly grown locally and from listening to local clinicians, nurse leaders and hospital leaders. One will find that if one talks to people working in Wexford, they will know what is best for Wexford and how best to get its capacity. There may be office blocks that can be repurposed as outpatient clinics with social distancing or additional beds that can come in for modular builds. There is a great deal of expertise locally if one really listens to the people who know their business best. It will not work on a central command and control, top-down system. That never works and it is just forced on people. The best and most innovative solutions will be in local communities with local clinicians and nurses.

I recommend fixing the pay cut, getting more people on the ground and listening carefully to local solutions. They should be given money and empowered.

I thank Professor Irvine and call Mr. Varley.

Mr. Martin Varley

To respond to Deputy Stephen Donnelly's question, we need to accelerate the opening of beds. A great deal of work has been done on opening and planning for intermediary beds for step-down. It is of the order of 1,600. In addition, we have improvised within the system to bring back into use approximately 1,500 acute hospital beds in public hospitals. They have to be opened and be put on a sustainable footing. To do so, we need to fund them, as has been outlined over many years, and to staff them. The service cannot be run on an overstretched basis. I go back to the fact that between 500 and 600 of our permanent consultant posts are vacant. The Government has taken a decision that we should end the discrimination and bring back those consultants, and that is a high priority if we want sustainable services during a peak.

Our IT facilities for radiologists reporting are far less than is needed. We have had engagement with the HSE on it in recent weeks and we just need to put in place proper IT services to allow people to work effectively and build on what has been a lot of agility and of innovation demonstrated by our consultants and hospital doctors in recent months.

I thank Mr. Varley and call Dr. Sadlier.

Dr. Matthew Sadlier

One of the tragedies of the past ten years of the health service, since the 30% consultant pay cut was introduced, was that 52% of interns, on completing their intern year, would emigrate. We now have an historic opportunity, largely due to restrictions on travel and on countries bringing people in, to retain our interns in July of this year and to increase our medical workforce. As Ms Clyne said, this is an historic opportunity where, as people are coming off their training schemes and getting their specialist qualifications, we can hold them in the country. Interns will have to stay in the country. This is an opportunity where we will not only expand the workforce but also have the expertise that will fill that expansion.

I will ask a couple of questions in the remaining time. Ms Clyne mentioned screening. What is the medical block to carrying out cancer screening, such as CervicalCheck, mammograms, etc., in Ireland? Will she explain the delay in returning to screening in Ireland, which seems to be greater than in other countries?

Ms Susan Clyne

On CervicalCheck, we hope to be able to return to that screening. The delay is to ensure that all parts of the system are working together. While tests can be carried out safely in general practice, we cannot do a lot of tests and then find there is not the capacity within the hospital to call back women who need to be seen. It is because screening is done at multiple locations, and the more complex the case, the more locations the woman may have to go to.

It is a capacity issue rather than it posing a particular risk to front-line staff who are carrying out the tests.

Ms Susan Clyne

It is a complete capacity issue.

Dr. O'Connor stated that, coming into this, there was a waiting list of 700,000 people, and he had a fairly dire prediction. What is the waiting list in the public health system likely to be in November?

Dr. Anthony O'Connor

That will be a function of how many appointments are conducted under normal circumstances that have not been conducted.

Unless we get the system back up and running for routine care in the public sector, we could be looking at 1 million people by November or December.

Could 1 million people be waiting?

Dr. Anthony O'Connor

It would not surprise me.

We have an opportunity. Maybe we can get the public outpatients system up and running a bit more quickly than that and then that would not be the case. It is not inevitable but there is time to act on it.

Professor Irvine was going to give an example of innovation and new methods that could be used. Having asked him, he said he had some proposals but I did not give him the opportunity to outline them. Will he briefly outline them now? The committee would appreciate any additional ones in writing.

Professor Alan Irvine

One needs to ask locally each organisation what will work best for them to fix their particular problems. To get systemwide solutions, one can look at core matters like IT and health identifiers. These should really be implemented for efficient running across the public system and better identification of patients and their needs.

To get innovative solutions, Ms Susan Clyne already mentioned looking at CityWest. There is much capacity and many spare office buildings around which can be used for low-level outpatients which we really should embrace to expand public capacity and its footprint.

On capacity, we have set up hospital clusters. There are acute hospitals with tier 2 hospitals around them typically right across the country. Does Professor Irvine think additional non-Covid capacity would be better developed in the acute hospital or is there a role for the tier 2 hospitals with greater care being provided in those?

Professor Alan Irvine

Tier 2 hospitals are hugely important. They get through much less complex work and give people the best care closest to home when they can. They need to be supported too. However, as has been frequently referenced, we run the public system at a 90% plus capacity. Now with social distancing that will come down. The HSE has stated it wants it to be 80% maximum. Our throughputs are going to be shredded as a result. The IMO submission stated 50% which is probably about right. It is probably at the higher end if we are trying to go from 40-patient clinics to 15-patient or 20-patient clinics. We are going to need much capacity, footprint and flow, much more than what we already have.

The level 2 hospitals are also cramped and overcrowded. They need capacity and modular build, just as much as the level 3 and level 4 hospitals.

We are repeatedly told that there is a difficulty in getting consultants to go out to tier 2 hospitals to carry out procedures. Will the Irish Hospital Consultants Association comment on that?

Mr. Martin Varley

I have seen some commentary to that effect. When I have checked it, however, it has not always turned out to be correct in terms of the reflection. I am aware that in the midwest, the Chairman's own region, there were commentaries to the effect that consultants were not going out. When I checked it, however, there was a long list of consultants who go out to practise.

The bigger issue is that there are restrictions on the type of procedures they can do in model 2 and model 3 hospitals. It also depends on the support facilities available. There is a range of procedures one can carry but some of the rest have to be done in the centres with high levels of support.

Did the Irish Hospital Consultants Association become aware that it was a type A only contract in advance? Was there any consultation in advance? Was the organisation consulted in advance when clinical indemnity was removed from consultants for testing of their existing private patients?

Mr. Martin Varley

I first heard of the type A contract through the media. Thereafter, I had engagements so it was an iterative process. We outlined our concerns and the contract was signed without those being taken on board. Could the Chairman repeat his second question please?

I asked about when the indemnity was being removed - because of the threat, well it was not a threat - for testing.

Mr. Martin Varley

Indemnity was removed in two respects. First, in terms of pro bono, I found out at 6 o'clock on a Friday evening on a bank holiday weekend. I had to inform my members at 9 o'clock or 10 o'clock by the time I got my communication out. This created huge problems.

Likewise for specimen reporting, I became aware of it after the event.

I apologise for cutting across everybody's answers but we are over time. I thank the witnesses for attending the committee today and for their answers.

The sitting will resume at 2 p.m. with Deputy Carroll MacNeill in the Chair.

Sitting suspended at 1.10 p.m. and resumed at 2 p.m.
Deputy Jennifer Carroll MacNeill took the Chair.