Health Service Reform: Hospital Groups

I remind people to ensure their mobile phones are off so they do not interfere with the sound system. I welcome everybody, including those watching, our witnesses before us, those in the Visitors Gallery and committee members. This morning we are meeting representatives of each of the seven hospital groups to discuss their contribution to reform of the health service.

In particular we are interested in discussing the role of hospital groups in developing a more integrated and effective health and social care system and identifying the barriers to achieving this.

Our meeting will be divided into two sessions. We will meet representatives of the RCSI Hospital Group, the Saolta University Health Care Group and the UL Hospital Group.

I welcome the following officials to the meeting: Mr. Ian Carter, chief executive officer and Professor Patrick Broe, group clinical director of the RCSI Hospital Group; Mr. Maurice Power, chief executive officer and Dr. Pat Nash, group chief clinical director of the Saolta University Health Care Group; and Ms Colette Cowan, chief executive officer and Dr. Paul Burke, chief clinical director of the UL Hospitals Group. I thank Mr. Liam Woods, national director of the acute hospital division of the HSE for attending to give a national perspective. Mr. Woods will not be presenting but will be in a position to deal with issues that arise that members need to raise with him. I thank Mr. Ray Mitchell of the HSE parliamentary affairs division, who is seated at the back and thank him for his assistance in setting up this session this morning.

We have already received briefing papers and submissions from each of the hospital groups and I thank the witnesses for their submissions. Time is short this morning because all seven hospital groups will appear before the committee so I ask people to keep their contributions as short as possible so that we can ensure there is enough time for a question and answer session.

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 on a particular matter and they continue to so do, 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. They are asked to respect the parliamentary practice to the effect that, where possible, they should not criticise or make charges against any persons or entity by name or in such a way as to make him, her or it identifiable. I remind members of the long-standing ruling of the Chair to the effect that members should not comment on, criticise or make charges against a person outside the House or an official by name or in such a way as to make him or her identifiable.

I invite Mr. Ian Carter to make his opening statement.

Mr. Ian Carter

I thank the Chairman and members for the opportunity to appear before the committee. As requested I will be brief and stick to the five minutes allocation.

The RCSI Hospital Group comprises seven hospitals: Beaumont Hospital, Cavan hospital, Monaghan hospital, Rotunda hospital, Louth hospital, Connolly hospital and Our Lady of Lourdes Hospital. It is a single governance construct with five HSE hospitals and two voluntary hospitals incorporated. The position of the chief executive officer of the hospital group and the chief executive officer of Beaumont hospital are both held simultaneously by me.

The RCSI Hospital Group serves a population base of 800,000. In terms of service provision, the group provides all secondary care services, a designated cancer centre and is also the national centre for neurosurgery and renal transplantation.

I will not dwell on the performance metrics as they are self-evident but every single patient modality in terms of activity is increasing. On every single metric we are looking at about a 10% increase in activity on last year's figures across both inpatients and the emergency department. The focus for the group this year has been on trying to secure performance improvements in respect of access to the emergency departments. The metrics are very clear and to date this year we have been able to secure an overall significant volume reduction in the number of patients presenting to emergency departments waiting for beds. That is continuing as we speak.

In terms of elective access, as our emergency department performance has improved, we are in a position as a group to increase the number of patients waiting for elective treatment to be brought in and treated and the figures to date compared with those for last year, show an increase of 2,500 in the number of elective treatments.

Our core budget is €676 million and we have a workforce of just over 8,000. We will break even in terms of our budget. Our workforce is broadly static in comparison to the end of last year.

We have six key objectives as a group. We want to improve access performance in terms of both emergency and elective access, doing no preventable harm to patients. We want to operate fiscal prudence and to work in terms of integration in two paradigms - the concept of a single control hospital facility spread across six sites, migrating the capability and capacity demands across the six sites and working strongly to integrate with the community, with particular focus on chronic disease.

The main action of the group beyond improving access has been its ability to treat more patients. This year the group has been able to treat more patients across the six sites. We are matching capability with capacity. A series of initiatives have been introduced whereby patients waiting in Beaumont Hospital for elective surgery are now routinely being treated in Cavan hospital. Patients waiting for endoscopy are routinely treated in Cavan or Connolly hospitals. With an ambulatory gynaecology unit on the Connolly campus, there is no longer a need to require patients to attend Beaumont or the Rotunda hospitals. With the creation of plastic surgery services on Connolly hospital campus, patients therefore do not need to attend Beaumont Hospital. The concept is to provide an integrated site, whereby Beaumont's role is as a complex provider and Connolly is able to provide a stronger service in terms of simple or non-cancerous surgery.

Likewise we have migrated services to the Louth campus. The aim is similar to the role of the small hospitals, to ensure we have productive units that are able to undertake simple surgery. On the flipside, we have moved complex upper gastrointestinal surgery to Beaumont, in line with the national cancer strategy. The idea is to transfer patients requiring complex upper gastrointestinal, GI, surgery or cancer treatments to the level 4 hospitals.

I will outline the key challenges for the group as we face into 2017. We face the ongoing difficulty of recruiting and retaining nursing staff. We have a workforce of just under 3,000 nurses and on average the vacancy rate is 16%. We have a less than optimal reliance on agency staff. Also, for the smaller hospitals we have difficulty retaining or recruiting consultant and junior hospital staff, particularly for levels 2 and 3 hospitals.

In terms of integration, we are working in a very hospital centric model. One broadly has two ports of call for a hospital, either through the outpatient department or the accident and emergency department. If we look at the fact that of the patients presenting to a hospital, 85% of them will have some form of exacerbation of chronic disease. We have an overly hospital-centric model, whereby more care could be delivered in the community, but the current structure means more care is delivered in the hospital.

While there is a good working relationship with community services in terms of the integrated pathway, we have a mismatch in terms of supply and demand, particularly when it comes to community support, which means that at any one time across the whole group, between 10% to 15% of our bed occupancy will be filled by elderly patients predominantly who are awaiting discharge to either community homes or needing home care support. At present about 170 beds are inappropriately occupied.

In terms of funding we face challenges in meeting the income target set by the HSE which will not be achievable.

I thank Mr. Carter. I invite Mr. Maurice Power, chief executive officer of the Saolta to make a presentation.

Mr. Maurice Power

Good morning Chairman and members. I thank the Committee for the opportunity to speak today. I am joined by, Dr Pat Nash, group chief clinical director.

The Saolta University Health Care Group was established in August 2013 and comprises one model 4 hospital, Galway University Hospital, UHG, four model 3 hospitals at Mayo, Portiuncula, Sligo and Letterkenny, and one model 2 hospital in Roscommon. The group has 1,750 beds, employs over 9,700 staff and has a budget of €700 million for 2016.

We are unique in a number of aspects. We were one of the first hospital groups established originally in 2012. We comprise only statutory hospitals and we provide care to a clearly defined geographical population, that is, over a quarter of the country from Galway to Donegal, a population of 830,000. We have a strong relationship with our key academic partner, National University of Ireland Galway, NUIG, and have recently opened medical academies in Letterkenny, Sligo and Mayo. The recently opened clinical research facility in UHG is a critical piece of infrastructure which provides the platform to develop new and innovative treatments, therapies and technologies. We work closely with our community colleagues in the west and north west. We have close links with Altnagelvin Hospital in Derry and this has delivered tangible benefits to our patients. The primary percutaneous coronary intervention, PCI, service is now operational and the new radiotherapy service is due to open later this year. The Saolta group provides a comprehensive programme of cancer care and we work collaboratively with the national cancer control programme, NCCP. The cancer programme is delivered through the clinical structures from Letterkenny down to Galway.

The basis for the establishment of hospital groups was to facilitate improved patient care pathways by integrating hospitals into cohesive networks. Our principal objective in the Saolta group is to provide timely access for all our patients to high quality, standardised, safe, sustainable and adequately staffed services in hospitals as close to patients' homes as is clinically appropriate. To maximise all our hospital sites, we are currently developing an integrated group clinical strategy which will be completed next year.

I am sorry to interrupt but there is phone close to the microphone which is causing interference. I ask everyone to ensure that mobile phones are switched off or are on aeroplane mode.

Mr. Maurice Power

Our current governance structure is a hybrid of hospital site-based management teams and cross-site clinical-based teams. To enhance our governance structures, we are developing a clinically led cross-site governance structure which will improve patient care and outcomes. A non-statutory board, which had been in place for the past four years, has recently come to the end of its term. A process is ongoing to appoint a new chairman and board. Although non-statutory, the board took responsibility for ensuring that the group was achieving its objectives and effectively managing its resources and maintained a strong emphasis on patient care and safety.

As a group, we face a number of key and inter-related challenges. Access is the single biggest challenge in our group, especially in UHG where our emergency department is not fit for purpose. It is too small and outdated and it is an ongoing challenge to manage the large numbers attending daily. Attendance at the department averages 180 per day and up to 240 on some days, making it one of the two busiest emergency departments in the country. This results in unacceptable delays for patients.

The development of the hospital group has added to capacity challenges in Galway due to the change in the referral flow patterns from other hospitals in the group to Galway. A key element of our clinical strategy will be ensuring the bidirectional flow of patients. This will involve the transfer of non-tertiary care from the Galway site to other sites in the group which will free up capacity on the Galway site. This is currently happening in plastic surgery and endoscopy in Roscommon and in other surgery services at Portiuncula. We are also actively working to implement the clinical care programme pathways and have seen significant benefits from an investment earlier this year in a new acute medical unit in Galway. There are also developments required in other sites, particularly in Sligo, Mayo and Portiuncula. Further investment in infrastructure will ensure that we can sustainably address the unacceptable delays in access to urgent inpatient and outpatient care.

Galway also requires additional inpatient bed capacity to meet its dual requirement to provide timely access to tertiary services for the group while providing secondary care to the people of Galway and Roscommon. A new 75 bed ward block is due to open in 2017. This mostly comprises much needed modern replacement beds, but will provide 15 new beds and additional surge capacity in the vacated older wards. Galway urgently needs a new emergency department but there is also a requirement to look at a long-term solution for acute hospital services in Galway and consider the future development of the hospital. Ultimately, the physical constraints presented by the UHG site mean that plans for developments into the future must include a new hospital on a site such as Merlin Park.

Our inpatient, day case and outpatient waiting lists present an ongoing significant challenge for the group across a number of specialties and sites. University Hospital, Galway, UGH, accounts for approximately half of the group’s waiting lists. We are implementing a variety of measures to reduce the numbers of patients waiting and the length of time they wait, including validating existing lists, moving activity between hospitals, running additional clinics, new appointments to key specialties and the development of health and social care professionals and nurse-led clinics.

The recruitment and retention of skilled nurses, particularly theatre nurses, remains a challenge for all our hospitals and is currently significantly reducing our theatre capacity, especially in Galway. The recruitment of consultants and non-consultant hospital doctors, NCHDs, remains a challenge mainly in Letterkenny and to a lesser extent in Sligo and Portiuncula. We face a number of information technology, IT, challenges and we currently do not have an integrated patient administration system, PAS, or integrated patient care record across our hospitals. This is key to facilitating safe and effective care. We have developed an IT strategy to address this which will require significant investment.

To conclude, the Saolta group is well established with a strong governance structure. Our hospitals work closely together and there is an eagerness to fully integrate our services. Our clinical strategy will help facilitate this together with the implementation of our integrated clinical governance structure and an integrated IT platform.

I thank Mr. Power. I now invite Ms Colette Cowan of the UL Hospitals Group to address the committee.

Ms Colette Cowan

I thank the Chairman and committee members for the invitation to attend today. I am joined by my colleague, Mr. Paul Burke, chief clinical director of UL Hospitals Group. I will confine my opening remarks to the following themes: positives of groups; governance and organisational reform; vision; the integrated model of care; quality and safety; and the future of health.

UL Hospitals Group was one of the only two hospital groups to be put in place with a functioning board. We support the concept of a network of hospitals working together as one virtual delivery model for the population of the mid-west, an arrangement that has worked with increasing success. We have robust governance structures and a defined policy on safe care in the correct settings, underpinned by the smaller hospitals framework. We also have close and strong links with the University of Limerick driving medical, nursing and health and social care education as well as a fertile research agenda which will be further enhanced by our new clinical education research centre on the University Hospital Limerick site.

For four years we have worked closely with our board which has brought valuable and enthusiastic expertise, oversight, vision and advice on the UL hospitals development and plans. We are coterminous with our community health organisation, CHO, and engage continually with the CHO to improve patient care and outcomes. The fact that the geographical area covered by the CHO and UL Hospitals Group is identical provides an ideal basis for implementing policy and procedure.

The future of health care requires a governance model and leadership approach to deliver collectively on organisational reform. The fundamental question in the hospital service is the optimal numbers and configuration required to develop an efficient and effective service. The smaller hospitals framework has clearly defined model 2 services, but model 3 hospitals would benefit from a similar framework to ensure the range of services for acutely presenting patients is defined and supported.

The governance structure at UL Hospitals Group is unique and is based on a small management team in four directorates responsible for all sites rather than hospital specific managers. This single clinical governance across all sites is key to providing operational expertise and guidance on service delivery and has been shown to be highly satisfactory in terms of increasing efficiency, improving services to individual patients and reducing delays. Performance measured against quality, access, finance and resources is driven via directorate structures managing vertically across six sites. Our structure fits neatly with the Department of Health and the HSE’s accountability framework.

Our vision for future health is articulated in our submission paper but I will outline some priority areas now. We must define funding models to develop CHO areas to create hospital avoidance strategies because community delivered care is more beneficial to patients who do not require expensive hi-tech, high speciality hospital settings.

We must extend clinical care programmes and tight communication systems to include formal dialogue with general practitioners, GPs, on opportunities and protocols. We must progress the commissioner provider model and base decisions on service delivery relating to demographics and population health. We must continue to increase IT funding to address the gap currently in the HSE service. We must also establish bed capacity to inform ten-year development plans.

The hub and spoke structure of the UL hospitals network, along with an identical catchment area for community health services, means that the UL Hospitals Group is in a unique position to provide an integrated model of care between our acute service and the community. That parallels the continual improvement of our specialist and emergency services at our model 4 hospital, University Hospital Limerick, UHL.

Clearly, the relationship with GPs is critical in determining how this integrated model of care continues to develop. We believe our model 2 hospitals in Limerick city, Ennis and Nenagh must provide support to our GPs at a local level, while helping to avoid admissions to UHL for less complex conditions. Increasing professional dialogue and communications with our GPs are among our top priorities. We are trying to ensure that GPs would have easy access to diagnostics and specialist outpatient department, OPD, services in the local hospital, which would link closely with the specialist supports in the community. In this co-ordinated way, people can receive the care they need in the most appropriate place, be it at home, in the community, at the local model 2 hospital and, hopefully, less often at the model 4 hospital. This is consistent with the HSE’s policy on prevention and management of chronic disease within an integrated care programme.

In using this local model, we are not only avoiding prolonged travel and access difficulties to our larger hospital but we are also reducing the burden on relatives and others, entrusted with the care of elderly patients. This model has huge social and economic benefits to the community. Additional medical specialty development at UHL in areas such as dermatology, rheumatology and neurology has meant more of these services being provided at the local hospitals, something that many would not have envisaged ten years ago.

Quality and safety was the driving force behind the centralisation of acute surgery, critical care and cardiology services six years ago, and all our clinical data is now processed through NOCA, the National Office of Clinical Audit. Our model of care for acute surgery was one of the first recommended by the national clinical programmes. Our cardiology service provides one sixth of the national PCI service for acute heart attack and we are also providing an acute stroke service through a newly built stroke unit, developed incidentally with the support of a number of voluntary agencies in the region.

Looking to the future, we envisage that with centralisation of our maternity services onto the main university hospital campus and with our favourable road infrastructure the UL Hospitals Group is likely to find itself serving more of the surrounding north Munster region. We undoubtedly need urgent expansion of our hospital bed capacity to cope not only with current demand, but with the change in hospital demographics that will inevitably evolve in the surrounding regions over the next decade

Our close relationship with the University of Limerick is of huge importance in improving standards of care, fostering education, clinical research and innovation so that the hospital complex is rapidly developing to become a major national centre for high quality as well as a major educational resource for the people of the region that we serve. That concludes my opening statement.

I thank Ms Cowan and all the witnesses for their presentations and for their brevity. I will bring in committee members in groups of three and I ask the witnesses to note their questions and then I will ask them to respond. I will start by calling Deputy Naughton.

I thank the witnesses for their attendance and their comprehensive opening statements. I would like to direct my questions to Dr. Pat Nash, clinical director of the Saolta group. University Hospital Galway has been frequently on code black and a maximum capacity protocol has been implemented on a number of occasions recently. As stated by Mr. Power in his opening statement, the Saolta group provides care for 830,000 people within the catchment area. Will Dr. Nash advise how the designation of University Hospital Galway as a centre of excellence has affected the hospital? It is the only model 4 hospital in the stretch of area from Donegal down to Limerick. I am shocked in that I believe it has had an adverse effect on capacity at that hospital, notwithstanding the exceptional expertise of the staff working there. Will Dr. Nash comment on the average length or rate of stay at the University Hospital Galway compared to other model 4 hospitals across the country? I understand it is better than most, which would be a positive reflection on the hospital's doctors, nurses and other staff, and would prove to me that there is a capacity issue.

An amount of €109 million has been spent on capital investment at University Hospital Galway during the past ten years but it has led to a reduction of approximately 157 beds in that period. As a clinician working at the coalface, can Dr. Nash advise how that has impacted on the day to day running of the hospital from the point of view of the patient and his colleagues?

Mr. Power referred to the Merlin Park site and the need for a new acute hospital in Galway. This is a site of approximately 150 acres of State-owned land. I am aware that over the years beds have been moved from Merlin Park Hospital to University Hospital Galway, and some have disappeared altogether. In hindsight, does Dr. Nash believe that was a retrograde step? Does a new acute hospital have the support of senior clinicians at University Hospital Galway?

Over recent weeks and months, this committee has had many discussions on community care, the need for primary care centres and how that would take pressure off hospitals across the country. It would be important to get the Dr. Nash's view on that in regard to the Saolta hospital group, the catchment area it serves, and whether that would make a huge difference regarding the need for extra bed capacity.

The witnesses are very welcome. The Chairman is cracking the whip so I will just fire out the questions because we are under time constraints. Do the witnesses believe the group structures within the HSE are working? Could they be improved? Obviously, they are not perfect and if they can be improved, how can that be done? How big an issue is the fact that they do not align with the community structures? It is certainly an issue and we should not fool ourselves that it is not. How big an issue is that for the witnesses in their day to day work? Is the fact that each of the witnesses has different structures as regards boards, management teams, etc., and alignment of hospitals under those headings a major issue for them? Should it be consistent? That is my first set of questions.

With regard to workforce planning, we had a very good presentation on that from somebody here. Recruitment is a huge issue across the board. How is it affecting the witnesses' planning their operations across their hospitals?

Regarding community care, I was very much taken by a number of references, particularly with respect to the mid-west. Would all the witnesses agree that it would make more sense to take a quantity of funding out of the acute space and put it into the community space in order to ensure they do not have the demands they have in the first place coming into the hospitals in which they operate? That came across in the presentation covering the mid-west in particular.

Regarding patient pathways care, what are the issues with moving patients across the witnesses' hospital network post-care, pre-care and so on? What are the real issues in that regard, particularly issues relating to delayed discharges, staffing and transport?

On the use of private hospitals, how will that fit in with regard to helping out the witnesses with their workload? We are facing into winter and in a number of the locations private hospitals are advertising their emergency departments for patients while some of the accident and emergency departments they run are jammers, which is insane.

We have a major issue in Ireland with the provision of doctors, particularly in many rural areas. Every member of this committee knows that. Is there real concern about that in that if it gets worse, demand for their services will increase again over the coming winter period?

That will leave the services in an even worse situation than they were in previously.

I have two final questions. With regard to IT, there is a great deal of different commentary on IT provision. Obviously, it is not up to speed. What do the witnesses consider to be the best developments they have seen over the last year or so in IT provision? It is incredible that in 2016 we are not managing patients and their details in an IT-efficient fashion and are still using old ways to do it.

Finally, have the witnesses any comments or what did they feel personally - this question is particularly directed to the CEOs - in response to the letter from the chief executive of the HSE, Mr. Tony O'Brien, a number of months ago which commented on their performance? How did they react to it? What did they take from it? Did they consider it necessary?

I have some general and specific questions, and I will try to be brief. With regard to recruitment plans, it is fair to say that whatever the witnesses are doing at present is not working and it is reasonable to ask them what they plan to do in the future. Clearly, one cannot run a health service without staff. It is a serious problem.

Regarding bed capacity, to what extent do the problems relate to physical capacity, that is, physical beds and bed space, as opposed to staffing problems? If the staffing problem was solved in the morning how many beds could we put back into the system?

There is much talk in this committee and elsewhere about primary care. Clearly, there is a blockage in that area. In particular, I wish to hear the views of the CEOs on what causes that blockage in the patient journey. Is it to do with staff or lack of capacity in primary care, or is it related to systems?

I have specific questions for the representatives of the Saolta group. Sligo, Letterkenny and Portiuncula hospitals were consistently among the top four hospitals during 2013, 2014 and 2015 that were the highest spenders on private ambulance services. People know my views on private health care and the poor value for money it represents. Why does that happen and are there any plans to phase it out?

Dr. Nash mentioned a significant IT investment in his presentation. How much is that and how many years are involved? What is it hoped to achieve?

The RCSI mentions targets in its presentation. If it does not hit those targets, what services will it cut first and how will it select them?

I have a question for Ms Cowen on the UL group. I am very familiar with that group, as she is aware. Morale among the staff in the group is at an all-time low. She will be aware of that too. To what extent are there specific plans regarding accident and emergency services in the UL group? It is constantly in the headlines. I am sure that does not please Ms Cowen, no more than it pleases the poor people waiting. What will be done in the short term in that regard? She also mentioned that liaising with GPs is one of her top priorities. Perhaps she would expand on that and give the committee an insight into what the group does in terms of how that liaison works and whether there are plans to expand on it.

There is a wide range of questions. Perhaps the representatives of Saolta, UL and RCSI will respond in that order.

Dr. Pat Nash

To respond to Deputy Naughton's questions, Galway is under major pressure. Part of that is due to the fact that the group was created without any planning of the alignment of the hospitals. It is the only model 4 hospital in a very large group. We have four model 3 hospitals and we are seeing the impact of the group on Galway with a marked increase in the referral for appropriate tertiary services while there has not been clear planning for the capacity or to manage secondary care issues for the counties of Galway and Roscommon, which were our immediate catchment area.

Can you clarify that Dr. Nash? You said the group was assembled without any planning.

Dr. Pat Nash

There was no strategic planning about the Saolta group being established and the impact of it on the alignment of hospitals and on the re-alignment of referral pathways. The groups were announced as part of the hospitals report in 2013 and our group was established in August 2013. From that point on there was an immediate change in referral patterns for tertiary services, particularly from the north west. Traditionally, the west and the north west had different health boards and were quite distinct areas. That had a significant impact on capacity problems in Galway. There are no unopened beds on the Galway site. The hospital is working at full capacity, so lack of staffing is not an issue with regard to creating additional capacity.

I wish to clarify that because the impression was created at the time that there was extensive consultation about the groups.

Dr. Pat Nash

There was consultation about the hospitals strategy and the Higgins report, but the announcement of it and the roll-out of Saolta group happened within a few months. It was the first group formed in August 2013. There was no time to do the strategic planning to be able to effect that. We are back to what Deputy Naughton highlighted. The Galway hospital site is currently overwhelmed. There is no additional capacity that can be turned on as all beds are open. I agree with Maurice Power that Galway needs a new emergency department but, ultimately, it needs a planned new hospital to be able to serve the six counties of the west and north west.

Integration with the community is a critical issue. Saolta has two community health organisations, CHO one and CHO two. The geographical boundaries are not the same. That is a big issue because we are looking after the same people and patients and we have different accountabilities. Regarding the proper and full integration of services, I fully agree with everybody who says that the key to addressing part of the overcrowding in hospitals is looking at chronic disease and elderly patients. However, that requires integrated governance to be able to manage them because they are separate governance structures. I agree that we need an integrated structure, but I would not necessarily agree to it in the short term. If one tries to move funding from the acute settings to the community without having a single governance, that will have a huge adverse effect on the acute hospital sector.

The other comment was about private ambulance use. Yes, it is a necessity. Given the geography there is a four-hour transfer between Letterkenny and Galway. To transfer a single patient and cardiologist from Letterkenny to Galway for an angiogram requires an ambulance for a full day. From Letterkenny to Galway and back is a four-hour round trip and that happens every day of the week. There is no capacity in the national ambulance service to be able to provide that in a timely fashion so, unfortunately, we end up being dependent on the private ambulance services for the non-emergency but urgent inter-hospital transfers.

Does Dr. Nash not think there is a better way to plan that so there would not be such reliance on the private ambulance service? Clearly, it does not represent good value for money. The Minister has commented on the private sector and the value-for-money element. Surely there is a better way to do it. It does not happen in other areas. Saolta is not the only hospital group covering a rural area.

Dr. Pat Nash

We have the biggest geographical challenge. Galway, as the tertiary centre, is on the very edge of the group geographically so it has the longest transfer times of any of the groups. Yes, ultimately we must develop an inter-hospital transfer strategy internally for the non-emergency transfer of patients or intermediate care patients between sites.

My specific question related to phasing out. Do the witnesses have plans in the short to medium term to phase out private ambulance services?

Mr. Maurice Power

Yes, we have. We are looking at going out to tender. First, we are looking at engaging with the National Ambulance Service in terms of intermediate care vehicles so that we can come to an arrangement with the National Ambulance Service to transport as many patients as possible. Despite that, there will still be a need for further transport requirements, particularly in Letterkenny and Sligo. Our intention is to go out to tender in that regard. My understanding is that there is a department looking at the transport issue across the country. Our intention is to feed into that work. There was a very good model in Donegal involving the rural transport programme and it would be our intention to look at some kind of model relating to it. We are spending in the region of €3 million to €4 million per year on transport, which is a significant cost. We need to move so that we use the National Ambulance Service as well as going out to tender for a new service.

They are going out to tender for more private services in the hope that this will help the public service.

Mr. Maurice Power

Yes.

I do not accept that but-----

Mr. Maurice Power

The intention is that we start in Donegal and work our way down because Donegal is the largest cost.

Could Dr. Nash tell us the average length or rate of stay at University Hospital Galway and comment on the move from the Merlin Park site to University Hospital Galway, the reduction and whether, in hindsight, this was a retrograde step? Could he give the view of his colleagues - senior clinicians at University Hospital Galway - about the need for a new hospital?

Dr. Pat Nash

The average length of stay in Galway is short. The exact figure is 5.7 days. When one generalises it across medicine and surgery, overall, it is 4.3 days but one needs to break down by medicine and surgery to get meaningful results. It is short because, traditionally, Galway did not have major problems with delaying and discharging patients into the community. This has become more of an issue over the past 12 months. The Merlin Park site is a large one. The profile of care delivered on the site has changed in the past four years because it was not felt appropriate for acute care on selected medicine to be admitted there so that put on additional pressure. We opened some capacity in Galway in 2012, and it was necessary to ensure and maintain the safety of care there. Speaking as a clinician, we made a submission as a group of clinicians in Galway to this committee that there is overwhelming support for investment in infrastructure and a new hospital building in Galway. We need a new emergency department, but an emergency department is only the front door of a hospital. It needs to be comprehensive and look at the entire hospital to be able to manage.

Dr. Nash might comment on recruitment.

Dr. Pat Nash

Recruitment, particularly as highlighted by Ms Cowan, in model 3 hospitals is very challenging. I am talking about consultant and non-consultant hospital doctor recruitment. We are looking at developing shared posts and providing shared posts with sessions in the model 4 hospital that will be key in the group. Again, geography will be the challenge there. We are struggling, and we have come up with a number of innovations. We have the first cross-Border appointment involving a cardiologist working between Letterkenny and Altnagelvin. We will be looking to that in the future, particularly for Letterkenny. In respect of the operational side, on a day-to-day basis, one of the critical issues in recruitment is in nursing, particularly theatre nursing. This is holding back our capacity to perform surgery, more so than beds. In any one day, we have rolling theatre closures where theatres are closed due to lack of capacity. This is due to a lack of available trained staff. We are actively recruiting. It is not just a west of Ireland issue. It will be more challenging in the more rural areas and smaller hospitals but it is a huge issue.

Ms Cowan was asked specifically about the organisational structures. As the only hospital group that has a coterminus area with a community health organisation, CHO, the UL Hospitals Group is in a different situation from everybody else. How important is that to the UL Hospitals Group?

Ms Colette Cowan

It is working very well and is of extreme importance. We have one CHO, as the Chairman noted, which is run by Bernard Gloster, the chief officer in the region. We have an identical footprint and work together day in and day out on patient flow in the region. Anything we develop in UL Hospitals Group is in collaboration with the CHO. We have teams of people from the CHO working on the campus of University Hospital Limerick to assist us and families with discharges. That is an example of how it works. In our view, a lot of funding comes in for transitional care and home care packages to help patients come out of hospital but we do not have delayed discharges in the UL Hospitals Group. The numbers are quite small.

I would like to see funding put into the CHO to develop services for hospital in the home and preventative medicine to keep patients out of hospital because we seem to be the first port of call when we should be the last through the emergency department. There are opportunities there for nursing, including advanced nurse practitioners, in the development of that role in the community. The only way to do that is to co-appoint. Nurses are mainly interested in working in hospitals when they come out of college. If there was creative contract with them so they could work or be required to work in the community on a sessional basis, there would probably be more nurses applying for those jobs. There are real opportunities there which we can stream and work towards. In my view, it works well to have one chief officer to talk to every day rather than several. While several different people will all be very expert in their area, having to deal with them takes a lot of time out of a CEO's day just to keep the show on the road. It is a model people could look at and develop further. It is key to the change for the next ten years.

I think this is a critical point for our committee because what Ms Cowan outlined works. To have somebody come into this committee and say that, effectively, the priority for her group is take funding and put it into the community is something we all agree with.

I think we all noted that.

I know. What interests me is whether the other witnesses agree with that 100%. Would they prefer to see a model-----

We are giving them an opportunity to do that. I will bring in the RCSI Hospitals Group to respond to that question.

Mr. Ian Carter

In respect of whether the group structures are working, each group is different but I confirm that I feel our group is functional. In respect of the alignment with the CHOs, in theory, it is always better to talk to one than two or three. However, what is probably more important is an agreed plan or pathway for the management of chronic disease, which we still do not have. While control-----

I am sorry. We had difficulty hearing that.

Mr. Ian Carter

While it is important or useful to be able to talk to one CHO rather than two or three - this is simple mathematics - the most important piece that is probably missing is not singularity in terms of engagement but the fact that we still do not have an agreed chronic disease pathway and set of objectives for how we move services to the community. While there can be changes in control - there are enough international models that have multiple or senior - the main piece that needs to be moved forward is an agreed pathway for how we manage patients nationally and locally.

In respect of moving funding from the hospitals to the community, 85% of what comes to our hospital is an exacerbation of chronic disease, ergo, in the majority of cases, the treatment should happen at an earlier stage with the hospital being the last resort as opposed to the first. The key problem is the fact that whether we like it or not, if one is going to build a new house, one must leave the roof on the old house while one builds the new one. If we are going to develop community services capacity capability, we must maintain the existing system. If we just move things in the space of a year, we will automatically have immediate problems. It will take time to develop community services and during that time, we will still need to continue funding the hospital system.

Reference was made to private hospitals helping out. Again, the issue is that the majority of patients in our emergency departments are medical patients with acute exacerbation of disease. The majority of the private hospitals are treating elective surgical patients. Therefore, while they are of some use to maintain elective treatment capacity, they are not the main solution. The main thing for our group, specifically, is the ability to successfully discharge patients to the community. As it stands across our group, 151 patients are waiting for community placement. The greatest capacity gain for us in the winter would be the ability to move those patients successfully to the community.

Information technology is another issue. It is well recognised nationally that we have limited, isolated, poorly-developed IT systems. The two key requirements from a hospital dinosaur perspective are the electronic patient record coupled with the national patient identifier. The benefits are significant. There are small isolated models in small isolated hospitals, but we are well behind and we do not have a national scheme either and consequently, our ability to talk across hospitals is further limited.

I was asked a specific question about targets and what I would cut if I did not achieve them. I have no plans to cut services this year. The targets are what we are aiming to achieve. We are comfortable that we will achieve them and there are no plans to cut services at the moment.

Mr. Carter specifically mentioned targets in his presentation.

Mr. Ian Carter

Yes.

Clearly, they are targets. I appreciate that Mr. Carter may not anticipate not reaching those targets. Nevertheless, they are targets and therefore a scenario does exist whereby the group may not reach them. In that event, I am keen to know what the group will cut and how that will be determined. Mr. Carter knows much better than do I that health care is not an exact science. Certain scenarios may arise. Mr. Carter brought up the issue of targets in his presentation. A possibility exists whereby those targets are not met. If those targets are not met, how will the services to be cut be decided upon? Clearly, in that event, cuts will have to happen somewhere.

Perhaps we could have clarification on the statement. Mr. Carter referred to unrealistic stretch income targets being set and stated they were not achievable. Can you clarify what precisely are stretch income targets?

Mr. Ian Carter

It would have been identified in the national service plan. Each hospital in the groups effectively has two budgets. It has expenditure and the requirement to generate income. The national service plan set stretch targets, as they are termed, for income. They are only achievable if a hospital gets more private patients coming in. In certain instances, not only in my group, that patient flow increase has not occurred. Ergo, in certain instances on the income side, it is likely that we will not achieve those income targets.

Can you clarify that? That is a significant point. Hospital groups are being set targets for income to be generated by private patients. When did these targets come into play? I was unaware that they existed.

Mr. Ian Carter

It might be more useful if Mr. Woods commented on a national level. Anyway, each year hospitals have, and have always had, income targets. It is part of the construct for a hospital. At the simplest level, it is a chunk of money for expenditure and there is a requirement to generate income from private patients.

We are talking about public hospitals. You are saying that targets are being set for income to be generated from private patients.

Mr. Ian Carter

Yes.

That is extraordinary.

Mr. Ian Carter

For the purposes of clarity-----

Mr. Carter is saying that these targets have been set. Let us suppose they are not met. Mr. Carter appears to be saying that there are no consequences. I believe there are consequences. I believe those consequences amount to a reduction in service for public patients. I will go back to my original question. When those targets are not hit – Mr. Carter referred to them as stretch targets that are difficult to hit – who gets cut? My view is that the person who gets cut is the public patient. I am keen to know. Perhaps, Mr. Woods can give us an insight of this HSE policy on a national basis. It is news to some of us.

Mr. Ian Carter

I will answer the specific question. There is nothing new about private patient income generation for all hospitals. Hospitals have a blend of patients, including those who come in privately and publicly. Part of the construct for having money to spend each year is, to all intents and purposes, made up of a block grant, which is the larger amount. On top of that, we have to collect income from our private patients. That is nothing new.

Perhaps the issue about the stretch targets, as Deputy O'Reilly suggested, is better addressed by Mr. Woods.

Mr Woods, will you clarify that point, please?

Mr. Liam Woods

I am happy to comment for the information of the committee on the point relating to the funding of the hospital system. As Mr. Carter has noted, hospitals were always funded based on a gross budget net of an assumed income. Income is not solely private income; it could include pension levies and other receipts within the environment. At a macro level there is a budget of €5.3 billion for hospitals. Approximately €1 billion of that amount is offset by income that arises. The position has been that way for a long time.

I will address the point on stretch targets. The service plan for 2016 recognised that there was a stretch target. It also recognised that private activity in public hospitals is primarily coming through the emergency departments. The income is not under the direct control of the hospital. It recognises a risk in that regard. In going through this year, provision is made for it. The idea of there being income generated by hospitals, in the case of charges or other income streams, has long existed. Hospitals are, in effect, funded net. That is to say, they are funded to a gross expenditure level less an assumed income.

The targets are new. Is that not the case? There has always been private income from people who have private health insurance who attend a public hospital. However, it is a question of the setting of targets. I am keen for my question to be answered by Mr. Carter in respect of how services to be cut will be selected.

Is it a new practice to set targets for private income?

Mr. Liam Woods

It is not, Chairman. The Estimates voted by the Oireachtas have always included an embedded income target for the health system. That comes in the Vote and it is distributed throughout the HSE and, when it is relevant to hospitals, to hospitals. The idea of such targets is not new. The reference from Mr. Carter and the RCSI Hospitals Group is that those targets for 2016 have a stretch within them. The question Deputy O’Reilly asked was what happens if that target is not achieved on the income side specifically. The HSE has made provision for the fact that those targets may not be achieved. To be fair, we are doing better than we thought. It has to be said that some of the stretch is being met. We have been clear all year that we are aware there is a risk. The service plan has identified that upfront. We have measures in place to deal with it that are not patient-impacting. I understand the point. Deputy O’Reilly's concern is around patient impact.

What are they if they are not patient-impacting? What gets cut?

Mr. Liam Woods

We have already made-----

One need not be an accountant to figure it out. The HSE has set a target. I maintain the targets are new. There always has been provision for private income within the Estimates. That has always been the case. However, it has been in place as a recognised income stream. The targets are new.

What happens if the targets are not met?

Mr. Liam Woods

The HSE has already made provision in its current-year funding for any risk around the non-achievement of the targets. A figure was identified. The figure in the service plan for the stretch target was €50 million. Mr. Carter is referring to a portion of that. We have already made provision for that and, therefore, we do not anticipate that there will be any cuts to patient services relating to under-achievement of income targets.

Why is that? Are you saying there is a contingency fund?

Mr. Liam Woods

The HSE received its budget upfront in the year and has additionally received supplementary funding mid-year.

It strikes me as if there is a perverse incentive. If hospitals are under pressure, then they have little choice but to maximise their income from private patients. That is not what public hospitals should be doing.

Mr. Liam Woods

I understand the wider point. The bulk of the private work coming through the hospitals is coming through the emergency department. It is referring in.

There is an incentive, however, for hospital groups to maximise the number of private patients because that is how they generate income. Is that correct?

Mr. Liam Woods

There is an income associated with that. There is also income associated with public patients.

Do you accept that there is a perverse incentive in place that works against a public hospital system?

Mr. Liam Woods

At a wider level, in terms of the wider health system, there could be such a thing. However, in terms of the activity-based funding being implemented this year, there is a resource associated with every patient and it is important that it is so.

A pot of money has to be found somewhere, even with the Supplementary Estimate, if targets are not met.

Or something has to be cut.

Exactly. We are finding out here that there has been no impact on patients, so nothing has been cut. Given the fact that the hospital groups have to meet these targets, it would be interesting if the committee could obtain a breakdown over the year of the income derived from private patients. From anecdotal evidence, I am concerned that there is a spike in private income coming towards the end of the year because of the need to meet these targets. Can we get that information?

Yes, certainly. There are two items of information, first, the targets which are set and, second, the actual performance. If the committee could have that across each hospital group, it would be appreciated.

Mr. Ian Carter

The majority of our patients come through the emergency departments. The majority of our private patients also come through the emergency departments. The criterion for admission is physical acuity sickness. The ability to engender more is not there. If one turns up to Beaumont Hospital with a chest pain, the decision to admit is not made on a private-public basis but on an acuity one. It is not on the ability to generate more income to year-end, as has been suggested. The main service that is compromised on the basis of bed capacity is that relating to elective patients coming in. Those are also both public and private.

Yes, but that perverse incentive is more likely to operate in respect of elective surgery if hospitals are strapped for cash.

Professor Paddy Broe

The Chairman is absolutely right. That leaves not only patients, irrespective of whether they are public or private, without a service in terms of elective surgery, it also leaves empty theatres, idle nurses and doctors. The potential contribution of hospital groups is that congested hospitals can move low-complexity patients who do not require the services of a level four hospital to another institution, so they get the service they require. Take the case of someone who lives at the back of Beaumont Hospital and is on a waiting list there. If the condition allows for that individual to be treated elsewhere, then that should be the case. That could never have happened without the development of the groups.

All three questioners have brought up the issue of the recruitment and quality of staff. As a medical director, my job is to ensure that staff at the front line are competent and of good quality. There is no doubt that the further one moves away from a level 4 hospital, the less likely the quality of staff and the more likely it will be a challenge. Part of the difficulty of recruitment of surgery-----

That is an outrageous statement to make.

How can the staff at a level 3 hospital not be as good at those at a level 4 facility?

Professor Paddy Broe

I am saying that in terms of recruitment. In 2006, we all agreed that the national cancer control programme, NCCP, was a terrific development for the treatment of cancer. That resulted in eight hospitals being developed to the highest level but also in reducing our ability to recruit high-quality staff to other hospitals. In surgery, for example, we have a training programme through which we train our own surgeons here in Ireland and encourage them to go away to train in fellowships and so forth. Due to the recession and cuts, particularly those directed at consultants’ salaries, our ability to recruit those people back to Ireland is a problem. Then one must factor in that, if they are highly trained, the difficulty will be whether they will be able to do the work they are fully trained for outside level 4 hospitals. The fact is that they are not.

Our job within the group is to develop linkages between hospitals in order that a surgeon can do highly complex work at a level 4 hospital and less complex work in some of the smaller hospitals. As Dr. Pat Nash said, the challenge there is geography and obliging people to travel.

We will take the next group of members, starting with Deputy O'Connell.

On the type of staff that certain hospitals attract, I assume Professor Broe meant that one wants to be working at the cutting edge of one's profession if one is ambitious and wants a career. I am assuming that a progressive medical person would prefer to be working at a level 4 hospital where there would be a massive throughput of cases and where he or she would be exposed to all they expect in their career. I imagine that the professor was not saying there are worse quality staff when one goes down the hospital levels.

Do the community health organisations and the Limerick hospital group overlap perfectly?

Dr. Paul Burke

Yes.

Do the other two groups think that would suit them better? Why has this not happened with the other groups?

When I hear terms such as "administrative function", I think layer of management and that bothers me to some extent. Can anyone give me any indication as to why there is resistance to move from an administrative role into a "just-sorting-it-all-out" role? What is the delay? Once that happens, is there any indication what layer is going to be got rid of? Are we adding another layer and will people be made redundant? How does that happen?

Due to the ideal overlap situation, does the Limerick group have a list of everything that is in that block, as in every bed, every staff member, every little community centre, every community health nurse and every GP? Has the group an actual inventory of a block? Is it very difficult for us to get information when there are overlaps?

Limerick already has a GP in the accident and emergency department. What are its plans to expand that? Is it looking towards the Carlow-Kilkenny model? Deputy Louise O’Reilly referred to a high priority to liaise with GPs. What does that mean? What has been done?

I welcome the witnesses, particularly Ms Colette Cowan and Dr. Paul Burke, who, like me, are from the mid-west.

Most witnesses so far have alluded to the fact that if we are going to improve the health service, we will need a very strong, highly-resourced, efficient and effective primary care service, not only in general practice but also with all the other components involved. The difficulty I see is in the deficit in the integration of primary and secondary care. There are roadblocks in the patient flow from primary to secondary care, particularly in terms of casualty, bed capacity and recruitment. How does one bolster the communication between primary and secondary care? How does one integrate them to allow the patient flow freely through the system?

Deputy O’Connell referred to the Carlow-Kilkenny model. Representatives from that hospital appeared before the committee and it seems to be a very effective model. While it may not be transferable to every area, how would the witnesses see it transfer to other hospital groups?

On the transfer of services to model 2 hospitals, many outpatient services, day care services are concentrated in level 3 and level 4 hospitals. There is capacity in the level 2 hospitals to take on much work, particularly with outpatients, and to bring them closer to the patients who require treatment. What are the witnesses’ views on that?

I would like to revisit the issue of unrealistic stretch income targets. The programme for Government states: "Service providers who fail to meet their targets and who do not engage fully with the new unit will be obliged to use their own budgets to ensure targets are met with the assistance of private sector providers." Hospitals basing themselves on an income stream from the State and an income stream from private practice is not new, unlike the issue of new targets. I am interested in the exploring the targets in the context of the comments of Mr. Carter that the stretch income targets are unrealistic. For example, the RSCI Hospitals Group submission states that the population in its catchment area has increased from 640,000 in 2002 to 817,522 in 2011 and it is projected to reach 875,000 by 2021. That is an increase of more than 27%. Has there been a commensurate increase in budgets? If not, how big is the shortfall? If the group is forced to fill the gap between State income and unrealistic stretch targets, what menu is available to Mr. Carter to generate private income? Is it solely down to income from private operations? To what extent might it involve borrowings and building up debts, which has been the experience with trusts in the UK? To what extent could that become a factor here?

The programme for Government states with regard to the issue of trusts:

We will advance progress made on Hospital Groups before strengthening their capacity to be stand-alone statutory Trusts. Hospital Trusts will gain greater autonomy (own their own assets, manage recruitment)...

Can the witnesses give us more information about how the trust system will operate? Is it the intention to get trusts to compete for funding and-or to move them off balance sheet? Where is this process at currently?

Ms Colette Cowan

I will reply to Deputies O'Connell and Harty on the GP aspect. I will hand over to my chief clinical director to explain what we are trying to do to improve communications, and around flow to model 2 hospitals to ensure they are sustainable and viable in the future.

Dr. Paul Burke

We have been on a journey with this, as Deputy Harty will be aware, over the past six years when we had to centralise our acute services. At the same time, only three smaller hospitals are model 2 hospitals. Part of the negotiations at the time very much focused from the GPs' point of view on the awareness that they felt they would lose many of the services in small hospitals when they were centralised. Our purpose was to persuade them that we just wanted to deal with the acute services problems centrally. While we always want to look after all the issues relating to chronic disease, ultimately, we have to deal with an acute problem when it arises. As Mr. Carter said earlier, one has to keep the roof on top of the house while everything is changing.

To attract highly specialised people home from abroad, they must be brought into the system through a model 4 hospital but all of them are still generalists. In other words, they all still have basic training. The key is to tell them they will be able to do robotic surgery and all sorts of sophisticated work but that we want to them to do basic surgery in the smaller hospitals. Our road system and geography within the mid-west region allows us in the UL Hospitals Group to do that and that has worked well because no one is more than a half an hour from Ennis or Nenagh and the other smaller hospital in Limerick city is ten minutes down the road. That can sometimes be a challenge in terms of the concept but when people realise that when they come home, as Professor Broe said earlier, they cannot access theatres, etc., in the bigger hospitals but they can use their skills in the smaller hospitals, it should be a win for everybody. It is an easier model to put in place for surgery because surgeons are task-driven and when they are told they can do these operations in the smaller hospitals, they will usually do that and they are quite delighted to do it. It is planned surgery in the smaller hospital and it will not be interfered with by an unanticipated massive number of emergencies coming into the bigger hospital, which take up beds. Separating the two in that way works well.

The aspect of it that has been a challenge demonstrates how the Carlow-Kilkenny model comes into play. It is a unique scenario in that Kilkenny is a model 3 hospital but, traditionally, in Carlow-Kilkenny - it started with overcrowding more than 20 years ago - the GP has always had direct access to the hospital. The GP could send a patient in and he or she would arrive on the ward without having to ask anybody. That has evolved over the years into a more sophisticated model at that level. That is not overly practical in Beaumont Hospital or in UHL but it is possible in the model 2 hospitals. The challenge has come from the point of view that when we reconfigured the hospitals, our physician colleagues, in particular, were concerned about unanticipated emergencies and deaths, etc., and when the anaesthetic services moved from the model 2 hospitals into the model 4 hospitals and there was no anaesthetic back-up at night, etc., there was a great concern about unanticipated deaths. In our area, in particular, we had a challenge in persuading our physicians to still invest in smaller hospitals at a local level and it was also a concern of our GP colleagues. As a result of that, we found that many of our semi-acute, chronic disease, exacerbation patients inevitably started coming into Limerick and, therefore, our challenge has been to try to get them to go back out again.

One of the ways we do it is simply to transfer them out quickly when they come into the emergency department but one of the problems we have had over the years is that this has coincided with the downturn in the economy and the difficulty of attracting back newly-qualified personnel, etc. If we try to bring back a new consultant physician with an interest in respiratory medicine from Harvard Medical School and say we will base him, with all due respect, in one of the model 2 hospitals, it will be challenging. A number of years ago, we asked these physicians to come to Limerick and told them we wanted them to go outside. They find lots of things to do in Limerick and sometimes it is difficult to persuade them to go out but if the jobs were attractive and the salaries and the circumstances were better, many people would apply for them, as happened 15 or 20 years ago when 40 people applied for a job in Cavan. For example, if they had a job in Cavan but were based in Beaumont Hospital three days a week, many people would apply for it. That is where we must move to in terms of the integration of model 2 and model 4 hospitals.

Deputy Harty asked about interaction with GPs. As we have managed with procedures such as endoscopy, minor surgery, etc., we are improving at providing the service at that level but the key is the management of chronic disease. Those pathways are well defined and they should be able to be integrated in the vast majority of cases through the model 2 hospitals with the physicians. In that scenario, we hope there would be greater interaction and that GPs would come into the hospitals more. That is the model we would like to explore. There is a resource issue at every level, including general practice. When we broached this subject a few years ago, some people suggested we put this forward in an attempt to use GPs to shore up the deficits in the model 2 hospitals where recruiting junior staff is difficult and expensive. Currently, we often have to use agency processes, etc.

One of the issues is to get the support from the Royal College of Physicians of Ireland in terms of training models for junior doctors. We want them to include model 2 hospitals in their training programmes. If we get recognition from the colleges at that level then it will allow us to put our good quality junior staff in model 2 hospitals. That initiative will, in turn, encourage everybody to refer more to the model 2 hospitals and, in turn, bring general practitioners into the situation.

Even though we are in the hospital it must be said that there is a resource issue in terms of support in general practice. That is reflected in the fact that 50% of the patients that present to our emergency department do not have a GP letter. That is a big challenge for us at the moment as well.

Does the RCSI delegation wish to respond?

Mr. Ian Carter

The use of levels 3 and 2 makes eminent sense. As I said in my presentation, we apply the capability of the surgeon to the capacity of level 2 and a classic example is Louth. The hospital in Louth is totally suitable for simple elective surgery and outpatients. We have started but not fully rolled out a service whereby vascular surgery is now routinely undertaken in Louth. The location has several other benefits. There is no emergency department competing for space and the site has the appropriate infrastructure. The earlier witness is right. As services are further rolled out we will consider the outpatient specialties as well so that is just a continuation.

In terms of making this attractive from a recruitment point of view, we have found that the best way, as has been alluded to, is to appoint a consultant to two sites. The aim is for him or her to do his or her specialist interest, if he or she has one, in the centre that has the specialist and the more general aspects of his or her service is normally in the level 2 or level 3 hospitals. The scheme works well.

As was said earlier, not all consultants want to be experts. A large number of consultants are general medical or general surgical. Let us remember that over 50% of the work that is done in the health care system is done in level 3 or lower hospitals. A relatively small amount of specialist work is done in level 4 hospitals. The recruitment of split posts works very well.

There are other reasons staff are not attracted to some of the smaller hospitals. In particular, on the consultant side it is on-call provision. If a consultant works in the Beaumont Hospital he or she will have an on-call commitment in his or her speciality of maybe one in eight. If a consultant works in a smaller hospitals that might be one in three or one in four. There are other issues relating to this matter as well.

I ask Mr. Carter to comment on the non-alignment of CHOs and hospital groups.

Mr. Ian Carter

Personally, having worked in two different environments, the key issue is that of a pathway. We do not have a pathway, I would suggest. Integration will more likely yield a pathway but we do not have a description. The Holy Grail for the health care system internationally is how to best manage chronic disease. Integration, logically, will bring it together. The main problem, and one can look at any international system, is how to do it. How will one actually do the task? Doing it under one tent is more logical than doing it under three tents or having overlaps. The absence of a pathway is a problem.

We accept that point. I ask Mr. Carter to comment on how organisational structures are seen to work against the principle of integrating services. What is Mr. Carter's experience of the RCSI group?

Mr. Ian Carter

By definition, we have different patient cohorts. Some are local secondary, tertiary or quaternary. We deal with patients from the whole of the country in our specialist areas and we are able to manage that piece. I am not disagreeing but suggest the following. One can have everything under a single tent and everything should work better. One can take that up to the top level and apply that.

Mr. Carter make the point earlier that his group has had 161 delayed discharges and I am conscious of them on the northside of Dublin. How can one get integration unless the two areas are aligned?

Mr. Ian Carter

Let us consider the causal problem. The main reason for 151 or whatever number of discharges that I quoted is not the result of there being three community healthcare organisations, CHOs, that I deal with. To some extent it is a capacity issue. I do not have that level of delayed discharges because of three separate CHOs and the issue of inter-digitation. There is a capacity issue in Dublin. I refer to the piece that Ms Cowan alluded to earlier. For the past 20 years there has always been a difference in the provisions in the community in terms of volume and capacity vis-à-vis Limerick and Dublin. That is why, and Mr. Woods can make a better contribution on this than me, there is not a long-term care problem in Limerick. There was not one 20 years ago when I was there as general manager. There has always been a problem with delayed discharges in Dublin. That is a capacity issue and not a control one.

I asked a specific question about bed capacity. I would like to hear the views of witnesses, particularly of the CEOs, about whether the problem of bed capacity is due to a lack of staff. Are the beds physically available and waiting to be opened? We are aware that in Donegal there will be a downgrading of beds in Ramelton, Lifford and Stranorlar. As that is happening Mr. Carter has said there are capacity issues in Dublin. I argue there is a capacity issue all over the country. I ask the Saolta group to confirm whether the downgradings will go ahead and if the beds will be closed and lost to the system.

Is the capacity issue due to staffing only? Do we need to build more facilities to hold the beds? Is there enough space available with beds but we simply need staff?

Mr. Ian Carter

Globally, it is probably both. There is a bed planning exercise to be done. One would argue that the current configuration of beds within my group or nationally in the current model is insufficient. The exercise that has not been done is asking how many beds are needed for a more community-orientated service.

In terms of the current model, at a simple level, there is a normal maxim that is used. Hospital beds, to operate efficiently, should operate somewhere between 85% and 88% full capacity as they can cope with peaks and troughs. Most of the hospitals here operate at more than 95% and their ability to cope with peaks and troughs is nil. There are not enough beds in the existing model because there are not enough beds as opposed to purely a staffing issue.

Have beds been closed due to staffing shortages?

They could be quickly re-opened.

I want a quick answer to my question.

Ms Colette Cowan

From the point of view of the UL Hospital Group, all of our beds are open with one exception. There are 15 beds closed in St. John's Hospital due to a recruitment issues. The hospital cannot get nurses to open them. We are working carefully with the hospital to resolve the matter.

There are 15 beds closed.

Mr. Maurice Power

There are ten beds in Letterkenny hospital that are temporarily closed but we are recruiting nurses.

Dr. Pat Nash

They were opened overnight to accommodate capacity.

I wish to return to my question on the downgrading of beds. The announcement was made by the then Minister for Health, Deputy Leo Varadkar. Will the beds be replaced?

Dr. Pat Nash

They are in the community and, therefore, are not under our direct remit.

In terms of what has been asked, coterminous or common governance is key. At the end of the day patient care is paramount. Care for patients is fragmented in the way we look after their care in the acute sector. The social care and primary care aspects of care are fragmented. It is key to have a single authority and single accountability in terms of care.

Are there only ten beds closed in the entire Saolta group?

Mr. Maurice Power

Correct.

What about the RCSI?

Mr. Ian Carter

I have four critical care beds closed in Beaumont Hospital. I have secured funding so I shall open an additional ten beds in Beaumont Hospital in about a week's time that I have developed.

Does Mr. Carter mean the only beds closed are his four critical care beds?

Mr. Ian Carter

Yes.

Do the witnesses agree that there should be an independent review of bed numbers?

I shall hold that question for a moment as it is on a different topic. Deputy Barry has asked a number of questions on private income, borrowing and the pressure placed on hospital groups to generate private income. I ask the witnesses to respond to his questions and I call on Saolta to commence.

My questions also dealt with trusts.

Mr. Maurice Power

Saolta was established in 2012 so our governance is well established.

The question relates to where we move to next. My understanding is there has been no legislation drafted relating to hospital trusts. My personal view is that hospital groups are a good idea and they can work very well, albeit with challenges relating to integration. No matter what structure is involved, there must be accountability, which is still with the Health Service Executive, HSE, or some form of organisation in terms of a commissioning unit. We would be held to account for the activity we do, the finance position, our performance and so on. That still must be in place.

I am not too sure of the long-term plans relating to independence. Irrespective of that, there must be accountability where the groups are performance managed. We are a small country and there will be national policy and direction given by the Department of Health and HSE on how we do our business and what catchment areas we cover and so on.

That is a policy decision.

Mr. Maurice Power

Yes.

It has not been formalised. It may be in the programme for Government but there has not been a decision on that yet.

Say there is a target to reach, and Mr. Carter had indicated he feels the stretched targets are unrealistic. It has already been teased out at the committee somewhat that topping up can be achieved by setting targets for getting private income through medical work. Are there other ways of sourcing private income? For example, I raised the question of debt. Deputy Kelly told me that at the moment that is not possible, the parties are not allowed to borrow and their hands are tied. Perhaps the witnesses would clarify that. Is the selling of assets something that happens at the moment or will it be coming in the pipeline with trusts?

Will Mr. Woods respond to those questions?

Mr. Liam Woods

On the issue of borrowing, there is no power for the HSE to borrow without the prior consent of the Government. There is no borrowing and that applies to groups and to the HSE globally.

There is no power at the moment for groups to borrow.

Mr. Liam Woods

That is without prior consent

It is in the legislation.

Is there power to dispose of assets?

Mr. Liam Woods

The HSE has power both to acquire and to dispose of assets.

Do hospital groups have that power?

Mr. Liam Woods

It is a function of the HSE centrally. It is a function of the directorate. In future, there may be a move to trusts. That is a matter for legislation. To be clear, the disposals taking place in the health environment have typically related to A Vision for Change policy in mental health. I cannot recall sales of any hospital assets. I can think of some acquisitions. There is no power to borrow or significant disposal programme of any sort in place.

I will ask the witnesses from the groups to comment further on pressures to generate private income.

Ms Colette Cowan

To be honest there is no pressure on us to generate private income. It is part of the normal workings of the hospital group that private patients come into hospital and they are billed accordingly. If we were to make cuts or try to come in on budget, it would not be on patient services. The patient is central to everything so one would look at other areas around non-pay to make some savings at year-end to reach a break-even position. One would look at medical and surgical supplies, drug usage and what is driving costs. That is the area we would focus on in the University of Limerick hospital group. We do not look every day at income to see if we can drive it up when it comes into the system. It is not as important as patient care. If we have to make service cuts, we would have long discussions and decisions around what we could cut in non-pay areas first to try to ensure we break even.

What is the Royal College of Surgeons in Ireland's view on generating income? Are there sources other than private patient income?

Mr. Ian Carter

Broadly, no. I take the point about the perverse incentives and a national picture. What I was alluding to is quite simply that I would not have the number of private patients coming in to reach a certain target that has been set. There is nothing I can do about that. At a very simple level, each of the hospitals I have are full, so their ability to take more is nil. What we sometimes forget with private income is that there is a dependence on the patient even coming in the first place. Currently, if there are not patients in my accident and emergency department who are private, there is nothing I can do about it. It is not as perverse as suggested.

If there are two patients in an accident and emergency department, with one private and one public, but there is only one bed left and a need to generate income, how is that decision made?

Mr. Ian Carter

They go into a queue.

I will go through questions quickly because of time constraints. There is the issue of private health care funding and targets being set. Will the witnesses elaborate on that, although it has been discussed already in terms of targets? Deputy O'Reilly referred to this. If the hospitals are full and running a big budget deficit, to be honest any accountant would say they should be filled with people who will pay for that bed through private health insurance. Where is the incentive not to do so? In other words, where is the incentive to treat people purely on a list basis? To be honest, no list comes through to an accident and emergency department and it is just about who presents there. I am quite sure decisions can be made as to whether these people should be referred further up the hospital or back to the community. Is there any incentive to refer people who may potentially contribute to the hospital through payment by private health insurance? Does it exist at that point to divert people to the hospital or send them home? There have been cases of people being questioned in accident and emergency departments about private health insurance and I have documentary evidence on that. I also have some of that from insurance companies which have informed me that people are being questioned in accident and emergency departments, leading to people being corralled up the hospital if they are private and, more than likely, home if they are not.

There is the broader issue of hospital groups. I have been the spokesperson for my party for six years on health and I am still unsure what hospital groups are and where we are going. If anybody around the table could tell me, I would be delighted. We were to establish a hospital group system and move to trusts that would compete with one another. This was based on the principle of the universal health insurance model, and although that has been scrapped, we have hospital groups up and running and in some cases boards are telling me they have some form of authority while others tell me there is no authority and they run, cap in hand, to the HSE the whole time. Are there varying degrees of autonomy between the various hospital groups?

Mr. Power referred to information technology, IT, systems. These are observations as opposed to criticisms. We have not exactly covered ourselves in glory with IT systems in this country, to be upfront about it. That is not just in the health area but across broader systems. While we have a wonderful software and IT industry, we seem to be incapable of transferring that as efficiently as we should into the Civil Service and public service. Who oversees the IT roll-out in the various hospital groups? Is it fully centralised? Mr. Power indicated there was a design for an IT system in the Saolta group but why is it not being designed for every other group if it is that good?

Neither the HSE nor the groups can borrow. Is all the equipment in every hospital owned by the HSE? I am referring to the likes of MRI, PET and CT scanners, which are high-tech equipment. Would a leasing system not be much better? Could we lease the equipment like any functioning commercial body? We could lease them from Siemens or other manufacturers. There could be contracts in place regarding replacements, repairs and maintenance. That just does not seem to be the case. I know a hospital waiting for a part costing €1.3 million but it cannot be purchased because the money is not available. Women have to travel from Cork to Dublin as a result for treatment because the piece of equipment is broken.

Could we be in any way imaginative on that? What are the views of the witnesses as representatives of hospital groups in terms of at least having the autonomy to enter into long-term lease arrangements with hi-tech equipment suppliers on a commercial basis, including maintenance and replacement?

If somebody mentions Beaumont to me, I think of a fine hospital but also of seven ambulances outside the door. When I hear "Our Lady of Lourdes", I think of queues and when I hear "Limerick", I think of chaos in the emergency department. It is the same in Galway. Let us be honest; that is what the public thinks. While it is sometimes propagated for political purposes, it is the factual reality for patients every day. What supports are the groups getting from the HSE nationally to assess the types of patients that are presenting? We have had evidence from Mr. Tony O'Brien himself pointing out that a lot of those who present at emergency departments should not be there in the first place. Are the witnesses getting any support from the HSE nationally to address that particular deficiency in community services and the primary care setting, to assess what patients are coming in, why they are coming in, who should not be there in the first place and what service deficiencies force them to end up in acute hospital emergency department settings? While the witnesses have probably discussed it already, I would like to hear some views on that.

We have always criticised the HSE nationally for its silo thinking. There is primary care, community care, acute hospitals and all the various silos in it. I am beginning to detect that this is symptomatic of problems within some of the groups as well. There is too much silo thinking funnelling down from the same sort of structure at national level and there is no clear co-operation between acute hospitals and community care, primary care or step-down facilities to work that in a basic, coherent way.

I thank the witnesses for coming in. I will cut to the chase as I am sure they are beaten down with questions at this stage. I was struck listening to Ms Cowan's presentation in particular when she said that single clinical governance across all areas was the key to providing operational expertise. That is the key to me also. I am not sure about the different groups. If we take recruitment for example, do any of the parties here recruit as a group? One has category 4, 3 and 2 hospitals. Graduates look for the category 4 hospital because that is where the most activity is going on and where they will learn the most. That is at the expense, however, of category 3 and 2 hospitals, which we need as much as we need category 4 hospitals. If a consultant, SHO or nurse is being recruited, he or she should be recruited for the group. The group should say to an applicant that he or she may be in Limerick or Ennis and the person can then go to wherever he or she is directed to go. That way, one will not get all the cream in one area and the rest left struggling. I do not know if that system operates in any of the groups. If not, it should. It would be a huge benefit. The situation in Kerry is the one with which I am most familiar and we will be dealing with it in the next session. There is one geriatric consultant in Kerry whereas there are 14 in Cork. It makes no sense that one or two of those cannot be seconded to Kerry on a six-monthly or 12-monthly basis to help out. It would provide great relief in the system if that was done.

I saw in the presentation the consideration of day surgeries in model 2 hospitals to relieve pressure so that an accident and emergency or trolley crisis does not mean having to cancel procedures. That is fantastic and a progressive way to maximise the use of model 2 hospitals and avoid impacts on model 4 hospitals. I would like to see that replicated. Perhaps the fact that only one CEO has to be dealt with is the reason it is possible to get all these things in place. It might be the model of best practice to which we should all aspire. I hope there is a capacity within groups to do these types of things. That is my next question. Is that capacity there? If a hospital group decided in the morning that it wanted to go along with the recruitment suggestion I made, could it or would there be obstacles in the form of unions or people refusing and an absence of the power to make it happen?

Dr. Nash spoke about how the hospital group was put together and what it has being what it has. Is the make-up as it stands correct or are there discussions among the groups where they say that Tipperary should be in with one or another? I am not asking the witnesses to make suggestions on the spot, but they might come back to us with suggestions in written form because we need to know these things. If there are one or two hospitals that are outside the group within which it would be better for them to be, we should be told. If we can make it happen, we will. This is an opportunity. There is no point in saying, "We should have". We should be told now because the witnesses are in position and know the workings. If there are positive changes that could be made, we should by all means be told what they are.

Deputy Kelleher mentioned information technology and Mr. Power said there was currently no IT link between the hospitals in his group. How difficult is that to achieve given that it is critical? It would save so much time and effort and the technology to do it is certainly there. How do we make that happen? The witnesses should tell us and we will do our best to try to get it delivered.

A comment was made that morale was at an all-time low in UL. Certainly, I have not found that in my experience. I live not too far away and I feel the morale in the group is good. I have no difficulty in saying that.

To conclude this session I have a few quick questions to add. On the question of private patient income, what is the situation in respect of bed designation within each of the hospital groups now? Are there designated private beds or do the groups work to a percentage?

In terms of people presenting at emergency departments, do the witnesses have an analysis of why people are presenting there in terms of the main diseases or illness categories? I note the point made that only two of the hospital groups, UL and Saolta, have actual boards in place at this stage. Why does the RCSI group not have a board? I will be asking the other groups the same question when they come to the meeting. Is the situation greatly complicated by the fact that there are voluntary hospitals in some of the other groups which are not HSE hospitals?

I would very much appreciate it if that group of questions could be addressed. We might start with UL.

Ms Colette Cowan

To answer Deputy Kelleher's questions on where we are going, groups, autonomy and authority, Saolta and the UL hospice group are in place for four years now in an interim state. We are very clear about saying that. We have had boards working with us but they have had no legislative power. However, they have been very effective boards and helpful in advising us on where we are going. We accounted to them every month as to how we were proceeding. There are varying degrees of autonomy and there are decisions I can make as-----

It is not obligatory to account to that board, is it?

Ms Colette Cowan

No. We attend on a monthly basis to give them that courtesy. These people are doing it voluntarily so we give them the courtesy of performance details. Regarding autonomy, as CEOs we are key decision makers. We are the accountable officers for everything that happens in our hospital group. We are held to account through a very strong performance accountability framework. There are areas that we have to account up to. Mr. Liam Woods is our national director. Sometimes, we would like more of the decision-making to be with us at the front line. We are not anywhere near moving to a trust status. We support a network of hospitals working together and that has played out with some of the positives around reconfiguration which predates groups. In UL that was driven by this gentleman here beside me, Dr. Paul Burke. We have to train our people to understand how to work like private sector business model units. We are public servants and we are here to serve the patients. I suggest that groups evolve as networks of hospitals working together, moving surgery out to the sites and moving work around rather than moving very quickly into a trust style model where we will not be able to account for every last detail. That is my suggestion on it.

Regarding IT systems we have just rolled out a patient master index across six hospital sites which is the first in the country. That was managed centrally through the office of the CIO, chief information officer. He got funding and has continued to get funding for IT services, which has been very effective because we can transfer patients now across the six sites and everybody can look in and see what that looks like. It was managed centrally but we had teams of project people on the ground delivering that. Mr. Maurice Power might want to talk a bit about his electronic patient record. He is trying to look at rolling that out and we would copy the system rather than every group trying to do something different. That is under way.

Regarding equipment and purchasing, we hold an asset register so all equipment belongs to the HSE. The leasing model is in place in small areas. The vascular team have leased equipment and sometimes that works. We are trying to have economies of scale so if we are ordering equipment for groups of hospitals we can do better deals on equipment rather than us all going out and spending enormous amounts of money belonging to the public purse on it. We work on that.

If there are five PET or MRI scanners to be purchased, for example, would the easier thing not be to have a centralised contract so the equipment would be leased as opposed to trying to capital purchase these things? They could then be given to the groups and they would be contracted for maintenance and repair works like the real world does it.

Ms Colette Cowan

We have central contracting in place nationally and there is an equipment strategy around that so we work very closely on medical equipment and how it is bought. That is in place. The leasing aspect is also in place but maybe we can grow it a bit more in the future years. Mr. Woods might want to address that.

Will the witnesses respond to the other questions?

Dr. Paul Burke

I will take the emergency department question. We know what is coming into the emergency department all the time. As I said earlier on, we know where they are coming from at the moment. Up to 50% of what we are getting is coming directly in the door. Much of that has to do with social situations and people coming out of hours and not going to general practitioners etc. There is the economic story with that as well. People are aware that if they come into hospital and wait 36 hours they will end up having had their CT scan and go out again. There is patient choice in much of this and much of it is the way our social infrastructure is affecting it. The vast majority of conditions that people come with are acute conditions. There is a 30% admission rate. We know exactly what the profiles are and we can see them year on year and day on day. Much of it is determined by public opinion and public expectation.

In terms of addressing the problem, it would be helpful if we had a detailed analysis so we knew that a certain percentage is presenting as a result of asthma, for example, and then we could prioritise the asthma programme in the community. That kind of approach could be taken.

Dr. Paul Burke

That information is there. The clinical care programmes have already identified that.

That is for Dr. Burke's group, but I am not sure there are national figures on that.

Dr. Paul Burke

There are the national clinical programmes-----

We would like to see them.

Dr. Paul Burke

-----and we have that data.

The next question is on the issue of bed designation.

Ms Colette Cowan

There are two questions there around the emergency department. All patients are asked if they have private insurance or a medical card. It is part of the normal queries that are made of any patient who comes into the hospital setting. There are clear bed designations. How much of each hospital can be designated as private is laid down through VHI and other private sector. Each hospital is different and it is laid down in a bed-mapping process. That is in place in all groups.

Who determines the bed designation?

Ms Colette Cowan

It is done through the HSE.

Perhaps Ms Cowan will just answer for her group.

Ms Colette Cowan

We discuss it with the HSE, there is engagement with the various private insurers and the designation model is agreed based on the population.

Is the 20% still cast in stone?

Perhaps Mr. Woods will address that question.

Mr. Liam Woods

On the bed designations, the legislation changed in the last number of years. There used to be a situation where there was a particular number of named beds, which I think the Chairman was referring to. In any hospital, there might be 100 beds of a specific designation which are identified as private beds and if private patients are in them, the hospital can charge. The law changed in the last three years to a situation where patients who are admitted and elect to be treated privately can be charged. What Ms Cowan has referred to as an assistance to the insurers to understand that a patient was treated in a bed or in a treatment location - it is not all bed based - is a bed database which is maintained as part of an MOU of them. The control is actually in the Act. That has seen a significant growth in income because there were always patients presenting who were private, who would have elected to go private and could not be charged. Over the last few years that has been amended.

There was a question on the managed equipment, perhaps Ms Eilísh Hardiman will talk more about it on the children's hospital side in the next session. The managed equipment service idea which is prevalent in health internationally looks at two life cycles of a set of equipment and entering into lease-type arrangements with specialist organisations. The Deputy named one or two of them. That is being explored within the HSE because there is a real challenge around maintaining the equipment base where we need it to be. We are doing that.

The HIPE data set records all diagnoses across all hospitals. Every one of the 1.6 million cases is coded so there is good information available nationally on diagnoses.

Is that on activity?

Mr. Liam Woods

It is but it also identifies the clinical diagnosis which is heading where the Chairman was going. It shows what conditions are prevalent in hospitals coming through emergency departments. That is identifiable.

Mr. Ian Carter

HIPE does not code emergency departments.

Mr. Liam Woods

No, it is only admissions.

That is the point I was making. Is there a detailed analysis of why people are attending at emergency departments?

Mr. Liam Woods

The point Mr. Carter referred to is that there is a detailed analysis of the admitted patients for emergency departments. The attending-----

That was not my question. I asked about those attending emergency departments.

Dr. Paul Burke

Some 70% of people who turn up in emergency departments are not admitted and of that group we have very significant knowledge of the type of work-----

Is that data collected and held nationally? Do we have any idea of the breakdown of people attending ED and why they are attending? Is for social reasons? What are the different chronic illnesses for which they are attending?

Mr. Ian Carter

In truth, there are several reports. Is there one book? No. There are-----

I am asking the question.

Mr. Ian Carter

There are several reports that will capture the data.

Is that data collected as a matter of course by the HSE or anybody else in terms of why people are attending emergency departments?

Mr. Liam Woods

There is not a live readily available data set nationally live but the clinical programmes have looked at particular conditions and types of population.

That is not my question.

We have asked Mr. O'Brien this. We have asked everybody. If 100 people go to a particular emergency department on a day, 70 of them go home and 30 are admitted, for either diagnostics or treatment. What we would like to know is the information of all of the people who presented that day.

How many of those people have asthma or COPD and so on?

We want to know what they presented with and why they were there. They did not just walk in because they wanted to visit the emergency department. Were they referred by a GP? Did they just present themselves? Have they chronic illnesses? Have they chronic disease? Is any of that information available?

It is very hard to see how the system can be responding if we do not have that basic data. On Deputy Brassil's question on recruiting by group, what is the position in UL?

Ms Colette Cowan

We recruit by group so when we go out to advertise for the group of hospitals the contract is with the group. If in future years the group needs to deploy people elsewhere, it does not have to go into the industrial relations arena because it has already been agreed on contract. We have been doing that for the past two years and it works quite well.

So a person could be moved from Limerick to Ennis for a two or three month stint.

Ms Colette Cowan

Yes, if required. I am speaking about the broader group. My colleagues spoke about consultants. We have to work on the sessional commitments. It is important for the brand as well. In terms of the development of hospital groups, we want people to be proud of the group they work in. We would prefer them to say they work for UL hospitals rather than at a specific site, which provides for greater collective bargaining at the table.

Perhaps the Saolta representative would respond to this group of questions.

Mr. Maurice Power

In regard to Deputy Kelleher's questions, ICT is a major issue for groups. There is a lack of integration across the Saolta group in terms of patient administration systems, financial systems and HR systems. As part of our ICT strategy, we are working with the HSE chief information officer to put in place some of those systems. For example, one of the projects in respect of which we propose to seek immediate funding is a group patient administration system which will tie in with the unique patient identifier. This will allow us to track any patient in any hospital. There is a piece of work to be done on that and in respect of the appropriate funding for it. We are also working on the introduction of a document management system which will involve the conversion of physical charts to electronic charts. Work on this system has commenced. Ultimately, the key ICT development will be in the area of electronic patient records, EPR, so that from the point of entry into hospital of a patient his or her full record will be available electronically to anybody who needs it. The critical issue in this regard will be integration of this system with general practitioners and the community care sector so that we have an overall patient record available to all staff. I understand that Mr. Richard Corbridge, chief information officer, has made a submission on the cost of an electronic patient record, EPR, system for the Republic of Ireland and that a significant capital investment will be required. This system is critical to the integration of services between GPs, communities and ourselves.

In regard to ED analysis, there is also a project under way, in respect of which Saolta is taking the lead, on the implementation of what is known as an unscheduled care information system. As stated by members critical to this will be information on the reason patients are attending emergency departments. As I said, work on this project has commenced, with a view to implementation of the system in 2017. Saolta is the pilot site in this regard. In regard to purchasing, I agree with the Deputy that we need to look at managed equipment services. In terms of capital spend, we do not have the necessary money to invest in equipment requirements and so we need to look at levelling off in this area over a period. Managed equipment services is the way forward in terms of delivery in that regard.

On Deputy Brassil's questions, we do recruit locally. We are currently facing challenges recruiting people to work in Galway and in Donegal. They are two difficult locations to recruit but in terms of Portiuncula and Roscommon hospitals we do recruit locally. In regard to the overall funding situation and targets, the current income deficit for Saolta is approximately €8 million, which is less than 1% of our overall budget. The priority for me as chief executive officer is to ensure that patients are admitted based on their acuity.

I will allow a brief question from Deputy Louise O'Reilly specifically on that point.

With regard to recruitment and contracts, are the limits on movement applicable under the Lansdowne Road agreement, which if memory serves me correctly is no more than 50 km in terms of a round-trip, being adhered to? For example, is it possible that a person recruited to work in Galway could be transferred to work in Letterkenny?

Mr. Maurice Power

Absolutely not.

I presume that those limits will apply to all of the other groups, nationally, unless renegotiated?

Mr. Maurice Power

Yes.

Dr. Pat Nash

The decision to admit in ED is entirely clinical based. The issue of public-private plays no role in that regard. The prioritisation of who gets a bed is entirely based on clinical need and the length of time waiting. The public-private mix and whether a patient is going into a public or private bed plays no role in this area. I can assure the Deputy that it is not a factor in terms of emergency department access to hospitals.

Perhaps the RCSI would respond now to this group of questions.

Mr. Ian Carter

In regard to medical staff in particular, we recruit from a group rather than geographical perspective. Each consultant contract will include a sessional commitment to one, two or even three sites that is not geography-specific. If I am recruiting consultant A, the contract will specify that he or she will work five hours in hospital A, ten hours in hospital B and so on. That is routine and it is done from a group perspective.

Is that set in stone or can it be changed?

Mr. Ian Carter

It is negotiable, as applies in respect of any other contract. For example, we can swap the balance of hours to be worked between hospitals A and B and we have done so. The rationale for moving some of the surgery to, say, Louth, would involve renegotiation of an individual's contract.

In regard to governance, why does the RCSI not have a board?

Mr. Ian Carter

That is not my decision. That is a matter for legislation. I do not set policy. I cannot set up a board.

Perhaps Mr. Woods would outline later why some groups have a board and others do not.

Mr. Ian Carter

For clarity, none of the groups has a legislative board. Reference was made earlier to the term "administrative". The less polite term often used is "shadow". There is an absence of legislation in terms of the formation of statutory boards.

Has the RCSI considered establishing an administrative board?

Mr. Ian Carter

We have a Chairman and we are dependent on nominees, in terms of additional board members, from the HSE and the Department of Health.

The RCSI is waiting for the HSE-----

Mr. Ian Carter

Effectively, we awaiting the advertisement of board member positions.

I presume the board will be an administrative or shadow board until the necessary legislation is introduced.

Mr. Ian Carter

Yes.

How is the chairperson selected?

Mr. Ian Carter

It is a ministerial appointment.

In regard to the voluntary hospitals, how is the issue of governance dealt with within a group?

Mr. Ian Carter

It is dealt with differently within each of the groups.

Dr. Paul Burke

As Saolta and UL are HSE-based they did not have any type of governance at hospital level. The voluntary hospitals, of which there is a small number in our group, have their own hospital boards, which have always been a source of support. As I said, Saolta and UL did not support that and they have been put in with us as a form of support.

Perhaps Mr. Woods would comment now on the board situation.

Mr. Liam Woods

Mr. Carter has summarised the position well. The requirement to have independent groups is based on the need for legislation. The interim requirement around boards, referred to as "administrative" boards, is, as Mr. Carter said, a matter of advertising for members and selecting of same for appointment to the administrative boards.

It is difficult to understand how we can have proper governance within a group if there is no board. That is a matter of concern.

Mr. Liam Woods

The preference would be to have legislation in that regard.

Has work on that legislation commenced?

Mr. Liam Woods

To be fair, that is a matter for the Department. The HSE does not have a role in that regard.

Is Mr. Woods aware if work on the legislation has commenced?

Mr. Liam Woods

I do not know. If it has commenced, it would be in its very early stages.

Thank you. I call Deputy Kate O'Connell.

If legislation was passed would there be any scope to redefine the borders? In other words, if the administrative board became a statutory board would there be scope to redefine the borders in terms of alignment of the community health organisations with the hospital groups?

That is a policy matter on which the committee will make a recommendation.

I would like to clarify one particular point. Deputy Brassil referred to the morale of nurses working in the University of Limerick Hospital, many of whom I know because I represented them for many years. An article in the media dated 9 November refers to nurses going home in tears because of unmanageable workloads. I suggest that the nurses in the University of Limerick Hospital are no different from nurses across the State in that their morale is on the floor, which we heard directly from the INMO.

We take that point. I thank Deputy Louise O'Reilly. I thank all of the delegates for their attendance and responding to our questions. We very much appreciate their time.

Ms Cowan wanted to reply.

Ms Colette Cowan

Should I reply to Deputy Louise O'Reilly on the statement that nurses go home in tears?

I do not believe it was a question but a statement. We will leave it at that because the committee has a lot of other business to conduct. I thank everyone for his or her participation.

Sitting suspended at 11.30 a.m. and resumed at 11.40 a.m.

For the committee's second session this morning, we are meeting representatives from the four remaining hospital groups, all of whom are welcome. They include Ms Mary Day, CEO, and Mr. Kevin O'Malley, group clinical director, Ireland East hospital group; Dr. Susan O'Reilly, CEO, and Dr. Martin Feeley, group clinical director, Dublin Midlands hospital group; Mr. Gerald O'Callaghan, chief operations officer, and Dr. Orla Healy, director of quality, governance and patient safety, South-South West hospital group; and Ms Eilísh Hardiman, CEO, and Dr. Ciara Martin, clinical director, of the Children's Hospital Group. Mr. Liam Woods is with us still.

In terms of formalities, 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 on a particular matter and they continue to so do, 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 entity by name or in such a way as to make him, her or it identifiable. I remind members of the long-standing ruling of the Chair to the effect that members should not comment on, criticise or make charges against a person outside the House or an official by name or in such a way as to make him or her identifiable. I invite Ms Mary Day to make her opening statement.

Ms Mary Day

I thank the Chairperson and members for the opportunity to address the committee this morning. I am CEO of the Ireland East hospital group. I am joined by the clinical director for the Group, Mr. Kevin O'Malley.

The establishment of hospital groups provides a unique opportunity to deliver integrated models of care and to bring research and innovation to the core of the clinical service delivery model. The Ireland East hospital group, IEHG, was established in January 2015 and is the largest and most complex of the hospital groups. Comprising 11 hospitals, six of which are voluntary and the remaining five of which are statutory, the Ireland East hospital group spans eight counties and four community health organisations and has a gross annual expenditure of in excess of €1 billion.

The Ireland East hospital group's ambition is "to be the national leader in healthcare delivery, with a strong international reputation, improving the quality of healthcare and better patient outcomes through education, training, research and innovation for the 1.1 million people we serve". To achieve this ambition, we have developed a ten-point framework programme, which will see the IEHG established as an independent hospital group, with an academic health sciences centre as its core.

Over the past two years, the group has established a management team to run the largest hospital group; prioritised developing integrated pathways across the continuum of care between the acute, primary, community and continuing care services; focused on developing a robust quality and patient safety function to ensure high quality safe care is delivered; developed our first clinical academic directorate in cancer as a move towards an academic health sciences centre model; introduced an unscheduled care transformation programme to improve patient throughput in our emergency departments, EDs, and enhance patient experience; and created additional surgical and outpatient capacity in the group by ensuring model 2 hospitals carry out higher volumes of low acuity work, thereby freeing up capacity in the model 4 hospitals.

We now want to build on the positive start and make meaningful changes to the delivery of care in order that every patient within the IEHG can receive the same access to high quality safe care, regardless of where he or she lives. To develop and fulfil our ambition further, we need to have primary legislation which will enable the IEHG to become an independent hospital group with its own board operating under the HSE's commissioning arm and with full accountability to the Oireachtas. Hospital groups, if properly constituted, will enable the acute hospital sector to integrate with the primary, continuing and community care sectors in a manner not previously achieved; ensure that we can meet the needs of the local population within a quality and safety framework that delivers high quality safe care; develop operating models that ensure smaller hospitals are aligned with academic teaching hospitals, thereby improving the quality of care to all our patients; optimise the use of resources, by ensuring care is delivered in the most appropriate location; and bring research and innovation to the core of service delivery, ensuring bench-to-bedside developments become a reality. Our link with University College Dublin is also vitally important to our work with generations of doctors, nurses and other health professionals who are graduates of UCD providing excellent services in our hospitals.

Patient care is at the centre of everything we do. To that end, the IEHG has developed a quality risk and patient safety directorate, which will develop a comprehensive risk management system which incorporates clinical and non-clinical risks. Another key element of our quality framework is to conduct a safety survey to enable us to assess comprehensively the practices and procedures behind the numbers.

A core objective of the IEHG is to develop an academic health sciences centre, where education and research contribute to patient care and well-being. Internationally, such centres have scored well ahead of non-academic centres for patient outcomes and safety and improved staff recruitment and retention.

In delivering this objective we have developed a clinical academic cancer care directorate, which allows us to combine the strength and scale of our clinical cancer services at the Mater and St Vincent's hospital along with the cutting edge research of UCD to enhance the care given to cancer patients, to improve their life expectancy, and to deepen our understanding of cancer. This will be the largest cancer care centre in the country, caring for more cancer patients than any other hospital group.

To meet the needs of the patients we serve, it is vital that primary care and acute hospitals work closely together. We have a GP on the group management team and we have endorsed the concept of local integrated care committees to improve the links between hospitals, community and primary care sectors. Such committees have already been established in Kilkenny, Wexford, Mullingar and Loughlinstown in Dublin, and work is under way in Navan.

Clinical integration with the communities we serve is also vital. The IEHG has a dedicated work programme on integration with primary, community, continuing and home care entities. The main aim of this is to ensure the needs of patients are aligned as seamlessly as possible across the continuum of care, with a special emphasis on managing the frail elderly patient pathway.

My opening statement is just a snapshot of who we are, what we do and what our ambitions are in the Ireland East hospital group. The written submission we made to the committee gives a much broader overview, including our work in unscheduled and scheduled care, genetics, human imaging and education and training.

I thank the committee for its time this morning. Mr. O'Malley and I would be happy to answer any questions the committee may have.

I thank Ms Day. I invite Dr. Susan O'Reilly to make her opening statement on behalf of the Dublin Midlands hospital group.

Dr. Susan O'Reilly

I thank the Chair and members for inviting us here today. I will focus a little on the future. I would like to introduce my clinical director, Mr. Martin Feeley.

Our group began less than two years ago and, like Mary Day's group, is a young group in evolution. We serve a population base of 800,000, our expenditure this year will be close to €1 billion and we have approximately 10,000 employees. It is a busy group. In the interests of time, I will not go through all the numbers. They are in the submission.

We have a distinguishing feature from some of the other groups in that 70% of our revenue goes into three large voluntary hospitals: St. James's, Tallaght and the Coombe Women's and Infants University Hospital. We have three general hospitals, Naas, Tullamore and Portlaoise, and we have the specialty three radiation oncology centres in Dublin - the St. Luke's radiation oncology network.

The two big general hospitals, Tallaght and St. James's, have both national and regional programmes. We are the national centre for burns and the national centre for stem cell transplantation. We have some of the national leadership roles in elements of oesophageal cancer, lung cancer, genetics, family cancers, etc. We have regional services for nephrology, renal dialysis, infectious diseases and ageing as key pillars.

Those two hospitals both offer broad general services as well. All five of our general hospitals include emergency department services, general surgery and general medicine. There are challenges. Our governance model is good in that we work collaboratively with voluntary hospitals by means of service level agreements and we directly manage statutory hospitals. However, all hospitals struggle with trolleys and waiting lists for elective procedures. We have a capacity problem that is universal across the country and it needs to be addressed.

In order to add value, a group needs regional leadership and management in order to progress. There have always been regional models, whether it was the old health boards or the RDOs. Some of them were integrated with the community and some were not. However, we work very closely with our hospitals, and particularly with their clinical leaders, in order to develop clinical networks for patient flow and optimal patient pathways. A very good example of that is the Coombe-Portlaoise maternity and neonatology network, which developed after we arrived as a group and which has been very successful in smoothing out where care is delivered. We are very appreciative that this has been such a success. We collaborate very closely with the two community health areas with which we work. Not only do our hospitals collaborate closely but we, the group, meet them very regularly – at least twice a month - to address admission avoidance and also to reduce delayed discharges. With their assistance, there have been very substantial improvements this year in how we manage delayed discharges but it is by no means close to perfect. It remains a problem in terms of bed utilisation.

Our future focus will be on integrated care with the community, with GPs, in particular, and with hospital consultants having more joint appointments. There are a few joint appointments currently and the CHOs in terms of their broad spectrum of activity are part of that plan. However, that is contingent on things we do not directly control. There needs to be a new GP contract, there need to be more GPs and there need to be more resources. I fully endorse comments made earlier to the effect that one cannot simply switch off spend in a hospital and transfer it to the community, one needs a very comprehensive plan that is graduated in order to get to the point where one shifts work and resources. Nobody would argue with that.

For general hospitals, for local reasons of need in the past - historical reasons - five of them are offering 24-hour emergency department, general surgery and general medicine. We have identified significant challenges through the work that we have been doing to show that low volume complex patient services are profoundly difficult to deliver in small level 3 hospitals. In particular, as members have already heard, recruitment is an issue. It is not even a matter of whether there are people or where there is money available. The jobs are profoundly unattractive if there is very little work to be done at the complex level and if there is very great difficulty for people to maintain their skills over time. We are very focused on having sustainable safe models for patients.

The group has been charged by HIQA, as a consequence of its report on Portlaoise hospital last year, and is expected to develop an action plan. We have put a huge amount of work into how we are going to ensure that we are providing safe care for patients in both general and maternity services. I wish to talk a little bit about how we are setting about doing that because it is still a work in progress within the HSE and the Dublin Midlands hospital group. It is not policy as yet. We are approaching the conclusion of all our work, which is being done in a very comprehensive fashion with eight national clinical programme leaders across the spectrum of all surgery, medicine, maternity and infant services in our group. Transportation is also an issue and the National Ambulance Service is involved and the acute hospitals division is very actively involved in co-chairing the process. It is very evident to us that, as members have heard from other speakers, we need to focus on providing complex, low volume but vital services that save lives in big hospitals and we need to focus on providing an increased volume and scope of elective high volume, lower acuity services in model 2 or model 3 hospitals.

That is part of a significant plan that is linked to an implementation plan we have developed, which is largely based on a very effective policy document that already exists, which is the Securing the Future of Smaller Hospitals: A Framework for Development. Implementation planning takes many years and capacity development is key. As members are aware, there are national and international shortages across all doctor appointments, junior and senior, and specialised nurses in particular. We need capacity for facilities and equipment to replace small, old unfit facilities. There is a massive shortage of capital at the moment. This will take some time but we will get there eventually. We have to reflect that front-line staff have performed heroically during the recession and the moratorium but we must ensure that for them to deliver services well, and for the staff to grow, they must have thoughtful planning, both in the community and in the hospitals to deliver a new model of care. Some of the models will make some members, individually, uncomfortable, but we must endorse change in order to be able to achieve that. The entire focus is on quality and safety for patients and I should add too, for our staff. We need to be able to give them an environment where they can do their jobs well.

Briefly, what will work is regional leadership and management. I endorse Ms Day's comment that we need legislative authority and a model extremely similar to the very effective voluntary hospitals. It is a type of accountable autonomy whereby one is accountable but has flexibility in how one develops one's programmes and one can be engaged and active in being as creative and productive as possible. It is not only a question of capacity, it is streaming patients around the clinical networks and pathways. Clinical leadership is vital at all levels. This was only formalised eight years ago. It has bedded in well and it is something we strongly endorse. Clinical networks and pathways are the sine qua non across community and hospital care and between hospitals. That is what we bring, because even the most effective, successful voluntary hospitals struggle to get the networking done in a comprehensive way without regional planning and leadership at the level we are doing it. Consultant-delivered services is the goal, as the national cancer control programme has pushed to deliver. We have evidence-based guidance from our 32 excellent national clinical programmes and the national cancer control programme. We must link to them for design advice and we will do the service delivery. The smaller hospitals framework models provide a very good underpinning.

In conclusion, 21st century medicine takes longer to achieve than a single Government term. My remarks are all based on a ten-year timeframe looking ahead. Change must be planned, agreed and resourced in order to provide staff, equipment and facilities, and implemented. It must not be all talk and then a case of individuals not wanting to go there. That is a challenge we must overcome as we move to get into the 21st century for all of our services. The committee has a great opportunity to do that. We want to be able to brief and encourage the committee whenever we possibly can to achieve that.

I strongly endorse the advice of my predecessor in leading the national cancer control programme - my previous job - Dr. Tom Keane, a colleague and friend, when he stated that we need collective political support to see our job through. In particular, I strongly endorse the Canadian public health care system which provides public universal access as an excellent model. We are nowhere near to that today.

Mr. Gerard O'Callaghan

I am delighted to have the opportunity to speak on behalf of the South/South West hospital group. I am. Gerard O'Callaghan, and with me is my colleague Dr. Orla Healy. The South/South West hospital group delivers care for a population of approximately 895,222 people across the counties of Cork, Kerry, Waterford and south Tipperary, with gross expenditure this year of more than €927 million. It is one of seven hospital groups serving 19% of the population of the State. We provide the full suite of acute hospital services across nine hospital sites. We have model 4 hospitals in Cork and Waterford, model 3 hospitals in Cork, Kerry and Clonmel, model 2 hospitals in Mallow and Bantry and exclusively elective hospitals in Cork and Kilcreene in Kilkenny. Emergency services are provided at seven of the nine sites in compliance with acute medicine programme and emergency medicine programme requirements. Cork University Hospital is the only acute hospital in the country providing the full range of trauma specialties. We expect that will secure its status as one of two major trauma centres for the country in the upcoming report on trauma centres.

We have reconfigured the hospitals in Cork and Kerry, in particular between 2010 and 2014. That included the closure and reorganisation of a number of emergency departments, which was challenging. We are continuing with the reconfiguration process. At this point, acute and complex work has been centralised and non-complex day-case work has been decentralised. We have now moved on from Cork and Kerry and we are commencing a process of service realignment across the entire hospital group. Since the establishment of the group in the past three years, the leadership team has been embedding a new governance and management structure. One of the key actions in the past year has been to meet the 40 clinical specialties across the group to assess their current state and develop the working of cross-group specialties. To that end, we are developing a clinical directorate structure and have just appointed a group clinical director for women and children as the first directorate in the group.

We are actively integrating care delivery with our colleagues in the community. We work with two community health care organisations, CHOs. We have an unscheduled care steering group as well as access, throughput and egress subgroups established with them. We also have multilayered collaboration across all hospitals with community service, including regular meetings at senior management level.

The leadership team is co-located with the management team of the College of Medicine and Health for the primary academic partner, University College Cork, UCC. Important progress has been made in building this collaboration such as, working with UCC to attract and rotate non-consultant hospital doctors, NCHDs, to all nine hospitals through a range of joint initiatives and establishing international working relationship with the Erasmus academic health centre, Rotterdam. Achievements include establishing a master of science, MSc, programme in physiotherapy with UCC and establishing a MSc in health care leadership in UCC, which commenced in September 2016. We are also examining a postgraduate radiography programme that we hope to get off the ground in the next two years with UCC.

The overarching strategic goal of the group is to achieve independent status with the imminent appointment of a board and the establishment of an academic health centre, in partnership with UCC. The best hospitals in the world are academic health centres and this model will attract the highest calibre graduates to work in Ireland. We are actively fostering our relationship with industry, especially the multinational pharmaceutical companies based in Cork to develop our services and realise the economic benefit for our population. To that end we are working with the Health Innovation Hub, which is based in UCC.

We share many of the same challenges as other groups that the committee is already aware of, such as staff recruitment and retention and cost control. However, we as a group face a particular challenge because of the ageing infrastructure of our hospitals. We need urgent capital investment to expand services at University Hospital Waterford, UHW, and University Hospital Kerry, UHK. Major infrastructural investment at South Tipperary General Hospital, STGH, in Clonmel. Consideration will be given to the complete rebuilding of that hospital but in the interim planned capital projects must proceed with full funding if the provision of services is to be retained there. The construction of a new hospital site for Cork city is critical. This hospital would see amalgamation of the two voluntary hospitals in collaboration with UCC. The range of services and facilities to be located at this site would include services currently provided at the two voluntary hospitals; a dental hospital; mental health services; ambulatory care; expanded diagnostics, a clinical research facility; a health innovation hub; and sub-acute rehabilitation.

To conclude, the delivery of high quality sustainable health services is dependent on strategic configuration and integration of hospital and community services. At regional level this translates to the requirement for evidence-based, well-articulated plans that are consistent with national policy but tailored to local context and it is possible to deliver this objective through the development of a hospital group and academic health centre organisational structure.

Where is the group's chief executive officer?

Mr. Gerard O'Callaghan

He is out of the country.

Ms Eilísh Hardiman

I thank the Chairman and members for inviting the Children's Hospital Group to attend the committee to outline plans for children's health care. I am joined by Dr. Ciara Martin, one of our clinical directors. Our group clinical director is on leave this week.

The Children's Hospital Group consists of Our Lady's Children's Hospital, Crumlin, Temple Street Children's University Hospital and the National Children's Hospital at Tallaght Hospital. Academic arrangements exist with all universities providing paediatric education and research. Collectively, these three hospitals have 443 beds and 2,865 whole-time staff delivering services to 25,000 inpatients, 27,800 day cases, over 153,000 outpatients and 118,000 emergency department attendances annually with an expenditure of €300 million. All national paediatric specialties are in the group, some with an all-island remit. We have specific access and capacity challenges for some paediatric services but in general, the three children's hospitals and their staff are held in high regard for the services they deliver despite these challenges.

A total of 23% of our population are children less than 16 years of age. The majority are healthy, but one-quarter of three year olds are obese; 16% of our children have a chronic disease such as diabetes, allergies and asthma and this is increasing; and 2% are acutely ill, some with very complex care needs. Currently, there is an over-reliance on hospital-based care, with many services accommodated in facilities that are not fit for purpose.

The plan for children's health care is the integrated programme for child health, involving acute paediatrics, social, community, primary care and mental health services. This cross divisional programme rightly reflects a population-focused, integrated and multidisciplinary approach to children's health care and the resources required to support parents, families, children and young people in achieving healthier outcomes and will take ten years to implement.

The plan for the acute paediatric services element of this integrated programme is the national model of care for paediatrics and neonatology, developed over four years through extensive engagement with parents' representatives, general practitioners, GPs, community colleagues and hospital staff in all acute paediatric and neonatal services. This plan outlines where and how acute paediatric services are best provided across the health system, with the new children's hospital designated as the central component of an integrated clinical network for acute paediatrics. The primary principle of this network is to conveniently deliver most paediatric services locally, with regional units clearly identified and supported from the centre and all highly specialised and national services consolidated in one children's hospital. Multiple health policy reports exist to support this service configuration for contemporary and sustainable paediatric services, and reflect how acute hospital services are developing in other countries.

The 12 member Children's Hospital Group board, chaired by Dr. James Browne of National University of Ireland, Galway, NUIG, was established in August 2013 as an administrative board with specific remits to integrate the three children's hospitals, develop a single clinical and corporate governance for paediatric services and act as client for the new children's hospital capital project and information and communication technology, ICT, programme collectively referred to as the children's hospital programme. The three independently governed children’s hospitals in the group have voluntarily agreed to merge into a new single legal entity before moving to the new facilities. The Minister plans to bring primary legislation for enactment in 2017 to establish this single entity and the Children's Hospital Group board.

The children's hospital programme will successfully merge these three hospitals into a new single organisation. It needs to transform general paediatric and emergency care in the greater Dublin area with the opening of the new paediatric outpatient and urgent care centres at Tallaght and Connolly Hospitals in 2018, implement an integrated clinical network for paediatrics across the health system and move services into the new children's hospital by mid-2021, the largest capital investment in the public system. In line with the Government's digital first public service ICT strategy, the new hospital is planned as the first "digital hospital" in the system with the implementation of an electronic health care record, as well as other evidence-based standards, such as 100% single rooms.

A decade after the first health policy position on acute paediatric services, the McKinsey report in 2006, last April An Bord Pleanála granted planning permission for the new children's hospital to be built on a campus shared with St. James's Hospital as well as the new paediatric outpatient and urgent care centres at Tallaght and Connolly Hospitals. The new hospital will provide national paediatric tertiary services, 22% of activity and secondary paediatric care for children in the greater Dublin area, 78% of activity.

In summary, the Children's Hospital Group's ten year vision for acute children's health care is to establish a national children's health care organisation that puts children's health first and foremost in its decision making; an integrated care programme for child health, with the new children’s hospital central to a clinical network of acute paediatric services in regional and local units and by using technology, to reach out to GPs and into children's homes; to reconfigure paediatric services within the other hospital groups to reflect the paediatric population served, keeping appropriate services local and supported by outreach from the new children's hospital; a 24 hour national paediatric and neonatal retrieval transport service to ensure timely transfer of the sickest babies and children to the most appropriate hospital; successful integration of the three children's hospitals into a state-of-the-art digital hospital, providing both national specialist services and a local paediatric service to the greater Dublin area that our valued staff are proud to work in; and progress a paediatric academic health sciences network with academic partners and industry to enhance paediatric education, research and innovation. These developments, which will positively affect one quarter of our population need to be considered not just in terms of how they will enhance health care for children but also how this integrated plan for acute paediatrics can demonstrate that the Irish health system can be reformed to deliver better, safer and more sustainable health care.

I thank the members of the committee for their attention. Dr. Martin and I are happy to take any questions they might have.

I thank the witnesses.

As in the last session, I will ask members to come in in groups of three. We will bank the questions and then ask the delegates to respond.

I thank the delegates for coming. I have some general questions and some that are area-specific. I will start with the general questions. In the last session we discussed the income targets in the generation of private income for public hospitals. I ask the delegates to outline the contingency arrangements if they do not hit these targets. If they find themselves short, what services will be cut and how will it be determined?

Earlier I asked whether bed capacity was a physical or a staffing issue. If hospitals had the required staff in the morning, how many beds would there be? From the hospital groups that gave evidence previously, I totted up the numbers. They indicated that they had a total of 29 hospital beds closed, which would probably leave the hospitals represented here with more than 600 beds closed. The figure we received for the number of bed closed was well over 600. I ask the delegates to comment on the number of beds that are closed within the system which could easily be opened.

We are aware that recruitment presents a challenge for every facility. As I said previously, whatever is being done clearly is not working. It would be helpful if the delegates could provide an insight on innovations or different practices in recruitment.

What are the delegates' views on primary care services? We all know that the patient journey from primary care to acute hospital care is not smooth. Where are the blockages? Does the issue relate to staffing in community care settings or do the systems and structures in place prevent patient flow?

I am sure none of these questions comes as a surprise to the delegates. What is the relationship between the CHOs and the hospital groups? Some of them match, while some do not. Where they do match, one person deals with one person, but it could be problematic where they do not match. Deputy Kate O'Connell asked this question previously. We are aware that legislation is to be introduced to underpin the boards. Could that legislation be tweaked to ensure the CHOs and the hospital groups aligned with each other which would be more efficient? They are the general questions I wanted to ask.

The presentation by the Dublin-midlands hospital group made reference to a plan. Dr. O'Reilly stated: "Our group has developed a draft action plan to consolidate specific complex services." Does she have a copy of that plan?

Dr. Susan O'Reilly

It is a draft.

It has not been published. As I am sure she is writing it, Dr. O'Reilly has seen it. Will it include specific timeframes and targets?

This and the other committee have discussed the national children's hospital. I have discussed it directly with Ms Hardiman. We all know that tri-location is best for children and mothers. When will a planning application be made for the location of the maternity hospital on the St. James's Hospital site? Ms Hardiman referred to it as the biggest capital investment; therefore, we need to get it right. Time and again we have been told that tri-location is the way to go.

My last question is for the South/South West hospital group. Mr. O'Callaghan managed to get through his presentation without mentioning the Herrity report. It is a very contentious issue, as I am sure he is aware. I know that my colleague, Deputy David Cullinane, has done extensive work on it. Some of the issues highlighted in the report relate to defining the catchment area for University Hospital Waterford. What does Mr. O'Callaghan regard as the catchment area for the hospital and also the group in the counties covered?

We need to keep things a little tighter if we are to come in on time.

I thank the delegates for coming. If they were observing on the monitor, they may notice that some of the questions are being repeated. My first question to the last group was related to recruitment. Does each of the groups represented have a group recruitment policy, whereby it can recruit and then send the expert in whatever discipline to the area in which the need is greatest?

I might be specific about the Cork and Kerry group as it is the area I know best. Does each individual department have a common governance structure? For example, for cardiology, geriatrics, obstetrics and gynaecology, is there a common governance structure across each of the hospitals in order that they can integrate and share information? If there is a shortage in one area, can it then be dealt with through the group structure? I regard the need to share expertise as critical for any group to work efficiently, particularly the grade 4 hospitals in Cork and Waterford and grade 3 hospitals elsewhere.

The IT question keeps coming up. What progress has been made in having shared IT across each of the hospital groups? Is this an issue for all of them? It is critical in order to progress services.

I have a specific question for Mr. O'Callaghan. It is very hard to justify University Hospital Kerry, a grade 3 hospital, not having a stroke unit. How can this issue be resolved? It might relate back to my previous questions.

I thank each of the delegates for his or her submission. I have three questions, the first of which relates to the issue of centralisation of emergency department trauma services. I direct the question specifically to Mr. O'Callaghan who made reference to it. I think he expressed a degree of confidence that CUH would be chosen to have one of the two key trauma centres in the State. I understand it will also involve the closure of the emergency department at the Mercy University Hospital and the centralisation of services at CUH.

Will a trauma steering group look at the issue on paper to see the advantages, but in dealing with the reality of overcrowding will we get the opposite result? For example, anyone who visits the emergency department in CUH, particularly on a Friday or a Saturday night, will know that it experiences overcrowding which sometimes is severe. With the potential closure of the emergency department in a nearby hospital and the centralisation of services without massive extra resources being provided at CUH in this case, it seems to be a recipe for disimprovement rather than improvement. Rather than asking it as a parochial question, I ask Mr. O'Callaghan to generalise because I understand the trauma steering group is considering the closure of nine emergency departments and the centralisation of services. The result could end up being negative rather than positive, unless massive resources are put in place.

My second question is on pharma and is to the South/South West group but perhaps Dr. Healy might be interested in taking this question. The group's opening statement states, "We are actively fostering our relationship with industry especially the multinational pharma companies based in Cork to develop our services and realise the economic benefit for our population". Can the witnesses elaborate on that? Does the hospital group receive funding from the pharma industry? There was an article in The Sunday Business Post two weeks ago about pharma funding for hospitals and the health services generally. If funding is received, to what extent and how much money is involved and what is the money for? Has the pharma industry paid for job positions? Do clinical leads in the hospitals receive payment from pharma companies? I would like more precise information about the relationship with the pharma industry in that regard.

Finally, I have a question that may be a bit parochial. Reference was made to a new hospital site in Cork city - an amalgamation of the South Infirmary Victoria University and the Mercy University hospitals. That has been talked about for some time. Can the witnesses give the committee an update on that situation? In order to make it less parochial and more of a general point, maybe some comment could be made around the type of timescale for these changes in the health service. Are things going more quickly or more slowly than had been anticipated originally?

I thank the Deputy. There are a number of questions there that are specifically for the South/South West group. I will first put the general questions to the other witnesses and will then come back to the South/South West witnesses for the specifics. The first of the general questions relates to income targets and what happens when a hospital falls short financially. The other general questions were around bed capacity and how many currently closed beds that could be opened if there was additional staff, around recruitment within the group and on information technology. I ask that the other groups respond to those issues first. We shall start with the midland group.

Dr. Susan O'Reilly

For income targets our group is expected to raise approximately €200 million of our core revenue budget in order to support services. This is part of the overarching funding model that currently exists. About two years ago there was a change where patients who have private insurance and who are admitted to public beds - principally through the accident and emergency department - can be charged to their insurance companies. There are issues about this model because patients often fear that giving their insurance numbers means their premium would go up - like a car accident claim can affect premiums. Globally, premiums will go up if we get more money off the insurance companies so some of the insurance companies are fostering the practice of not giving out this information. We are in a slightly bizarre model. It is not a model I like but it is the one we have. There is no impact on delivery of services if we fall below these income targets. As the chief executive officer of a group, and I suspect my other colleagues are likely to agree, we would not be cutting back on services if we do not reach stretch targets generating private income and other revenue.

Could Dr. O'Reilly explain how that works? It is hard to understand. The group is given a set budget and must operate within that budget, part of which is a target that the group is required to meet for private income. If the group falls short on that, how does it not have implications?

Dr. Susan O'Reilly

Let us think about stretch targets. The reason for having a stretch target is that for the last two years there has been an opportunity to be consistent about requesting people's insurance coverage, as they come in through the accident and emergency department or through any referral or outpatient visit, and not necessarily a private referral. Patients are asked for that information. The reason we are being tasked to do this better is to make sure hospitals have processes in place where they very consistently, and invariably, request this information as they would request medical card information. The information goes in onto the admission form. That is the stretch target. The reality is that if people come in and they do not have insurance or do not give their numbers, there is nothing we can do about that. As a leader and deliverer of health services, to be put in a position that suddenly one should rush and cut back on the acute or elective services because of an estimate - based on gleaning all the information that might be out there about a yield of a certain amount of money - is somewhat difficult to deliver on. This is notwithstanding the fact that in my director's report to Mr. Woods this year I would rather beg for forgiveness than ask for permission to cut back on services.

Explain to the committee the implications of not meeting that target.

Dr. Susan O'Reilly

There are implications and, again, this would revert to the HSE and to the Department of Health around the funding and being the accountable officer myself for the funds that we provide to our seven hospitals. The issue could be that if we failed to manage our budget effectively and well there could be penalties. It could be that the budget deficit carries forward to the next year and then the group starts off at a disadvantage which, if it happens, is a very difficult thing to deal with. We are incentivised to do the best we can but we can only do the best we can; we cannot actually magically produce more money than the insurance held by these individuals. It must be remembered that a budget is a plan for where we are going to get to, which is based on assumptions. It is like the Government's annual budget. We are unlikely to be 100% spot on. I will be very interested in how my colleagues address this particular challenge.

Again, it is hard to comprehend how it actually works in practice. In the absence of a supplementary budget, which is what we are facing now for the future, it is hard to understand how falling short on private patient income does not have implications for service provision.

Dr. Susan O'Reilly

First, in line with my supplementary comment, this is the first year we have had a realistic budget. Before we had a supplementary budget on day one of our budget allocation we could look forward and say that our group will be €45 million in deficit. We would know that based just on logic and predictions of spend because most of it is on staffing. We endeavour, however, to bridge that gap as best we can. This year I believe we are going to be coming in reasonably close to balance. We do the very best we can. One could have options of looking at certain things that might not be done. That is a situation we would endeavour to avoid at all costs because we are currently in a position where we have waiting lists in all directions and are reliant on the national treatment purchase fund to bail out some of the elective activities.

Okay, I thank Dr. O'Reilly. On bed capacity, does the group have beds closed currently as a result of staff shortages?

Dr. Susan O'Reilly

We have beds we can open and we have money allocated for a winter surge. We have applications in for next year for additional funding. We are aggressively targeting being able to open more beds. Tullamore hospital has money for a winter surge and they are now actively recruiting nurses and we need staff in. Naas General Hospital had money for a winter surge last year but we could not spend it because we could not recruit the nurses. One of the benefits to the group, and which I very much appreciate, is that Tallaght hospital has an international recruitment machine running and has assisted us in recruiting nurses for Naas General. Nurses are now beginning to roll into the Naas hospital and we hope that money will be spent. The issue has been less around the resources and more about finding the staff that have the expertise in theatre, accident and emergency, and intensive care unit beds.

Can Dr. O'Reilly tell the committee how many beds are currently closed due to staff shortages?

Dr. Susan O'Reilly

I cannot give an accurate number today but I can get that information for the committee.

Can the witness provide an estimate?

Dr. Susan O'Reilly

I will not give an estimate today in case I am inaccurate. I am more than happy to look into it and give it back to the committee. There is always a challenge counting how many beds could be open if one had the funding. It is a moving target.

Okay. We would appreciate it if Dr. O'Reilly could bring that back to the committee.

Dr. Susan O'Reilly

We are aggressively pursuing funding for nurses for critical care because this is a burning need across the State.

We would like to have the figure on the number of beds that are currently closed.

Dr. Susan O'Reilly

Yes.

Is recruitment done on a group basis? I note Dr. O'Reilly's comments on Tallaght hospital recruitment.

Dr. Susan O'Reilly

We do not, at this time, recruit on a group basis principally because 70% of our revenue goes into the voluntary hospitals and they have their own board structures and run their own recruitment, and they do it well and quickly. We tap into some of their activities to assist us. That has been very positive from our perspective. Generally, where nurses can be moved to is governed by the union rules. Doctors generally want to know where they are going to be working and their contracts usually will specify if they are joint appointments or not. I believe we have been quite effective in having joint appointments in a number of specialties. In the interest of time I will not list all of them now but should the committee need them I would be happy to do so. That is ongoing across a number of our hospitals and it is very important

Will the witness clarify that within her group there are three voluntary hospitals-----

Dr. Susan O'Reilly

Yes.

-----and they each do their own recruitment?

Dr. Susan O'Reilly

Correct.

This constitutes about 70% of the group revenue?

Dr. Susan O'Reilly

We have oversight on the numbers of staff and the spend. Our group allocates the budget. Their boards and ourselves hold them accountable for existing within that spend, but there is flexibility around that.

I take it that there is no movement of staff between the three voluntary hospitals and the HSE hospitals.

Dr. Susan O'Reilly

There is some. We have cross-appointed obstetricians and we are in the process of recruiting neonatalogists and other staff between the Coombe Women and Infants University Hospital and Portlaoise hospital. They are appointed through the Coombe hospital and they work jointly in both centres.

Dr. Susan O'Reilly

We have similar models in Naas-Tallaght, St. James's -Tallaght and St. James's with other hospitals.

But not in respect of nurses?

Dr. Susan O'Reilly

These are doctors' appointments I am specifically talking about but in fact we are looking at how we move to recruit midwives under a similar scheme in due course.

What is Dr. O'Reilly's view on whether the structures impede the aim to integrate services?

Dr. Susan O'Reilly

It is more important to have collaborative working, and effective means of working, with our community partners and to have appropriate cashflow into them to deliver services. More than a year ago, when the tap to community supports and long-term care was switched off, we got into desperate trouble in the hospitals. This year, significant resources are going into community health areas and they are able to meet most of our needs, except for some very complex and costly cases, even though we continue to pressurise them to get this done. The working relationships are a bit more important than the structures. Although in principle it would be very nice to have integrated management structures, it does not specifically impede our group at present. Other people may have comments on this.

Does Dr. O'Reilly accept that if activity is to shift to the community, budgets must shift also?

Dr. Susan O'Reilly

Yes, but I am very keen to point out, as Mr. Ian Carter did this morning, that we cannot switch off funding in one place and just switch it on somewhere else, because the hospitals would fall over. We must have a very sensible plan for a graduated evolution into integrated care.

On the issue of IT.

Dr. Susan O'Reilly

We have very good national leadership for ICT in the HSE, and the committee has already met Richard Corbridge. We are tapping into a lot of the progress and developments in ICT, but this is an area that has been grossly underfunded over the years and not enabled by the financial crisis in the country. We are in major catch-up mode. We are very fortunate to run a universal SAP payroll and HR system in our group. We are also very fortunate to have universal transfer of images throughout our hospitals. We are leading on the roll-out of a national laboratory system and we are second in the queue for what we are doing on integrated maternity and neonatology ICT. We are not close to having a comprehensive clinical record system, which we would all love, but are aware that many countries have done this badly and had to back up. We are on track to get it right. It will take years and a commitment of investments, but there is a crying need for it.

I ask Ms Day from the Ireland East Hospital Group to respond to the general questions.

Ms Mary Day

I concur with my colleague, Dr. O'Reilly, on the income targets set. There are very good processes and they have developed over the years to ensure we get the best value and best targeting with regard to meeting the stretch income targets for the group. We do not pull back services. When looking at meeting our budgetary allocation at the end of the year, we tend to look at non-clinical rather than clinical. Perhaps Mr. Woods from the HSE would like to comment on the income targets.

Ms Day said she looks at non-clinical areas, which is good and is progress because at least we know someone will be looking at something, but what does she mean by non-clinical areas? My experience of the health service is everything that could be cut was cut with regard to staying away from service delivery. All non-pay elements that could be cut were cut. I do not know where Ms Day would find additional savings.

Ms Mary Day

When I speak about non-clinical I mean looking at efficiencies with regard to laboratory costs and drugs spend. In respect of some of the pharmaceutical products we use, some biosimilars are coming onto the market that do exactly the same job but are cheaper.

With respect, why would Ms Day not get them anyway?

Ms Mary Day

In fairness, these biosimilars are just coming onto the market. Much research must be done before they come onto the market to ensure the effectiveness of these products. Once the pharmacies and laboratories in the group hospitals become aware of them we speak to our clinicians about ensuring we get the best value for the spend. There is an accountability issue, which is something Dr. O'Reilly has already has mentioned, which is absolutely right. We are accountable for the services we deliver. Of course we look at areas where we can bring in efficiencies, such as laboratories, radiology and drugs spend.

This strikes me as something that should be done anyway.

Ms Mary Day

We are doing it anyway.

Would Ms Day not have factored into the budget for the year potential savings from generic drugs?

Ms Mary Day

Absolutely, when we are given a budget allocation at the beginning of the year we undertake to deliver services within the budget allocation and we look at a cost containment plan to do this. Most of the cost containment plan involves looking at non-clinical areas. Deputy O'Reilly is correct that when we look at where we are in 2016, much of the fat has been taken out of the system. We are looking at being innovative in how we deal with procurement processes and deliver efficiencies. This is where the group comes into its own.

There is more leeway now, with wider availability of generics which may not always have been there.

Ms Mary Day

With regard to bed capacity, very low numbers of beds, only 30 to 40, are closed in my group due to staffing. As for whether it is due to physical or staffing causes, I would argue that when we look at bed capacity it is about having the right bed in the right place for the appropriate patient. We have done a lot of work in recent years on reducing the length of stay in acute hospitals. We need to look at having sufficient rehabilitation, reablement, step-down and transition beds. We need to see patients being taken from the acute system into appropriate beds. This is not just looking at how we develop our bed capacity but also our processes. In 2016 no patient should be signing a fair deal application form in an acute bed. Going into a nursing home is one of the most important decisions an elderly patient will make in his or her lifetime. With regard to looking at bed capacity modelling, we need to examine length of stay, processes, having the right beds in the right place for the appropriate patient and pathways to deliver this.

The recruitment issue also involves retention and workforce planning. One of the first things we need to do is look at workforce analysis throughout the group and whether it has the right number of people to meet the service delivery. In Wexford we have begun work on a very thorough workforce analysis in the hospital, which will be rolled out to our level 3 hospitals and then into levels 2 and 4 hospitals. Over the years we have not been that good on having the right numbers to deliver the services. From a nursing home point of view, the Department of Health is doing very thorough research on having the right skill mix. Retention is very important, and this is where the groups can deliver good strong initiatives. In the Ireland East Hospital Group the universities play a big part in training and education. In the Mater hospital and St. Vincent's University Hospital we want to deliver two academic hubs, which will link in with level 3 hospitals and deliver education and training to staff delivering care at the bed side.

As is the case with Dr. O'Reilly's hospital group, ours has a mix of statutory and voluntary hospitals. It would be helpful if we had a single recruitment entity in the group as we could recruit for the group. This should be part and parcel of future legislation. At present, statutory hospitals recruit under the HSE arm. We have six voluntary hospitals with their own boards which recruit. Of course as a group we have an employment control framework, but a single recruitment entity would give us flexibility. We are looking at developing a nursing bank throughout the group. If we had this, a nurse living in Wexford working in St. Vincent's University Hospital could take a shift in Wexford on his or her day off. This is the type of flexibility we would look at. It is all about having a single employment authority.

What about primary care structures generally?

Ms Mary Day

We have really embraced primary care. The point is absolutely correct that there has to be a shift in patient pathways in respect of how we integrate primary care with the acute hospital sector. This time last year, we were very fortunate in that we have the Carlow-Kenny model in our group's area. We have a primary care physician, Dr. Ronan Fawsitt, who not only chairs the process but also sits on our Ireland East Hospital Group executive team. We set up local integrated pathways in a year in Wexford, Mullingar and St. Columcille's. We can really see the benefit of general practitioners working with the acute hospital sector and talking about patient pathways and how to move patients from the acute hospital side into primary care. It is also a question of how valuable care can be provided with the lowest complexity and in the right place. It is always about providing the right care in the right place at the right time.

But the group does not have a role in determining the budget between primary and secondary care.

Ms Mary Day

I do not have a role. That is a good point because, in fairness, it is not all about the structure. It is about the pathway and how the money flows with the patient in regard to the delivery of the care within that pathway. What we are doing within the group is working with the general practitioners on identification. We have actually put some initiatives in place in this regard. For instance, there is movement in certain areas. In Kilkenny, in particular, the emergency department is very much a GP-led service. One comes in with one's GP letter and one is triaged by one's general practitioner. The general practitioner is one's senior clinical decision-maker. With regard to the budgetary piece, it is a separate stream that comes from primary care positions.

What is the position on IT?

Ms Mary Day

As with Dr. Susan O'Reilly, I advocate having a very good national leader for ICT. We have some pockets of really good ICT. St. Vincent's and the Mater hospitals, for instance, have good ICT, but these are bespoke models. What we want to do is deliver an ICT model involving the development of ICT that can connect in with level 3 and level 4 hospitals. One could even consider portal technology in the short term regarding how data can be brought out from the system. We are examining all our ICT across the group at present. There is work across the level 4 hospitals. It requires investment. We have been bereft of that investment in ICT over the years. There is an opportunity to work with universities on this. We spoke to a lead in Southampton, for instance. He was chief informatics officer. He worked in the University of Southampton and actually delivered his role within the trust. He was the main conduit in regard to how one can take the data and expertise from the university and apply those to service delivery.

I ask Ms Hardiman to respond to the general questions.

Ms Eilísh Hardiman

I can confirm that the Children's Hospital Group plans to break even in 2016. We do not plan to make any service cuts. We have a unique issue in regard to income. I refer to the policy contradiction whereby the position on cards for children aged under six is such that children who attend, some for highly specialist services, do so under those cards. Previously, they would have done so privately. We have lost our ability in this area. We are working with the national acute hospital office to raise this as a formal issue so hospitals will not be penalised where there is a policy position that actually has an impact on the income that was generated by paediatric hospitals in the past.

With regard to the under-six cards, is Ms Hardiman referring to GP visit cards?

Ms Eilísh Hardiman

Yes. Heretofore-----

What are the implications of that?

Ms Eilísh Hardiman

If they had private cover, they could come in and use the oncology service, the national services. Now that they are entitled to a card, they use it and do not come in privately.

The GP visit card?

Ms Eilísh Hardiman

No, the sick cards.

I beg your pardon.

Ms Eilísh Hardiman

We fully support what those concerned are doing, but it means that the income line we had in the past will continue to decrease.

We have installed an electronic system to examine our income collection. I refer not only to private health care services, but also to road traffic accidents and ED cards. Going purely electronic has actually generated better income for us than in the past, certainly this year.

With regard to bed capacity, we have 17 beds at the moment that are not in operation but I heavily caveat that. Fourteen of them are of very limited use. They are in the basement in Temple Street and there is no lift. We tend to open them up on a temporary basis as a discharge lounge during the winter when have peaks in emergency department activity. We have three in Crumlin. These are very small, cubicle-type beds. We tend to use them. We have very little capacity to open up new beds within the children's hospital.

With regard to ICT, I have stated very clearly that the hospital is identified to be open as a digital hospital. It is planned that way, as are the workforce and patient flows. The hospital is designed that way. We have a burning platform as a health system to identify when we will make decisions about the electronic health care record, in particular, in addition to other electronic systems. That is coming very close because the business case identifies, for the children's hospital, the need to have the electronic health care system in place. It can take three to four years to implement that type of system.

It is critical for the network that we plan. Already, our consultants in Temple Street and Crumlin go to Cork, Limerick and Letterkenny with patients. It involves charts in cars and it is not the way to deliver services. We need to move to having one system, with data available in the right place so the right people can be supported to deliver the right care locally. That needs to go right out to GPs. As a strategic direction for the next ten years, it is a critical enabler to allow us to become more sustainable. There are huge inefficiencies in the system purely because of paper records.

With regard to working with community services, we work with all the community health care organisations in Dublin, but also nationally. Our long-stay issues pertain to children with complex care needs. We have very small numbers but they can remain in our hospitals for a really long period. One may have heard parents talking about this issue.

What we have developed with our community and social care personnel, and sometimes with Tusla, is a pathway for complex care needs children. Each time, it goes out to whatever community it is based in. It is usually about transferring children with tracheostomy and very complex care needs requiring 24-hour services care in the community. In recent years, it has not been a funding issue. It was perhaps two years ago but there seems to have been progress on this, which is positive. The community services do find it a challenge to get staff on a 24-hour basis to manage very complex care needs. We work closely with them and train them. We send our nurses out to train them and to try, as much as possible, to move the children out of the acute hospitals in Dublin, mainly to locations outside Dublin.

On recruitment, I will give Dr. Martin an opportunity to talk about what we do from a consultant's perspective.

Dr. Ciara Martin

From 2009, we have had a common contract such that any hospital consultant appointed in one of the three children's hospitals is appointed to the future children's hospital also. Most of those appointments have a cross-city dimension. We have a number of working groups set up. We have secondments at nursing and administration levels between hospitals. Where a hospital may have a shortfall, we second staff from other hospitals. There is a joint junior hospital recruitment policy across the three hospitals. We run joint interviews. Our laboratory managers work across the three sites also.

Ms Eilísh Hardiman

With regard to the specifics on trilocation, trilocation is the optimal objective for the campus but I am cognisant that my colleague behind me is actually accountable for the Coombe services. I am really pleased that the Minister attended a meeting of the Joint Committee on Health on 10 November last and committed to a process to begin the planning for the move of the Coombe to the site at St. James's. We previously made a presentation to the committee. My colleagues from the development board have outlined that it would probably take two years to design the new hospital and get it through the planning process. It would probably take two years to build, and then it would take probably three months to actually commission it. That is the timeline once the decision is formerly made to start with the design brief. That would actually fall into the timeline for the completion of the children's hospital.

I thank Ms Hardiman.

A number of specific questions were posed for the South/South West Hospitals Group, in addition to the general ones. I invite Mr. O'Callaghan to respond to them.

Mr. Gerard O'Callaghan

One question was on our financial targets. This year budgets have, for the first time, been based on the rate in the previous year, which is much more practical. Instead of getting a supplementary budget at the end of the year, we get figures in the middle of the year, and if we wish for certain targets, we can have the money rolled over to the following year. The south-south west region is on target so we do not have any plans to cut services at this time.

On capacity, there are both physical and staffing issues across our group. At the moment, 16 beds are closed, of which six are in Cork University Hospital, CUH, and ten in Waterford which are staffing related. Of the six in CUH, one is an infection issue which will be cleared up in a couple of days and there are a few bedclothes issues. The number is small and there are extra beds elsewhere in the hospital. A big challenge for us is the issue of theatre nurses and this has had an impact in recent months, leading to a lot of theatre work being put off. We do not have any beds closed that cannot be reopened easily.

I was asked about recruitment, and we have done a lot of work with UCC on education. We commenced an MSc course in physiotherapy because we do not recruit or train physiotherapists in Cork and it was an opportunity to create those positions. It allows people to have an affinity with Cork hospitals and more physiotherapists will be available going forward. We are also discussing radiography services and are hopeful that we will get an MSc in radiography off the ground in the next two years. In this way we are hoping to address staffing issues in the areas mentioned. Nursing is also a big area for us.

Is recruitment done as a group or by individual hospitals?

Mr. Gerard O'Callaghan

It is done as a group for our statutory hospitals and consultants, with our two voluntary hospitals doing their own recruitment. We are trying to introduce more flexibility for nursing. It varies between hospitals so we are trying to standardise what goes on across the group as well as having international recruitment to increase our numbers. We are recruiting but people are leaving as quickly as we are getting them in, which has been our problem. There are a couple of issues in regard to medical group recruitment. In our big geographical area the somewhat peripheral hospitals, namely, Kerry, Clonmel and, to some extent, Waterford are having difficulty recruiting consultants in certain areas. The cost of locums is twice that of hiring someone normally, so we are working hard to improve the situation. If we do not get permanent consultants, it becomes more difficult to recruit junior doctors, who do not want to work with these people. In addition, one needs accreditation for training but one cannot get that without a consultant. It is a catch-22 situation but we can address the financial issues by recruiting consultants to some of these hospitals. We are doing a lot of work behind the scenes in this regard. We are trying to get non-consultant hospital doctors, NCHDs, working in the peripheral hospitals as well as in the larger hospitals, and that should help the situation. Our locum costs in Kerry and Clonmel are extremely high.

We work with two community health care organisations, CHOs. CHO 4 is purely Cork and Kerry, which is ideal for both of us, but CHO 5 in the south east works with Ireland East and ourselves. It is working quite well and we have established fairly good management groups. Over the winter it is challenging to get people around the table to ensure quick discharges and to get community intervention teams and home care packages in place. We have almost daily communication with our friends in the community. It is not all plain sailing but there are structures in which we can work through the situation.

Has the group put those structures in place?

Mr. Gerard O'Callaghan

Yes, we have set up a steering group across the group with three subgroups below it, one dealing with access to hospitals, one with throughput and one with egress. We have representation from consultants as well as all disciplines on those groups. We got these off the ground last December and, with the winter season coming, we have daily teleconferences on how we can move things on.

Does the hospital group have any community representation on those three committees?

Mr. Gerard O'Callaghan

Yes, they actually co-chair most groups.

Dr. Orla Healy

I will deal with three points. One was on catchment, one was on governance arrangements and the third was on the academic health centres and the research and innovation environment.

Hospital groups were set up with a governance and management structure and did not prescribe catchments, nor have we have prescribed catchments for our area. We have looked at population bases and at where people go to hospital and people generally use their local hospital. As a group we are self-sufficient and provide over 95% of the care for our population. Waterford is a model 4 hospital providing tertiary level services across a range of specialties. There are particular specialties such as nephrology, which operates across the entire former south-east region, and orthopaedics, which also operates across the entire former south-east region and draws from outside the region, as does the national cancer control platform, NCCP. The population base has not been interfered with by the establishment of hospital groups. The county populations are calculated at more than 800,000 but the catchment extends beyond that. The methodology used by Herity involved looking at the actual cardiology activity in the hospital and where patients came from and he extrapolated from that, which is legitimate for him to do. The remainder of specialties are drawn from the wider south east.

The point about pharma and academic health centres is part of the wider issue about developing an academic health centre model and fostering an environment of research and innovation within the hospital group. We do not receive direct funding from the pharma industry but we are working with our partner in UCC to develop an academic health centre model and we are looking at the health innovation hub and the clerical research facility. This point came up at the time of the development of the reconfiguration roadmap for Cork and Kerry. We have a very important pharma industry in the region which is a major source of employment in the region. It was suggested the industry use Cork for research and development and it was noted that, for clinical trials and research at the next stage up, the industry goes outside the region, back to the United States or elsewhere where it has access to wider patient bodies and patient populations. A group would have to offer a wider population and patient base to further that agenda. We are working towards that with our academic partner but it is not something we would do ourselves It is a matter for UCC through the health innovation hub and the clinical research facility. The question was not specific to pharma and another example from the reconfiguration of the health innovation hub, which was its predecessor, was the development of an electronic GP to outpatients referral system, which we piloted in Cork and Kerry and was subsequently taken up and rolled out nationally.

Deputy Brassil asked about cross-group governance arrangements and cross-group specialty working. We do not have these but we do want them. We are working towards them and, as we mentioned in our submission, we had 40 specialty group meetings across the group with a view to supporting the smaller and stand-alone units.

That is why we are working towards a cross-group directorate structure as well. We have started with maternity services. We are about to appoint a clinical director for maternity services who will embed the cross-group collaboration and co-operation for the specialty.

To be parochial, we need support in the areas of geriatrics and cardiology in County Kerry. The system Dr. Healy is speaking about would be quite beneficial.

Dr. Orla Healy

Absolutely. We are quite aware of it. The arrangements and clinical pathways are in place. We have managed clinical networks to a degree. We have our model 4 and model 3 hospitals. The pathways are in existence, but we need to work towards more cross-cover arrangements. We need to actively support smaller and stand-alone units, in particular.

I ask Dr. Healy to let us know if there are obstacles in making that happen. We have to get over any such obstacles if this is to work.

Dr. Orla Healy

I think that comes back to the autonomy of the groups and their ability to function as groups.

Deputy Barry asked questions about the centralisation of emergency services at Cork University Hospital and the possibility of a new hospital for Cork.

Dr. Orla Healy

I do not think we want to pre-empt the findings of the trauma report. Our view is that we would like a trauma centre to be located in Cork and that Cork University Hospital would have a lot to offer in that regard as a model 4 hospital with a full range of specialties. I accept that the emergency department at Cork University Hospital is busy. It has problems with trolleys. However, it gets through the patients and meets its nine-hour patient experience time targets. Despite the high attendance at the department, virtually no patients have to wait longer than nine hours.

Deputy Barry also asked about the closure of a second emergency department in the city. We have already closed one emergency department in the city and activity has been transferred as part of that process. The emergency department at Mallow General Hospital has been converted into a local injury and medical assessment unit. The throughput in those units is now at the level it was at prior to the closure of the two departments. The level of activity is more or less exactly the same. The same cohort of patients is being seen through a different model. The same is true of Bantry General Hospital.

The original reconfiguration plan for Mercy University Hospital in Cork provided for a move to a 12-hour model. It was subsequently decided under the acute medicine and emergency medicine programmes that a model 3 hospital can function either as a 12-hour or a 24-hour facility. It is not for us to pre-empt the findings or recommendations of the trauma report with regard to this site. I agree with Dr. O'Reilly that one cannot move to another model overnight. If such changes are to be made, one must have capacity in place.

Deputy Barry also asked about the new hospital for Cork.

Dr. Orla Healy

I ask Mr. O'Callaghan to speak about the new hospital for Cork.

Mr. Gerard O'Callaghan

There are proposals on the table. Local discussions are taking place at present. CUH and some of the other hospitals have made proposals. It has not moved beyond that stage. Deputy Barry is right. I remember discussing the same plan 15 years ago. It did not come to fruition. These plans depend on financial and many other factors.

Dr. Orla Healy

It needs to be pointed out that we are talking about an exclusively elective hospital. We have a very efficient model of an elective hospital in Cork. The South Infirmary hospital is now exclusively elective. It has high levels of activity. As earlier groups suggested, we need to differentiate between the types of services that are provided in hospitals so that we can provide elective care in a protected environment. We need to develop that because of the physical infrastructure of the existing hospitals in Cork.

Would the witnesses be prepared to comment in broad brushstrokes about the extra resources that would be needed to ensure the situation gets better rather than worse as a result of the centralisation of trauma services at Cork University Hospital? I put it to them that in the absence of massive extra resources being put into Cork University Hospital, such a move would almost certainly result in a disimprovement in services. Can they comment on the level of resources that might be needed to ensure there would not be a disimprovement in services in the event of all the throughput from Mercy University Hospital being put into Cork University Hospital, which already has overcrowding and other problems?

Mr. Gerard O'Callaghan

There is no doubt that serious investment in Cork University Hospital would be required. At the moment, we are looking at developing a helipad on the grounds of the hospital as part of an overall plan to improve the situation there. As Dr. Healy has said, no decision has been taken with regard to the other hospital at this stage. I reiterate that the creation of an elective hospital in Cork has made a significant difference for people on waiting lists, etc. There are no cancellations. All the orthopaedic work and all the ear, nose, throat, head and neck surgery is being done at the elective hospital. Between 8,000 and 9,000 day cases were being done at this hospital ten years ago, but over 30,000 day cases are being done there now. The creation of an elective hospital has been a huge success. When we moved the orthopaedic service from its previous location, the average length of stay for someone having a hip or knee procedure was ten or 11 days. That was reduced to five days within 12 months. Huge efficiencies can be achieved when everything is moved to a single hospital.

As we have been here for more than four hours, I want to bring the meeting to a close as quickly as possible. I ask the remaining speakers, Deputies Kelleher, Harty and O'Connell, to keep it very tight.

I will make some brief points. I raised some of my questions with the other hospital groups earlier. It is not that I have less interest in the groups that are before the committee now; it is just that the previous groups responded to my questions and I do not think the answers of the groups before us now would be very different. I would like to put my first question to Ms Day and her colleagues from the Ireland East Hospital Group. If they were given a pen and a map of Ireland, would they draw the Ireland East Hospital Group as it currently stands? I suggest that Our Lady's Hospital in Navan, which is north of Dublin, has just been thrown in there. It is probably more suited to the RCSI Hospital Group or the Dublin Midlands Hospital Group, but it is in the Ireland East Hospital Group.

Issues with other hospital groups arise in this context. I assume the strategic drafting and planning of the groups was done without any medical snobbery or interference or anything. Are all the hospital groups strategically drawn to ensure they are capable of delivering care at the most appropriate point? In my view, some geographical definitions that would have been considered more logical have been frayed away. I know we are not completely bound by geographical definitions, but it seems to me that there are outliers in some parts of the hospital groups. I can say honestly that the South/South West Hospital Group, which includes Cork, is a case in point. It was originally proposed that University Hospital Waterford would be a model 4 centre for the south east. That is a fact. Others then decided to plump for the Mater hospital and other hospitals. We now have University Hospital Waterford included in the South/South West Hospital Group and St. Luke's General Hospital in Kilkenny and other hospitals included in the Mater group. We have to be honest with ourselves as well. The hospital groups have to work with what they are given. I am asking about the delivery of services in the specific case of Navan. Mr. O'Callaghan might refer to Waterford as well, now that I have raised the issues there.

National plans involving the reconfiguration of services are published from time to time. Examples include the national maternity strategy and the trauma report. Do the hospital groups have the flexibility to be creative and imaginative in such circumstances? Do they always have to be prompted by the overseer of the national reconfiguration, as set out in national reports from time to time? What level of flexibility do the hospital groups have in that area?

I intend to raise the issue of recruitment and planning of personnel with Ms Hardiman in the context of the children's hospital. When a farmer ploughs a field, he knows he will sow it, tend it and reap it. In the health sector, we tend to build theatres and expand services only to realise we have no staff.

We must then run around half the world trying to find staff. Why is there not a seamless process in place for the conception, creation and delivery of the service? It is currently done in a stop-start fashion. At Cork University Hospital, for example, psychiatric services were moved without personnel being available. Why is such an irrational approach taken? Perhaps there is a logical reason for doing so but I cannot get my head around it.

What is the reason for the serious difficulties being experienced in recruiting theatre nurses? Is it that we are not producing sufficient numbers of theatre nurses, having lost many of them in recent years, or is there a global shortage of theatre nurses? What are the various hospital groups doing to expand training capacity or is this a matter exclusively for the relevant national bodies?

The Children's Hospital Group will clearly face major challenges in trying to bring together the three children's hospitals in the years ahead. The building of a new children's hospital is another exciting challenge. Should we be worried about the delivery of hospital services for children in the period before the new national children's hospital is completed? I refer, for example, to the issue of scoliosis. I recently met some of the families involved and some of the stories I heard were deeply troubling. Ms Hardiman is aware of these issues and I am not arguing that the Children's hospital group is not sensitive to them. Families have indicated that a theatre was commissioned but there is now a shortage of theatre nurses, which means the theatre is opened as a general theatre. What problems will the Children's hospital group face in the period before it achieves its goal of having a beautiful children's hospital on the St. James's site? Is it being squeezed a little more in terms of the delivery of services than would be the case if the new hospital were not being built?

Deputy Mick Barry referred to University Hospital Waterford and the fact that it is a model 4 facility. People in the area are concerned not only about the cath laboratory at the hospital but also the possibility that the hospital will lose services to the other model 4 facility in the region, Cork University Hospital. They are concerned that it may be run down as opposed to enhanced.

Obviously, having hospital groups delivers significant added value. Dr. Susan O'Reilly alluded to this in her opening statement. Recruitment is still a problem and while hospital groups make it easier to recruit staff, they do not resolve all the problems in this area. I ask Dr. O'Reilly to address the problems in recruitment, for example, bringing recruits out to the periphery to staff smaller hospitals.

I am aware that there is added value in integrating hospitals and information technology systems. How close are we to achieving a single, integrated digital patient record that can be accessed by hospitals and primary-care providers?

On governance structures, what are the problems facing the groups? Are they administrative, financial or logistical in nature? Governing several sites is obviously a problem. Could these problems lead to a consolidation of hospitals in the groups in future?

How active are hospital groups in integrating with primary care? Given that primary care will be the foundation of the health system in the future, it must be integrated with the hospital groups. How actively is this being pursued?

Do any of the witnesses believe that the lack of legislation on hospital groups is delaying progress? Have the hospital groups reached a roadblock that is preventing progress?

With regard to the hospital groups, is it essential to have an academic university and research base attached to each group? I have a major concern that the hospital groups are not aligned with community health organisations and that we may be spawning mini-HSEs. When I hear that recruitment takes place in one way in voluntary hospitals and in another way in other hospitals, I wonder why there are no streamlined, comparable and replicable models available for all the groups? It seems astounding, given the population base, that this is not the case. Is there a reason we cannot have a set menu of services for each of the seven hospital groups? While I understand that Beaumont Hospital will continue to specialise in neurosurgery and that not every group can provide neurosurgery, I cannot understand the reason for the profound differences between each of the groups. When policymakers are considering this issue, we need to have figures that we can compare to enable us to plan for the future.

Has the board of each group quantified the amount of work being done in the group by the private hospital sector? What percentage, expressed in money terms, of the work being done in the hospital group is being done by private hospitals?

Last week, at a meeting of either this committee or the Joint Committee on Health and Children, we heard that a report had just been done on recruitment. I cannot recall the name of the person who spoke about the report. She was seated by Mr. Liam Woods at the meeting in question. Have the people who are in charge of the hospital groups seen the report in question? Surely they should know about a report done on recruitment when they are discussing the issue.

On the Deputy's second-last question, major issues arise with regard to the governance and ownership of the various elements of the health service. We have inherited a system with a significant number of voluntary hospitals which operate independently. There is no doubt that serious governance issues arise in this regard and that these issues need to be addressed. They complicate the creation of a single structure in terms of the groups. I ask Ms Hardiman to respond first.

Ms Eilísh Hardiman

The group structure is very much drawn for us. We are providing for the greater Dublin area, which is across all of the community health organisations and nationally for almost a quarter of our services. We have to function across whatever structures are put in place. For us, it was about developing pathways around complex care where we need to reach out. I have discussed this issue with my group CEO colleagues, whereby instructing their services within their regions, we work collaboratively. This means, for example, that our clinical lead would work with the clinical director for women and children in Cork on how to develop services collectively.

One of the fears that we have in the Children's Hospital Group is that if we do not work collaboratively to support services locally, parents will believe, on the basis of the good road infrastructure, that they have to come to Dublin for paediatric services. This is not the case because the vast majority of services are delivered locally. However, there is considerable inconsistency in this regard. If one takes emergency department attendances in paediatrics, which we have measured, the difference in admission rates varies from 8% of those who attend being admitted in two of our hospitals to 48% of attendances being admitted in another hospital. I have been quoted on this previously but children do not fall out of trees differently in Dublin than they do in other areas. We must work collectively on why such a variation is in place.

We have an over-reliance on the acute hospital system. In the next year, as we roll out the model of care, we expect to work with our colleagues in the other hospital groups to reconfigure services in order that they are less dependent on inpatient beds. Resources should be realigned around consultant delivered services to achieve more effective decision-making and keep patients outside hospital and supported.

Regarding the flexibility to configure, there is flexibility to work within that because there is consideration of how to make one's existing resources work better. However, this takes time to plan, and some of it requires investment in capital structure to bring it to fruition.

Regarding recruitment and workforce planning and retention, we have developed a workforce plan for the next five years up to 2021. It is a challenge, but we have identified in the plan the supply elements we need to put in place and the changes in roles and positions which heretofore may not have existed in the system but which in five years one would expect to be in place. The changed roles and positions replicate very well-established posts in contemporary health care systems. For example, nursing being an area of common concern, a nursing workforce planner is coming onto our team and we have developed a paper with the nursing policy unit to work with all the universities on increasing the number of nurses going through children's nursing. We are producing nurses, they are all getting permanent contracts with the children's hospitals, and our colleagues in Cork can get permanent contracts with us, but we are not producing enough. During the 12 years in which we have been moved to the degree system for paediatrics, we have not increased the number of students on these courses, so we will present a plan of how and what we need to develop.

I think my colleagues would agree that the other issue is theatres. We see new roles such as an operating theatre department developing. We must create these new roles. They sometimes can be seen by some other colleagues in the system as a challenge, but they are well-established in contemporary systems and are already in place in the private sector in Ireland. They must be introduced as a way of relieving the pressures we find. Nurses generally want to go out and work, but some of these theatre-type roles are very repetitive, so there needs to be consideration of roles in which staff are specifically trained to deliver these services but in a safe way.

We have a huge challenge in the children's hospital in that much of the emphasis has been on the building and too much on the issue of its location. We know and understand the concerns and we would like to work with the families raising them to address them because we believe we can and we know we have a responsibility to do so. However, our focus within the Children's Hospital Group is now increasingly on successfully merging the services. We work very well with the boards. We meet every fortnight with the four CEOs, the four clinical directors and the group management team. We have a structure in place and a plan for our staffing, a plan for engagement and a plan for how we will move from where we are now over the next five years. However, this is resulting in pressure and it requires resources. One does not introduce a change as significant as this, that is, a 473-bed hospital with two new paediatric outpatient urgent care centres in the periphery and a digital hospital, without having resources to implement the change. All our colleagues would probably concur on that. We must keep the ship going. At the same time, many people need to be employed. This week 200 of our staff in the children's hospitals are engaged in designing the 6,000 roles. They are coming out of those services and we are trying to make sure that the work is carried out at a convenient time in order not to impact services. The potential to impact services will only increase when we move to the really hard work, namely, standardising how we deliver services across the system. This requires resourcing, which we have included in the building of this project.

Scoliosis services are a long-standing issue in children's health. I heard about it before I came into my post. We have managed to secure funding to address it. Our challenge is that while we have the consultants in post, nurses for the ward areas and anaesthetists, we have seen a huge turnaround in our theatre nurses. Some of them moved out of Dublin when posts were offered in the rest of the country, but we had as much as a 25% turnaround in nurses in our theatres, which has resulted in rolling theatre closures and the inability to open the new theatre. Our plan is international recruitment because there is no resource available within Ireland to address this. Our directors of nursing are going out next week and we have lined them up with a plan to have recruitment open by the second quarter of next year. In the meantime, we have an opportunity to consider what services in the old theatre could open up into the new theatre so that the staff and patients would at least be in new theatres. The new theatre should not be left sitting there as it is fully commissioned. We will be outsourcing some of our services between now and the year end with the funding that has been provided for waiting lists to address this. Probably more importantly, we have engaged with the three advocacy groups and they have committed to come on board with us to co-design the services. We want the same as what they want. We do not wish to be seen on opposite sides. Our consultant staff are meeting with us to identify consultants, nurses and people with process and lean experience to work with the advocacy groups to design how to work around this challenging issue. It will take us about a year to get this into a better spot from its present position.

I ask the other witnesses to pick up very briefly on the outstanding issues such as the question of voluntary hospitals and how they work and the role of private hospitals within their group area.

Dr. Susan O'Reilly

I was astonished when I landed in Ireland six and a half years ago by the complexity of hospital governance. Even in the public sector, between voluntaries and statutories there is a two-tier system. The voluntaries have been very effective over many years with their boards in building the resources they need to get the jobs done. As a consequence, there is a balancing act here. Having said that, our voluntaries are highly effective. They have strong legislative authority and strong boards, and I support their carrying on in that role for now. I am not in the business of asking for the decommissioning of that approach because one would have to be 100% confident that what one will do in the future would be better and stronger. One must be very thoughtful about that. We have worked very effectively in collaborating in governance structures with the voluntaries, particularly around elements of policy and patient safety, instead of imposing certain governance structures to try to interact with them. That has been a win.

Recruitment is a huge challenge. We have lost hundreds of thousands of hours, weeks, months and years of experienced nurses from the country and we have lost younger nurses. Now that we are beginning to recruit effectively, both directly through the HSE for the statutories and through the voluntaries that are assisting us - and this is where we are collaborating very well - we find very young nurses coming in who have much less experience, need more training and take a lot of maternity leave. We have a challenge at one of our hospitals now that 20% of our midwives at any one time are on maternity leave. We cannot backfill them from agencies. This is a huge issue and it concerns recovering from almost eight to ten years of being in a very difficult recruitment position. The same goes for consultants. I think consultants will be attracted to work in highly functional environments in which they can do the job well. It is not all about pay, although pay does matter. It is about the environment, the team, the capacity, the career development and the opportunities for research and teaching, being part of an academic teaching unit, which is what we are. There are excellent strengths in St. James's, Tallaght and the Coombe in particular, together with Trinity College Dublin, and these are key to bringing people back on board. They do not only want to care for patients; they want to do many other things too. We are now in a position that we know full well that one will not get the best permanent staffing competing on extremely low-volume jobs on the periphery. One must either move that complex low-volume patient population to where they can get the care or build joint appointments, particularly for surgery, where people can attend for a certain number of days a week. It is a complex process. I do not find the voluntary approach in the mix in our group particularly difficult. I love what is happening in the children's hospital. It is a model for the future in that there is a goal and a direction around legislative authority. However, it must be done extremely thoughtfully before one dives off the deep end on any of this.

Did the Chairman want me to address one other point?

I asked a question about the role of private hospitals.

Dr. Susan O'Reilly

First of all, occasionally, our voluntaries purchase a certain service in a very small volume. For example, they were having difficulty getting urology surgery done and they have purchased some private insurance. We understand what they spend. It is a fairly small volume in the scope of their budget. We typically get the rest of private services through NTPF funding. We do not control it and it is not in our budget but we know how many patients go out. We have a general sense of what is spent, but what comes to us is more in the line of national data. There are some creative ideas, one of which we are considering with Tallaght hospital. Tallaght hospital is very keen to provide some endoscopy services through the public providers but by purchasing private space and private support for so doing. That is a different model we can follow.

Intrinsically, to get stability in health care, we should not just ping-pong into purchasing through the National Treatment Purchase Fund, NTPF. We need to resource our base to do the work. It will take some time to get there. The NTPF outsourcing is a very good safety valve for certain care, particularly elective surgery, right now. It is not a great model for medicine. People often need to come back to base to have a liaison between their community GP and the hospital for long-term care.

Could Ms Day address the issue of Ireland East hospital group, specifically in respect of Navan?

Ms Mary Day

In response to Deputy Kelleher's question about the structure of the hospital group, I would suggest that there are two elements - structure and implementation. When I look at the structure of my group, my key component is how I implement this structure. I use connectivity for that. The Ireland East hospital group is in a unique position in that it has two large teaching hospitals, three model 3 hospitals, two model 2 hospitals and a number of key voluntary specialty models. To answer the specific question about Navan, we talk about how smaller hospitals need larger hospitals for safer patient care and the right patient in the right place at the right time, which is true. Likewise, larger hospitals need smaller hospitals to deliver the appropriate care. The Mater hospital never had the opportunity it has now in relation to Navan where we can deliver elective, non-complex surgery within Our Lady's Hospital in Navan because we never had that construct until now. We are doing that in Our Lady's Hospital in Navan. We are looking at surgeons from the Mater hospital going to Our Lady's Hospital in Navan and delivering surgery there. Not only does it provide that connectivity, it also gives a boost to Our Lady's Hospital where expertise can be seen coming down that connects them to a much larger connectivity model.

The point is that in sending patients to Navan, the hospital group is passing Beaumont Hospital. There does not seem to be much logic to the group's-----

Ms Mary Day

We would send our elective patients from the Mater hospital to Navan so this would enable us to meet our elective waiting lists.

I know, but why does an overlap between the different groups exist? There does not seem to be much logic to it geographically.

Ms Mary Day

I missed that point.

In the groups.

Ms Mary Day

I believe there is logic in respect of how we make Navan work for the Mater hospital and how the Mater hospital enables Navan to provide safe, good quality care. In respect of roadworks, the distance from Navan to the Mater hospital is probably under an hour. If the right care is put-----

At integration pace, it is impossible to have that.

Ms Mary Day

We are integrating very effectively with Navan. We look at delivering the less complex surgery there and our surgeons going to Navan. We are also looking at non-consultant hospital doctor rotation with Navan. The clinical lead in Navan very much links in with the Mater hospital but as part of the entire group. I suggest that we have quite good integration, but it is important that we put a good implementation model in place to ensure we have that connectivity to make it happen.

Just to clarify, when we talk about integration, we are mainly talking about integration between primary and secondary care, not integration within the group.

Ms Mary Day

Maybe I misunderstood the question. I thought the question was more about the geographical location of Navan compared with the Mater hospital

For example, there is talk that the emergency department in Our Lady's Hospital in Navan will eventually be moved to Our Lady of Lourdes Hospital in Drogheda. That is fairly loose talk around the place and I am quite sure it is policy behind the scenes but we will find that out eventually. It is just the location of Navan itself. It is in County Meath and is nearer the RCSI group. It is certainly nearer the Dublin Midlands hospital group. When the boundaries were being drawn and the hospital groups put together, it looks like a bit of an outlier in the context of the rest of the group. Equally, we know that this group was formed because of resistance from hospitals in Wexford and Kilkenny because it was originally meant to involve the south. That is not Ms Day's concern because she is the CEO of this new grouping. The reason I am asking these questions is because this is meant to be about a strategy for the next ten years.

Ms Mary Day

Absolutely.

If we cannot even get the hospital groups right, we may as well all go home now.

Ms Mary Day

My answer to that is that in respect of the pieces of work, what we have been doing with Navan and the Mater hospital and ensuring that this connectivity is successful, and I would suggest that we are doing a huge amount of work to make that connectivity successful, Navan is in the right group. Navan is as important to the Mater hospital as the Mater hospital is to Navan so we are providing an enhancement model for Navan. We have excellent hospitals and the right level and number of hospitals within this hospital group. Deputy Kelleher asked whether there was any strategic intent. I would suggest that there is strategic intent in the Ireland East hospital group because long before the hospital group structure was created, the Mater hospital, St. Vincent's hospital and UCD had come together to look at forming an academic health science model. The core of that group is two major academic teaching hospitals with a university leading out care across the pathway. Mr. O'Malley may want to comment on the Dublin Academic Medical Centre.

Mr. Kevin O'Malley

We did not see the hospital groups coming down the road but, eventually, that was the basis on which it was set up.

To clarify, this refers to the Dublin Academic Medical Centre?

Mr. Kevin O'Malley

Yes. It is a tripartite grouping of UCD, the Mater hospital and St. Vincent's hospital that has been in place since 2007. It is an incorporated institution. As regards Navan, to me, it is all about the clinical links. There have been significant clinical links and referral pathways over the years between Navan and the Mater hospital. Being a bit presumptuous or greedy, I would have said we were a little surprised we did not get Cavan included in our group as well because of our joint appointments between the Mater hospital and Cavan. We were not surprised by the inclusion of Navan.

I will say a few more things about academia and the chief academic officer, CAO, a point raised by Deputy O'Connell. I do not think any of our groups feel that the academic part of it is anything other than highly important. In our submission, we stressed our ambitions to set up an academic health centre. We cannot do that without an ambitious third level institution behind us. Our CAO has been integral to everything we have done so far and is embedded in the management of our group on a daily and weekly basis. Unfortunately, we are going to lose him as he is about to become president of the University of Limerick. For us, the appointment of his successor will be critical to how the university and the hospital group go forward. Trying to get the governance between the hospital group and the university right is very difficult, but to us it is critical.

I will make one last remark about medical recruitment, which is a recurring theme. Nationally, the squeeze is on model 3 hospitals. I am happy to say that within our group, competition for the model 4 consultant appointments has been relatively robust - maybe not quite as good as it has been in the past but relatively robust. If we can get the linkages between the model 3 hospitals and the model 4 hospitals properly organised, and we have already appointed about half a dozen different people with joint appointments between the Mater hospital or St. Vincent's hospital and a peripheral hospital, it will make the consultant appointments in the model 3 hospitals far more attractive. There is a consultant appointment committee in our group. Every new and replacement appointment goes through that committee and is looked at from a group point of view as to whether the sessions should be reconstructed a little, so a Mater job might give up a quarter of its time to Mullingar and so on.

Could someone respond to Deputy Kelleher's question about the status of Waterford?

Dr. Orla Healy

The hospital group's report reiterates that Waterford is a model 4 hospital. We intend to maintain Waterford as a model 4 hospital, develop it and have at least one anchoring specialty for the group based in Waterford.

I do not see the group structure threatening Waterford hospital's status in any way, certainly from the perspective of the hospital group.

I have addressed the point made about the catchment area. The hospital continues to draw from a wider catchment for certain specialties. We see the group structure as providing an opportunity to support the development of specialties in Waterford hospital, rather than the reverse.

I ask Mr. Woods to be very brief. I hope we will be able to schedule a meeting in two weeks time.

Mr. Liam Woods

To respond very briefly to Deputy Kate O'Connell's questions, as I understand it, in HR terms, the document referred to is shared, but I can ask Ms Rosarii Mannion, head of human resources, to confirm this. Second, a directory of services is being prepared. It will describe the services available across the country and where and when they are available.

A directory of services for whom?

Mr. Liam Woods

Deputy Kate O'Connell asked whether a detailed set of information could be created for Deputies on services available across the country, to be used not only in their policy-making role, but also I presume in their constituency role. It is being prepared within the HSE.

My final observation is that the approach to integrated primary care and acute services to which the Chairman referred is not necessarily mitigated by having groups in their current form, although I accept that there are higher level considerations in that regard. The population clusters of 60,000 to 90,000 that are pivotal for the approach to primary care services are smaller than those for both CHOs and hospital groups and can work effectively in providing shared care services in dealing with chronic conditions and older persons. That is where we are headed strategically.

In fairness, I think the jury is out on that issue which is raised with us week after week. We know from our constituencies that it is problematic, to say the least.

I thank the delegates for their time and appearing before the committee. As I know that they have been here since 9 a.m., it has been a long day. I thank them for their presentations.

The committee adjourned at 1.45 p.m. until 9 a.m. on Wednesday, 23 November 2016.