Brian Hayes
Ceist:63 Deputy Brian Hayes asked the Minister for Health and Children her actions in recent months in the development of the new national tertiary paediatric hospital; and if she will make a statement on the matter. [18000/07]
Priority Questions.
Hospitals Building Programme.
I congratulate Deputy Howlin on his election to the Office of Leas-Cheann Comhairle. I have no doubt he will be an outstanding Leas-Cheann Comhairle and that he may be tempted from time to time to intervene inappropriately, given that he is a man with strong opinions on many subjects, including health.
There have been a number of important developments in regard to the new national paediatric hospital during recent months. On 8 March last, I announced the appointment of Mr. Philip Lynch as chairman designate of the National Paediatric Hospital Development Board. I recently signed an order establishing the National Paediatric Hospital Development Board on a statutory basis. The development board held its inaugural meeting last Monday.
The principal functions of the board will be to plan, design, build, furnish and equip the new national paediatric hospital in accordance with a brief to be approved by the Health Service Executive. The brief will set out the preferred model of care, the core services to be delivered at the new hospital and the additional range of services to be provided in an urgent ambulatory care setting, taking account of international best practice.
The HSE is being advised in this context by Rawlinson Kelly & Whittlestone Limited, RKW, an established UK-based health care planning company. In finalising its work RKW, together with a panel of international advisers, has arranged a series of meetings later this week with key stakeholders, including the three paediatric hospitals.
The development board has begun the process of putting in place the necessary project support structure to progress the development. I am aware that the position in regard to the provision of paediatric services in Tallaght Hospital has been a matter of concern for the hospital and the local community. I was, therefore, pleased to confirm recently that a major ambulatory care centre in Tallaght will be advanced as part of the initial phase of the new paediatric hospital development. This ambulatory care centre will offer a comprehensive and wide range of services to children, including an urgent care service, a major expansion in outpatient services and a significantly increased day surgery service. This followed an analysis of the current location of major paediatric populations in the catchment area for the new hospital and the need to minimise the travel time for children requiring access to such services.
The vast majority of current attendees at the existing children's accident and emergency department in Tallaght Hospital do not require admission and will continue to access their care at the ambulatory care centre.
I thank the Minister for her kind comments.
I would like to be associated with the Minister's kind remarks in wishing the Leas-Cheann Comhairle well and to assure him that we, on this side of the House, will support him in his difficult task.
I thank the Minister for her reply. She has confirmed to the House that RKW undertook, at the request of the HSE and her Department, to identify locations for the new centres? Why then did the Minister announce on 16 May last the development of a new children's care centre in Tallaght which many of us representing the local area believe is an attempt to substitute for the closure of our local children's hospital? Why did the Minister make that announcement before RKW had completed its work and was still involved in ongoing discussions with all the stakeholders? Did the Minister consult or inform Professor Drumm and the HSE of her intention to make the announcement on 16 May?
I thank Deputy Brian Hayes for his kind comments.
Professor Drumm informed me that that recommendation had been made. I acquired the information from the HSE. I believed it was important that it be put into the public domain as quickly as possible given the confusion caused by the misrepresentation of what was happening in this area. It was always the case, as the Deputy will be aware, that in addition to a national children's hospital, there would be ambulatory care centres. RKW believes that the major centre, which will be under the auspices of the children's hospital and will not be stand-alone or separate, should be located in Tallaght. It may well be that two further centres will be located in the greater Dublin area. However, that remains to be determined.
The Minister did not make an announcement in respect of the other two sites prior to the election.
They will not be major centres. There will be only one major centre and it will be located in Tallaght.
The Minister has confirmed to the House that she made an announcement prior to RKW's completion of its work in consultation with the stakeholders. That is a fact. The Minister has also confirmed that that information came from Professor Drumm which, I suspect, other stakeholders will be interested to learn.
On the now established development board, which will seek to bring the tertiary hospital at the Mater all the way in terms of development, will the Minister confirm that two of the three hospitals cited in the statutory instrument which she signed into law two days before the general election, when the House could not discuss the matter, have refused to nominate a person to the development board? As there is not unanimous agreement on the best location for the national children's hospital, is it not premature to advance? If the Minister's model of paediatric care in Dublin city and county is put in place is she satisfied that no child will die because two of the three existing 24/7 accident and emergency wards in Crumlin and Tallaght will be no more?
I am satisfied the model of care being put in place will deliver higher quality care to very sick children from the whole country. This is not only a hospital for Dublin. It is a hospital for the entire country. Between 40% and 45% of the patients will come from outside the Dublin area. This is the model of care that operates in the best children's hospitals in the world, such as those in Toronto, Philadelphia, Chicago and one being put in place in Manchester.
It is not true that the other hospitals have refused to nominate persons to the development board. Tallaght hospital wished to send somebody to the meeting last Monday. It said it had not chosen its representative on the board and asked if it could send a different person. A view was taken by the chairman that it would be better to wait until its representative could sit on the board.
On 8 March 2007, I made it clear that we would establish the development board. Mr. Philip Lynch was announced as chairman designate. He and I consulted the three hospitals affected regarding the appointments to the board. I made it clear that as soon as that consultation process was completed and the legal instrument was in place I would sign it. There was no question of that not happening. Nothing secret was done. The process began on 8 March.
Why does the Minister believe it appropriate to sign a statutory instrument two days before a general election when the House did not have an opportunity to debate or annul the order? Why did the Minister feel she had the right to make that decision two days before a general election? She also made the decision regarding Tallaght hospital one week before a general election when her own seat was at risk. That is not the way to do business. One does not employ a group of people to do a piece of work and gazump them while they are doing it.
As someone who tried to scare people in the Tallaght area I am sure Deputy Hayes was surprised at the outcome of the election.
The scare-mongering came from the Minister's side.
Deputy Hayes told the electors there would be no children's services for all of Tallaght.
I did not.
I saw his big hoardings.
I said exactly what would happen. I said the Minister was choosing to close Tallaght children's hospital. That is what is happening. The Minister will not get away with misrepresentation.
More than 80% of the children currently treated at Tallaght will continue to be treated there. There will be an increased volume of activity at Tallaght.
What will they do after 8 o'clock in the evening?
The will go to the secondary care centre in the centre of Tallaght.
With suspected meningitis? What will happen next?
If people have suspected meningitis they should be in that kind of centre. They should be in the primary centre.
If the Government believes, with the support of the Health Service Executive, that we should have a single paediatric hospital for very sick children it is appropriate that we go ahead with that. Among the people urging me to proceed was the chairman designate, who was keen to get on with the job.
Hospital Services.
Dan Neville
Ceist:64 Deputy Dan Neville asked the Minister for Health and Children her plans for dealing with the crisis that currently exists at Mid-Western Regional Hospital where patients in need of dialysis have been turned away due to the fact that the hospital cannot accommodate new patients; and if she will make a statement on the matter. [18001/07]
The Health Service Executive has informed my Department that the number of patients receiving dialysis treatment at the Limerick Regional Hospital has increased by approximately 20% in the last two years. I understand the dialysis service in Limerick now runs on a seven days a week basis, working at maximum capacity, providing 277 treatments for 99 patients a week. Five patients from the mid-west area are currently receiving their treatment at neighbouring units as an interim measure until dialysis capacity is increased locally. Arrangements are well advanced to provide for increased dialysis capacity in Limerick in the short and medium term. The HSE has invited tenders for the provision of additional dialysis services and is also working with the Irish Kidney Association in an effort to increase capacity locally.
Additional revenue funding of €12 million was provided for the HSE in 2006 and the current year to support the provision of dialysis facilities, the development of a living-related renal donor programme and the implementation of the national renal strategy which is due to be published shortly by the HSE. I understand it will recommend the development of additional consultant-led renal services on a regional basis.
A number of new renal dialysis facilities have opened recently and others are due to open soon. These include: a nine station facility opened in St. Vincent's Hospital in 2006; eight new dialysis stations at Cork University Hospital which are due to open later this summer; and a 17 station unit is being opened as part of the new hospital development at Tullamore which will open at the end of this month. In addition, 155 patients are being treated in dialysis units operated by the private sector, while 15 living donor transplants will take place this year in Beaumont Hospital.
I also wish to add my congratulations and wish you well in your very important role, a Leas-Cheann Comhairle.
Go raibh maith agat.
Will the Minister comment on the statement by the Irish Kidney Association which she quoted that the situation in the dialysis unit at the Mid-West Regional Hospital in Limerick is appalling? The IKA has blamed the Health Service Executive for the situation that has developed there. Does she agree that the overcrowding in Limerick has been reported and well documented during the years? This inevitable situation which has been highlighted many times to the HSE arose because of a lack of foresight by the HSE. The Minister informed us that she had invited tenders, but does she agree that tendering for dialysis services from the commercial sector — I presume she was referring to that sector — could take up to 18 months to implement? Will she comment on a proposal that the mobile dialysis service in Tullamore should be moved to Limerick when a new hospital dialysis centre is commissioned there in July?
People frequently talk in terms of crisis and things being desperate in the public health care system. Recently, the chief executive of the Bank of Ireland said some commentaries on the economy might send us into a recession. We need to be careful about the comments we make.
It was the Irish Kidney Association.
The fact is that 20% more people are availing of dialysis services at Limerick Regional Hospital than was the case two years ago. There are five patients from the region who cannot be facilitated there, which is why the HSE has gone to tender. The Tullamore unit is still in operation because the move to the new hospital does not take place until later this month. I hope the HSE will be in a position to move the facility to Limerick or wherever it can be put to best use. Since the Irish Kidney Association recommended Limerick, I have no reason to believe that is not the appropriate place for it.
The national renal strategy report was completed in December but has not been published. Why has there been a delay in publishing this important report on renal treatment? Does the Minister agree it is unacceptable that patients must travel from the mid-west area for such treatment? Is it fair to expect them to receive dialysis treatment at night time?
It is appropriate to receive dialysis treatment during the working day. Dialysis treatment should be provided as close as possible to where people live. It is not just a once-off treatment because, as we know, people must attend a minimum of three times a week for a long period. Therefore, the treatment should be available as close as possible to where people live. That is what we are trying to do. In the beginning the dialysis service was only available in major population centres.
I understand publication of the strategic review by the HSE is imminent.
Health Service Funding.
Liz McManus
Ceist:65 Deputy Liz McManus asked the Minister for Health and Children her views on the disclosure that the Health Service Executive handed back almost €100 million in unspent money to the Exchequer in 2006; the amount returned in 2005; the amount spent to date in 2007; the projects submitted to the HSE in 2005, 2006, 2007 related to new hospital beds, step-down beds and new hospital equipment and their cost; and if she will make a statement on the matter. [17866/07]
The final outturn on Vote expenditure for the Health Service Executive in 2006 shows a capital saving of €114 million, of which €42 million was used to offset a revenue overspend, while a further €47 million was used to offset a shortfall in appropriations-in-aid. This left a balance of €25 million to be surrendered to the Exchequer. The Health Service Executive's appropriation account for 2006 will show an overall surrender of €365 million — €25 million capital and €340 million in respect of the long stay repayment scheme.
In 2005 there was an overall surrender of €79 million. The capital programme had a saving of €50 million, non-capital programmes saved €4 million and appropriations-in-aid showed a surplus of €25 million. With regard to expenditure to date in 2007, the latest figures available from the Health Service Executive report total expenditure to the end of May as being approximately €4.8 billion against projected expenditure of €4.77 billion. Within these figures the trend in expenditure is much the same as in 2006. The capital spend is behind that planned, while the non-capital is running ahead of budgeted spend. I have discussed corrective action with the CEO as a matter of urgency.
The capital programmes submitted by the HSE in each of the three years, and approved by me, included sufficient projects to absorb its capital allocation for each year. However, actual capital expenditure in 2005 and 2006 turned out to be less than had been planned.
The HSE has taken steps to strengthen its capital management capacity, including the establishment of a single national estates function and the appointment of a new director. The level of capital funding provided to the HSE for 2007 will support a continuing high level of investment in our public health services and will enable the completion and commissioning of many new acute and community health care facilities.
I congratulate the Ceann Comhairle and promise to obey him as best I can.
Complimentary remarks will never eat into the Deputy's allotted time.
Even if it takes an hour.
Does the Minister not feel she should hang her head in shame? The news is worse than what was published in the papers. In 2006, €114 million of the capital fund was unspent and that is truly shocking. We have just heard about dialysis patients in Limerick who are unable to access dialysis at a reasonable time of day and there are similar needs across the country. Does the Minister accept responsibility for this? Against the best advice of her Secretary General and officials she decided that the HSE would be the Accounting Officer when it was established.
Year after year there has been underspending and a failure to deliver, even though the capital fund is anything but generous. Will the Minister for Health and Children accept responsibility for this? Rather than suggest the HSE will set up yet another Department with yet another highly paid director, which seems to be regarded as the solution to everything, will the Minister indicate to us how the funding will be spent for purposes we in this House determined it should be spent? There should be close evaluation because even the Comptroller and Auditor General was unable to assess accurately how money was diverted towards information technology projects within the HSE, with an overspend in that regard.
One thing is certain, the Deputy has changed neither her tune nor her language.
Unfortunately, the story is still the same.
I strongly stand by the decision to make the CEO of the HSE the Accounting Officer. I know of no good management system where a person is responsible for the delivery of services but is not accountable for the money involved. I do not believe that could lead to good management practice. I believe it is appropriate that the HSE should use expertise from outside the health service to run its estates function, as it recently did. The person appointed, Mr. Brian Gilroy, comes with a great deal of experience of projects in other sectors and I believe there will be a huge transformation in the manner in which this new national organisation sets about putting in place its capital programme.
Under the old health board regime the approach was to spend money no matter what. Money is allocated for particular projects and it is the duty of the HSE to ensure it is spent on those projects rather than spent merely for the sake of spending it. I strongly support this policy and I believe, though there will always be capital requirements, Ireland, together with Norway, at 5% has the highest percentage of capital spending on health of any country in the Organisation for Economic Co-operation and Development. I believe this is an appropriate level of investment.
The health budget in Ireland is different to other countries because there is a large element of social funding. It seems the Minister has not changed her tune either. She is relying again on private consultants to the tune of €100 million in terms of what will be done in the health service.
While we all understand that not all projects proceed on time, does the Minister accept that checks and balances are in place in Government Departments to ensure that money not spent on one project in a given year would be diverted to other vital projects to prevent it from being returned to the Department of Finance at the end of the year? That is the way in which Departments work. However, the Minister's wilful decision has left us in a mess and the HSE's solution, yet again, has been to establish another department and increase bureaucracy. Meanwhile, patients are desperate for care, hospitals are desperate for extra beds and primary care centres are not being delivered. All these physical facilities and services are being denied to patients due to the Minister's incompetence.
It would be arrogant for me to comment on my competence or otherwise. That is a matter for others to decide. It is important that money allocated by the Exchequer, through the Oireachtas, is spent on the projects for which it is identified. Allocated funds are switched to other projects. For example, money was reallocated to minor capital works last year.
Yes, it went back to the Department of Finance.
These moneys belong to taxpayers. It is right that if taxpayers, through their elected representatives in this House, identify projects on which money is to be spent, this money should be protected for those projects in future years in the event that it cannot be spent in the year in which it is allocated. Funding was switched to other projects, for example, to certain capital works, particularly in the care of the elderly, which were completed last year. I am confident the new expertise acquired by the HSE will make a major impact on ensuring capital projects are completed on time and within budget. Mr. Gilroy has been appointed full-time on a five-year contract and will not act as a consultant.
Departmental Bodies.
Brian Hayes
Ceist:66 Deputy Brian Hayes asked the Minister for Health and Children if, in view of recent comments by the chief executive officer of the Health Service Executive regarding aspects of the health service, she continues to have confidence that he supports all Government health policies; and if she will make a statement on the matter. [18002/07]
I am entirely satisfied that the chief executive officer of the Health Service Executive fully supports the Government's health reform programme and I have full confidence that the Health Service Executive is implementing Government health policy.
I assume the Deputy's question was prompted by comments made by the CEO in the course of his address at a major health conference in Dublin on 12 June last. In his address Professor Drumm pointed out that, among the major areas where change is required in our health system, are the building up of primary and community services and reforming the acute hospital system. The points made by the chief executive officer are fully consistent with Government policy.
The programme for Government includes commitments to extend the GP out-of-hours service nationwide to ensure patients can be seen within one hour of their call. This will give access to on-duty GP care 24 hours a day. GPs will be fully equipped to ensure their expertise and skills minimise the need for their patients to attend an accident and emergency unit. It also includes commitments to improve GP cover by developing primary health centres in socially deprived areas; work with GPs to ensure constantly improving out-of-hours cover for patients; ensure there is a primary care team serving every community, with particular reference to new and rapidly growing areas — 500 such teams will be funded by 2011; introduce improved supports for GPs who work in remote and disadvantaged communities, both for those starting out and those already established; and continue to implement measures to ensure the availability of real alternatives to hospital for those who require lengthy convalescence.
As far as acute hospitals are concerned, the programme for Government commits to the provision of an additional 1,500 dedicated public only beds. In addition, the HSE is reviewing the acute hospital bed needs up to 2020. This review will identify the number of acute beds required and the capital and revenue implications and advise on how to meet the identified need. The findings and recommendations of this review will inform the Government's policy on developing capacity in acute hospitals into the future.
The Minister has informed the House that she is entirely satisfied with the position taken by Professor Drumm and the Health Service Executive, yet in his recent comments on the number of acute beds in the health care system Professor Drumm could not be clearer. He stated that providing more acute beds would not improve the health service or deliver greater efficiency. This position is entirely different from that of the Minister. What is the true position?
Recently, Professor Drumm also stated: "I see co-location as being a competitor for the HSE." Does the Minister agree or disagree with that comment?
I totally agree with Professor Drumm regarding beds. If we had 10,000 more beds in the morning, they would not significantly improve access and patient care if they were not appropriately used. For example, the recent survey showed 13% of admissions are inappropriate and that people should not be in hospital. On the day the consultants reviewed all of the hospitals, 39% of patients should not have been in the acute hospitals.
Yet the Minister is planning 1,500 extra beds.
We are planning to use the beds we have efficiently and effectively and to have quicker access times for patients. The point made by Professor Drumm — I have made it many times, both here and at the Oireachtas Committee on Health and Children — is that if we do not use the existing stock of beds more efficiently and effectively, no matter what the number of beds is, if we do not get access to diagnostics from GPs so patients do not have to be admitted to hospital to have diagnostic checks carried out, and if we do not manage chronic illness at GP level in the community, people will end up accessing hospital beds.
The decision of the HSE board to pursue co-location was made on the recommendation of Professor Drumm. Competition exists between public hospitals at present. The Deputy is a member of the board of the children's hospital in Tallaght so he does not need me to tell him how competitive it is vis-à-vis the other children’s hospitals. In fact, this is one of the reasons there is such controversy attached to creating a single hospital. Competition is no bad thing between service providers, whether they are in the public sector, private sector or a mixture of both.
Interesting as the Gettysburg address is, I am simply interested in the answer to the question. I would like a "yes" or "no" answer. Professor Drumm stated: "I see co-location as being a competitor for the HSE".
That is true.
Is that the Minister's position?
Yes, it is.
That is the exact opposite of what she told the House yesterday, when she spoke about a unified system on the grounds of public hospitals between public and private hospitals. We have now got an admission from the Minister that she sees this competition by the new co-located hospitals against our public hospitals as in order. That is fundamentally different to what she told the House yesterday and to her stated position. Has the Minister full confidence in Professor Drumm, given that he is clearly opposed to her ideology-driven model of providing additional private beds on public lands?
The Deputy is wrong. I told him the HSE board signed off on co-location on the recommendation of the CEO and the management——
It was a Government decision.
No. The HSE board signed off on these projects for the individual hospitals on that recommendation. Professor Drumm put in place a process of thorough audit within the HSE in regard to each individual site to make sure——
But that——
There is no point in the Deputy asking me a question if he will not listen.
The Minister will not answer.
It was put in place to make sure that what was happening at each site complemented what was needed in the public hospital. There will be an element of competition. Tallaght Hospital competes with St. James's Hospital. Has the Deputy ever got into discussions with those hospitals? Consultants compete with each other even within hospitals. This is the nature of how services are provided. People compete for resources, capital investment, more consultants, more staff and more services both within and between hospitals.
Can I ask a brief supplementary question?
If you do so, we will lose the final question, which is your question. I call Question No. 67.
Accident and Emergency Services.
Brian Hayes
Ceist:67 Deputy Brian Hayes asked the Minister for Health and Children if she is satisfied with the finding of the recently published accident and emergency task force report which states that at least seven accident and emergency units are unfit for their purpose; and if she will make a statement on the matter. [18003/07]
The HSE recently published the emergency department task force report. The infrastructural deficits identified in the seven hospitals referred to are being addressed through a combination of interim and long-term capital improvements and refurbishment.
The task force recommends that the issues in emergency departments be examined on a whole-hospital and whole-system basis. It identifies the requirement for hospital-specific initiatives as well as the development of national responses in regard to key structural issues. A key requirement is the development of strong internal management control processes at hospital and community levels to ensure capacity is fully optimised and that measures designed to unlock capacity are supported by strong controls that enable appropriate balancing between emergency and elective workloads.
My Department is assured by the HSE that a series of additional measures are being put in place to ensure the delivery of an improved service for patients and to reduce pressure on accident and emergency departments. These include a series of hospital avoidance measures including the following: the expansion of the hospital in the home scheme to the Dublin academic teaching hospitals; the development of community intervention teams; the roll-out of more primary care teams; the expansion of out-of-hours GP services and the expansion of community diagnostic services. Measures being taken to improve and optimise acute hospital capacity and capability include the following: seven new community nursing units in Dublin, additional long-stay beds outside Dublin, development of admission lounges, acute medical assessment units at Navan and Naas, acute medical admission units at Beaumont, Sligo and Tallaght and the development of enhanced diagnostic capability in hospitals.
Will the Minister confirm that this damaging report, which showed that seven accident and emergency wards were unfit for purpose, was effectively suppressed until after the general election? The report was published on 1 June but was expected at the end of last year. Why was this bad news left until after the general election?
Returning to a point made by Deputy Liz McManus, who will take responsibility for the guarantee given that by February 2007, six hours would be the longest waiting period for patients in accident and emergency wards? This is another deadline missed. Who takes responsibility for that in the brave new world that is the HSE?
In the previous question the Deputy asked me if I had confidence in Professor Drumm. I have 100% confidence in him and think we are very lucky to have someone with his vision, determination and courage at the head of our health services. Given his clinical background, he brings enormous credibility to the HSE.
On the matter of publication of the task force report, I had no hand, act or part in its publication. I am unsure whether it was published or whether it came into the public domain by way of response to a freedom of information request. However, it is no secret to any active citizen that deficiencies exist in many of our accident and emergency departments. That fact is of no surprise to anybody. The challenge now is to put in place infrastructural improvements, some of which I mentioned. For example, significant investment is about to take place in Drogheda and we have already made significant investment in Wexford. Since the compilation of the report, many of the matters referred to in it have been dealt with.
The matter of the time, from arrival in accident and emergency units to admittance or going home, is one on which we need to concentrate. We should not just concentrate on the time spent on a trolley from the time a decision has been made to admit a patient. Often, the experience is that from the time people arrive, it is a couple of hours before any clinical expertise is available to them. That is the issue. I hope that in future the HSE will be in a position to put in place short time lines throughout the country.
Some 95% of the 3,000 people who visit accident and emergency units every day have a relatively pleasant experience. Research has shown that the issue concerns the remaining 5% in a few key hospitals. The HSE is working with those hospitals to improve performance.
Will the Minister accept that the key problems within the accident and emergency departments referred to in the report are the lack of beds and the need for additional capacity? Given that we have missed the stated, firm deadline that by February 2007 no one would be left waiting for more than six hours, what is the latest commitment? Will it be October, November or February 2008? I have only been spokesperson on health for a matter of weeks, but it appears we have a shifting deck of responsibility with regard to certain people taking responsibility for actions that are unmet. The Minister is very keen to inform the House of the responsibility of the private sector when it comes to deadlines and commitments, but when it relates to the HSE and matters falling under her Department, she is less responsible. When will this commitment be met?
As the Deputy is aware, the HSE acquired the assistance of outside expertise to visit a number of hospitals, look at their processes and make recommendations. Many of those recommendations related to improved procedures and processes within the hospitals and had nothing to do with extra capacity. For example, the HSE has acquired diagnostic capacity at Smithfield in Dublin for approximately 2,000 older patients who suffer from chronic illnesses who are directly referred there. The HSE required capacity for the waiting list in the Mater for an MRI and that was cleared in a matter of weeks by a private provider.
Direct access by GPs to diagnostic facilities will greatly improve performance in accident and emergency units, as will the provision of the out-of-hours service, particularly in the north of Dublin and in other parts of the country where many people end up in accident and emergency units who do not need to be there. These improvements will work together like a jigsaw — one does not work without the other. Simply providing more capacity without changing the way we do the business and what we do at acute hospitals will not lead to the improvements to which we all aspire.