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Joint Committee on Health díospóireacht -
Thursday, 11 Nov 2021

Delays in Accessing Scoliosis Treatment and Surgery: Discussion

Today's meeting will be split in two sessions to discuss the delays in accessing scoliosis treatment and surgery. I would like to welcome our first group of witnesses, Dr. Connor Green, consultant paediatric orthopaedic surgeon, and Professor Damien McCormack, consultant orthopaedic surgeon.

Members now have the option of being physically present in the committee room or may join the meeting remotely from Leinster House. Members and all in attendance are asked to exercise personal responsibility in respect of protecting themselves and others from the risk of contracting Covid-19. They are strongly advised to practise good hand hygiene and leave at least one vacant seat between them and others attending. They should also maintain an appropriate level of social distancing during and after the meeting. Masks, preferably of a medical grade, should be worn at all times during the meeting, except when speaking, and I ask for the members' full co-operation in this regard.

Witnesses are reminded of the long-standing parliamentary practice to the effect that they should not comment on, criticise or make charges against any person or entity either by name or in such a way as to make him, her or it identifiable or otherwise engage in speech that might be regarded as damaging to the good name of the person or entity. Therefore, if their statements are potentially defamatory in relation to an identified a person or entity, they will be directed to discontinue their remarks. It is imperative that they comply with any such direction.

I call on Dr. Green to make his opening remarks.

Mr. Connor Green

I thank the Chair. We are both delighted to be here today at the request of the committee to answer questions around scoliosis at Children's Health Ireland, CHI. We are both dual North American fellowship trained paediatric orthopaedic surgeons, both of us practising at Children's University Hospital, which is Temple Street, and the National Orthopaedic Hospital, which is Cappagh Kids. We are both practising as consultant surgeons and neither of us is in an administrative position.

Scoliosis has diverse cohort of patients and it affects kids in very different ways. Most of these children do not require surgery. In regard to those who do, some very young children with very complex disease require surgery in order to survive beyond their 20s. It is a completely different group of children in their teenage years. The reason we operate on them in order to reduce their chances of breathing difficulties but not until their fifth or sixth decade of life. It is not a homogenous group and it is important that we understand that. I am happy to answer questions around that later on.

It is great that the committee understands the challenge of timely treatment in scoliosis, and it is great that it understand the anxiety and the suffering it is causing, not only families but medical professionals as well. We both genuinely thank the committee for the opportunity today to advocate for children.

In order to adequately advocate for my patients and colleagues, I need to leave the committee with a very clear message. The care of children with scoliosis in this country is absolutely inadequate. However, the care of children with other orthopaedic conditions is just as bad. This becomes alarming when I tell the committee that scoliosis only represents about 20% of what Professor McCormack and I do. Therefore, the real crisis is not in scoliosis; the real crisis is everything else.

As paediatric orthopaedic surgeons, we see children with a huge potential to contribute through their abilities to Ireland in the future. Unfortunately, these abilities are being destroyed physically and psychologically by inadequate access to care. For example, there are children with spina bifida who are amazing, intelligent and mature. While these children have been waiting for surgery, they have gone from walking independently to using wheelchairs full time. They have gone from participating in school to staying at home full time.

They have gone from wearing shoes to sitting at home with open sores. These are not isolated conditions; this is a group of children.

In regard to children with cerebral palsy, the majority should live independently in this country. Not only that, through their amazing abilities they should be able to contribute to Ireland of the future. Instead, these treatable foot and hip deformities these children have leave them not only not contributing, but they leave them at home and in pain and missing school.

It is not just children with additional needs. We have children without any other medical problems at all who have hip deformities and limb deformities, and these children are in pain and ashamed of their appearance. They are not going to school and they are not being educated. They will not get an opportunity to give Ireland the benefit of their abilities.

We have no universal screening for hip dysplasia while we have universal screening for other things. This is a silent condition and when it is left untreated it accounts for 40% of hip replacements in people under 50 years of age in this country. Therefore, we are not only making the surgery around people's lives more significant, we are increasing the economic burden to the State.

We need to create a sustainable paediatric orthopaedic service for the children of Ireland, and for us medical professionals. The solution cannot wait until the national hospital is delivered. Furthermore, the committee needs to understand that a building alone will not fix all of these problems and it will only lead to disappointment. A sustainable solution will involve infrastructure and staffing. I can tell the committee that you would not find better colleagues anywhere in the world than the group of colleagues I have in Temple Street and in Cappagh. This is across nursing, therapy and my medical peers. We hold ourselves to an exceptionally high standard. You must go abroad for international training for two years before you have an opportunity to be a paediatric anaesthetist or a paediatric orthopaedic surgeon. Therefore, the access to care is the barrier here. It is definitely not the quality of care that can be delivered in this country.

However, over the last five years, it is very clear to me that this is coming to an end. You are not going to find people who will drag their families away for international training. You are not going to see nursing staff stay that extra hour continually in the face of adversity and with staff shortages. All of this goodwill has dried up. If we do not act now, this elite standard of care in this country is definitely going to reduce itself to "yellow pack", because people will not go abroad to train. Furthermore, it is equally likely that the next generation will leave and not come back.

We are not asking for much. We are asking to be allowed to do our job. We are asking that when we come to work there is enough staff and that we will not have to fight every morning to get a bed for our patient, so we can come in and operate. As surgeons, we are asking that we have an operating room to go to. I know it sounds ridiculous, but I was appointed as surgeon with no operating room. My colleague has just been appointed with no operating room.

I really hope that the new hospital will live up to expectations, but care for these children cannot wait. I know a ridiculous and obscene amount of money has been spent on the new hospital, but we still need to resource children now.

In Temple Street, our clinical director has been fighting hard for one operating theatre to be delivered by the end of next year. Why is it not two? Why are we waiting until next year? The American Army can set up a hospital in desert overnight, so why can we not have two operating rooms sooner?

Anybody listening to the radio this week will understand that stand alone facilities are the only way to deliver care in this country. We cannot provide elective care on acute sites. It is fantastic to see that the HSE and the Government are supporting these elective care facilities and we are going out to tender for it. However, we already have one in orthopaedics. We have the National Orthopaedic Hospital where we have Cappagh Kids. In the last two weeks, when all elective activity was cancelled in the acute settings, we did 20 cases on children when nothing else was happening. We can do more on these elective sites, but we need to be resourced to do so. A plan was submitted to the HSE and a plan was submitted to the Houses for an expansion in Cappagh. It will raise the standard of care not only in children, but in adults as well.

We need to be resourced. I promise members we will retain colleagues. We need to give my colleagues a reason to stay. We need a national system to be proud of, and we need the ability to care for our patients.

Thank you very much. It is refreshing to hear your passion while advocating for the patients who you represent and for your colleagues.

Everyone tells us scoliosis will not fix itself. As elective representatives, we have received some really disturbing letters from families outlining the trauma they are going through in relation to their children and the challenges they have been facing. One family told me the preliminary diagnosis for their child happened when it was still in the womb. They say the years between three and ten are supposed to be the best for response to scoliosis.

You were performing surgery yesterday. Will you talk us through what is actually involved? I know there are three types of scoliosis: idiopathic, congenital and neuromuscular. Apparently, we do not know what causes idiopathic scoliosis. It can be congenital and it can run in families. The main thing parents want to know is when their child will be seen, how they get that preliminary assessment and how long it will take after that assessment for them to get treatment. I suppose it the same with children who are on different spectrums, where families are waiting up to two years to get an assessment.

In the current situation, how long does it take? Will you talk us through what it is like going through the surgery and what you have to do? Also, will you comment on the challenges you, as a surgeon, faced during the cyber attack and what your colleagues went through in relation to that?

Mr. Connor Green

I thank the Chair. What I will say every time I answer a question about scoliosis is that I want to remind everyone that scoliosis is not the major challenge here. I really want the members to understand that when we leave today.

In relation to scoliosis, idiopathic is a group we do not have a cause for. We call it idiopathic because as doctors we like to sound smart and do not like to say we do not know. The Chair spoke about the time to access the care and about it being diagnosed in the womb. You have the group of children who will be diagnosed early in life who have no other medical problems. That is the idiopathic group. If we leave them untreated, they can potentially not have a big enough lung capacity to survive beyond their 20th year. In fact, most of the work done in that originally was in Ireland. We need to consider that scoliosis is just a symptom; it is not a diagnosis.

The most important thing, and I say it to all families when I meet them, is that the first thing we have to do is to decide what has caused their scoliosis. That means you need access to a physician and also some advanced imaging. If you are a child born with scoliosis, in theory we should get at that group quite quickly because there are very few of them. Early-onset idiopathic scoliosis is a really rare diagnosis and we should be able to see this small group relatively quickly. When it is said the important time for treatment is in the first ten years of life, that is true for that group. However, the most important time for treatment is probably the first five years of life because that is when children's lungs are developing. We call it the golden age of alveolar development. If you can get to a child during the time, there are two potentials. You can reassure the family in some ways that this might not be a curve that will develop at all. If we can treat them, then sometimes we can even reverse it.

The second group is the neuromuscular group, and this can occur at an early age as well. Most of these children need surgery to help with seating and with pain. They can have their surgery in a controlled way, and that is probably the biggest group we deal with in the acute hospitals.

The final group is the idiopathic scoliosis group in adolescence. In Cappagh, we have that group under control.

It is the one group we have under control through our rapid access service. We have decreased our waiting time from 18 months to four weeks. We have decreased our time for surgery from about a year and now we just give families a date when it suits them. I have the biggest waiting list in Cappagh still, but it is only five or six. We are in control in idiopathic scoliosis.

Does Mr. Green want to tell us about the difficulty following the cyberattack?

Mr. Connor Green

It did not make much difference. We kept working. During the cyberattack and the pandemic we kept working. It might have made it harder to get patients in but Professor McCormack, the neurosurgeons and I just continued to do our job. It is dishonest of us in any way to blame the cyberattack and the pandemic on the waiting lists in scoliosis and in paediatric orthopaedics. They made it more challenging certainly, but the numbers were there before they started.

I will open the floor to questions.

I welcome our witnesses this morning and thank them for coming before the committee and giving us of their views. How can the group in Cappagh that has been successfully catered for and managed successfully and satisfactorily be applied to other children in the various cohorts? How can the witnesses bring it to a satisfactory conclusion in a short time? Every parent watching a child suffer and in acute pain suffers along with the child. As we all know, the child is not in a position to do something for themselves. Children do not understand why they have to be on a waiting list and why they have to wait interminably while preparing for the surgery that should be available to them. How can we apply the approach right across the entire cohort, and what is required to do so? Is it possible to provide a fall-back system if something goes wrong in one area and there is a hold-up such as a lack of theatres or medical or surgical staff? To allow the waiting lists to grow is appalling in the 21st century. We should not have this situation. I want to know now whatever is needed to be done to achieve that.

Professor Damian McCormack

I will answer this question as best I can. We have to take a national look at this. We are employed in Cappagh and Temple Street and we do the best we can there with the resources we have. Each week I do a national clinic in the Central Remedial Clinic, CRC, for neuromuscular disability. Those patients are supposed to be from the local catchment area, but they are coming from the entire country. As a paediatric orthopaedic surgeon, I can see a patient with a spine problem in the CRC and I can operate in Cappagh. There is no equivalent of me anywhere on the west coast, the midlands or in the north east. There used to be. Twenty years ago, there was a paediatric orthopaedic surgeon in Sligo. There was one in Galway, in Limerick and in Cork. These were very well trained, very hard working consultants who ran the local service to a very high level. Only high-risk children with difficult issues were sent to Dublin. Nationally, now, that is all broken down. We do not have a paediatric orthopaedic surgeon service in Galway. A locum service is being provided out of Crumlin, which is unsatisfactory when you think about it. We do not have a paediatric orthopaedic service established in Limerick. They are talking about dropping it completely. Sligo is struggling. The north east, which recently built two new theatres for paediatric surgery, does not have a paediatric orthopaedic surgeon.

In the days of the health boards, the regions had access to their own facilities and provided for them, which is a subject we have discussed here on many occasions. That is apparently being addressed at present. We have been informed and hope it is being addressed and that such regionalisation will occur. I fully accept what Professor McCormack says. Otherwise, the inflow all comes to the Dublin area and it must be dealt with and it is then all emergency because it has not been dealt with in time.

Professor Damian McCormack

Precisely. The second element of that is the staffing, because if you have, frankly, a poor quality individual anywhere, be it in a Dublin hospital or a peripheral hospital, that individual is not going to take on these more difficult cases. That is really a problem because in my personal opinion if you have a good quality surgeon, you will have a good quality staff and a good quality service. The key thing is the good quality surgeon. That comes right back to training. That is where the major issue is. You can build all the hospitals you want and all the theatres you want, but if you do not have a surgeon who is comfortable doing high quality surgery, it will not happen.

We accept and understand that. We have to build in all the support facilities that are required at the same time. Otherwise, there is no sense in having one part of the accommodation available and a gap for the next part.

If we were to ask Professor McCormack to come back in six months' time, having addressed the issue in the intervening period, could he say to us with reasonable confidence that he could overtake the current acute waiting list? How long would it take?

Professor Damian McCormack

It depends on how one defines a waiting list. Numbers of children are quoted as waiting for scoliosis surgery. I do a lot of scoliosis surgery. Some of the surgeries take me ten minutes. If I am extending a telescopic rod in a three-year old, that is a scoliosis operation, as defined by management. Some of those surgeries take all day and they are dangerous and life threatening. It depends on how we count and how we define what exactly we are doing. There is a disconnect between what I do day to day and how I see these patients and how they are quantified on lists and presented. I have to take patients one at a time, and I do not pay too much attention to what is happening elsewhere.

I will finish with this point. I realise we are running short of time. It is correct that Professor McCormack has to take patients one at a time. Some patients may be more acute than others and require more urgent treatment. Is there any way that he can address those cases in the short term in order to, first, eliminate some part of the waiting list?

Professor Damian McCormack

Absolutely. For 20 years that is what I have done. Perhaps one patient was cancelled and went public, but I have not ever to my knowledge had a distressed waiting list in scoliosis in 20 years because I will bring acute patients up the waiting list and do the surgery where that is necessary and explain to the next patient that they are waiting a week because this patient has to be done. That has happened quietly, professionally in the background for 20 years. My cohort have not been in the media. That is what it takes. It is not a case of a general, global solution for everybody, it is one at a time. If a patient is in trouble and needs to be done, my list is cancelled until that patient is done. It is capacity really, because we are swamped.

Thank you, Chairman.

I welcome both witnesses. I thank them for their work in this area as well and for advocating for children and their patients. In his opening statement, Mr. Green says the current service for scoliosis is inadequate. I am very taken by what he says which is that, while scoliosis is very important and is the subject matter of today's hearing, there are also concerns about children with spina bifida, cerebral palsy, hip deformities and limb deformities. Their needs are important as well. Are those services equally inadequate?

Mr. Connor Green

Yes.

I want to get to the consequences of that. As politicians, we have been dealing with this issue for many years. Children and their parents have received a lot of promises. There have been a lot of glossy brochures, plans, presentations, and strategies yet the two specialists are sitting here today telling us that even still the service is inadequate. The witnesses are the specialists and they mentioned some of this in their opening statement. I seek agreement that what I am saying is true in terms of the consequences of an inadequate service.

Would it be correct it has an impact on the mental health of the children because they are concerned about their appearance-----

Mr. Connor Green

Yes.

-----that they miss school-----

Mr. Connor Green

Yes.

-----that they are left in pain because they are waiting far too long for treatment-----

Mr. Connor Green

Yes.

-----and that cancelled procedures have a real impact on the children? We are talking here about children who are getting ready, getting prepped and psychologically preparing for surgery with their parents and then getting a late call to say that their surgery is cancelled.

Mr. Connor Green

Yes. There is an effect on the children but an effect on the family as well.

Those are the consequences. I suppose what people want to hear and what families want to hear are the solutions. These guys have advocated, and made submissions as well, and they are fighting for resources. From speaking to all of the consultants, nurses and doctors that I meet in healthcare, and I meet many in my role as health spokesperson, I know they want the tools to do the job. They want to be better supported and if they do not have the tools, they cannot do the job as best they can. Nobody would put any responsibility on these guys for the failures in the system. What they need are the resources to be able to treat children quicker.

Mr. Green states, in his opening statement, that there was an expansion plan submitted with the HSE for more investment. We will hear later, from Children's Health Ireland and the HSE, that we will see more capacity. Can I ask these guys, first, what additional capacity is needed because that is what we need to get to the nub of? In 2017, when the Ombudsman published his report, and in all of the commentary we have seen since, there has been a lot of talk about additional investment, and plans and strategies yet here we are still today with an inadequate service. Specifically, what additional capacity and resources do we need to, once and for all, get to grips with this issue?

Mr. Connor Green

I will deal with it on the two different sites separately - Temple Street and the National Orthopaedic Hospital at Cappagh - because they are two different cohorts of patients.

In Temple Street, if we are specifically looking at scoliosis, the biggest rate-limiting step is the intensive care unit. We have an eight-bed intensive care unit where, on a daily basis, six beds out of the eight are only staffed by nursing staff. The reason for that is they cannot get the skilled nursing staff to do it because these nurses are not being remunerated, educated and supported appropriately. I do not know who would want to do that job. I will go into more detail on that afterwards due to the limited time. We need to resource our ICU staffing better. We need to ring-fence an intensive care bed for elective surgery and we need to support our intensivists to recruit more of them in order to look after the patients afterwards. The first thing I do on a Monday morning every time I come to the operating room is go up and look around the ICU.

We need two more theatres, at a minimum, just to get us through the next couple of years in Temple Street. I have a half-day operating once a week. That is all I have got at present. I cannot do a spine in a half-day. It is impossible. That time is nearly involved with anaesthetics. Therefore, we need more operating space in Temple Street. There is space to build two.

In Cappagh, there is a €17.5 million plan which will give us ten extra high dependency unit, HDU, beds and 16 extra ground-floor beds with increased paediatric and adult services. The rate limiting step in paediatrics in Cappagh at present is the high dependency units. In addition, we need staffing for our rehabilitation service. We are trying to set up a four-bed unit which would decompress the main hospital and allow patients to go to Cappagh for their recovery. That would also give us two additional operating theatres in Cappagh which would allow us to operate two paediatric orthopaedic lists a day instead of the current one, on a Monday to Thursday. We currently have 18 potential beds in Cappagh but we need to recruit the nursing staff and the support services to support them. Specifically, the support services we need to recruit are around physiotherapy and specialist nursing. We need a psychologist urgently.

Deputy Cullinane spoke of mental health issues. The suicide rate when you transition from paediatric care to adult care in spina bifida is astronomical. It is well published that the depression rate in these children is terrible.

Could I make one final comment because our time is tight and my time is up? Nobody would disagree with anything Mr. Green has said there. Here we are all of these years later and we do not have properly resourced paediatric ICU beds. We do not have the appropriately skilled staff to be able to operate those beds.

We do not have enough surgical theatre capacity. Mr. Green is saying we need two. My understanding is that maybe one might be coming, and it might be the end of the year, when, as Mr. Green stated, there is no reason that cannot be done quicker. There are other specialist staff that Mr. Green has mentioned as well.

Mr. Green also spoke of one of his colleagues - he himself had this experience as well - being taken on without having an operating room. Was that a recent appointment?

Mr. Connor Green

Mr. Kelly was appointed nearly a year ago but he only took up post in September. He has had no operating room since September. Let me tell the Deputy the difference between me and that colleague is that I am here because I miss my mammy and my children are here and this fella has nothing to tie him. He was trained in University of California, Los Angeles, UCLA, and they are trying to get him back there. I actually do not know why he bothers staying. I really do not.

We hope he does.

There is one final point I want to make. Mr. Green stated that Covid and the cyberattack cannot be used as an excuse for the unacceptably high wait times. I wrote down what Mr. Green said. I think he stated that we would be dishonest to blame Covid and the cyberattack. Children's Health Ireland and the HSE state that the problem is the cyberattack and Covid, that is what has driven up wait times and that is why we have the unacceptably high wait times today. Would Mr. Green accept that?

Mr. Connor Green

I do not accept that. The unacceptably high wait times were there before either of these events. They have made it worse but they were there beforehand. Nothing was in control before the pandemic. Nothing was in control before the cyberattack. I have said to the people - I have issued a letter to my waiting list - that I do not want that put on the letters because it is dishonest.

One thing that people need to be is honest with families. One should not tell them we will solve this next year. It will not be solved next year. That is impossible. You will not recruit the number of surgeons. You will not build the infrastructure. You will not put the support in the communities. We are rolling out progressive disability services across Ireland at present and there is so much happening. Let families know not to be hanging on week to week.

In Mr. Green's expert opinion, how long would it take? If it is not a year, what would be a reasonable time?

Mr. Connor Green

Honestly, I do not know. As Professor McCormack says, I fight one day at a time and I try to get to Friday, and I try to spend some time with my family. My job is to look after children and I cancelled two clinics to be here today to advocate. Because we are here advocating today, 60 children are not being seen today.

Also, I do not know how long I can continue doing this. The reality is that - the Deputy hears about children's operations being cancelled - I am the one who has to go up and tell families that their operations are cancelled. I have asked management to do that and they will not do it. Why should I have to say that the hospital has failed to get them a bed?

Professor Damian McCormack

There seems to be a notion that there will be a day when this is solved. A health system is an extremely complex system. Here, in this country, it evolved until the 1970s with a consultant contract, with a staff and with a religious input which was significant. There was an evolution, which was imperfect. Christ, people worked very hard back then and there were not these huge waiting lists. There were not 48,000 children waiting to be seen.

In my 20 years, from the former Minister, Mary Harney, as change-for-the-sake-of-change policy, I have seen the system which had already evolved become more and more chaotic. Every little change now is the butterfly wing that is just creating more chaos. Everything is in flux. Everything is chaotic.

Deputy Cullinane asks when will it be solved. We would need a day to go through the specifics from the privatisation of medical education so that children are paying up to €70,000 a year to do medicine. They cannot afford to look after children with disabilities. When they train, they are gone.

With the privatisation of post-graduate education, you can now buy a PhD. You can buy a master of surgery degree. You can buy it. You do not have to do research. It is ridiculous. This is what we are seeing - this fallacy of skill set - and real skill is diluted. There is a significant dilution of critical skill.

I thank Professor McCormack. I need to move on. Deputy Shortall is next.

I thank both of the witnesses for coming along. Those last few comments are demoralising, to say the least, where Professor McCormack talked about everything being chaotic and much of this is down to the tendency towards privatisation in recent years in the health service. I would not disagree with Professor McCormack on that at all.

They made the point that nothing is working from the point of view of paediatric orthopaedics at present. I do not know what they propose, and I am not necessarily saying it is their job to propose it, but what are the proposals for solving these problems and having a proper system?

Mr. Green referred to the plan for Cappagh hospital. We have not seen that and I would be interested in doing so. How quickly could things be geared up at that hospital to provide a reasonably good service? That is all we can hope for in the short term. How many additional public surgeons need to be employed full time, or the equivalent of full time, and what needs to happen in terms of theatre space and ICU beds at Cappagh?

Mr. Connor Green

I apologise to Deputy Cullinane for raising my voice. It was not directed at him.

Angela Lee, whom I consider one of the best CEOs in health in this country, is the CEO of Cappagh hospital. She has a passion for change at the hospital and she and the board have a plan that will deliver, in ten months, the ten-bed high-dependency unit, HDU, 16 additional beds and all the groundworks required for further expansion. The drawings have been done, the architects have completed their work and the soil examination has been carried out. I do not know whether I am saying the right or wrong things here, but we tried to push this through when the planning restrictions were lower during Covid because it was faster then. We tried to push it through when the costs to industry were lower.

Is there an estimated build time on that?

Mr. Connor Green

Yes, ten months. It is modular.

What is our total number of orthopaedic surgeons who deal with children and what ratios are regarded as best practice? How far out of line are we?

Mr. Connor Green

There are six in Temple Street hospital until January, when one of our colleagues is leaving, at which point we will be down to five. The latest estimates, which were carried out by Ms Paula Kelly, our clinical lead, were done three years ago and we were way down among the lowest numbers in Europe. I think 21 is the number we need, and that was our plan originally, when we moved to the new build. Ms Kelly, who will speak at the next session of this meeting, will be able to correct me but I think the plan following the move is for 14. The reason for that is not that it will get us where we need to be but that it is all we will have space for on the new campus. We will not have space for enough surgeons based on the number of operating rooms we have been given in the new hospital.

Much of the concentration is on the waiting lists for surgery and they are pretty scandalous. There are no two ways about that. There is also the waiting list of almost 44,000 children for outpatient appointments and that, again, is shocking. Many of the parents say there are serious problems with the lack of communication and they do not know where they stand. They are waiting to hear a date for an outpatient appointment or a day case appointment but they just do not know where they stand. Mr. Green referred to this earlier. Who does he think should be communicating with parents in respect of priority lists and the period they should expect to have to wait?

Mr. Connor Green

As surgeons, we should be communicating it. If a family asked me directly how long I thought they would be waiting, most of the time I would say I did not know. The next question tends to be when the operation should happen and I am never going to lie to a family, so I will them when I think it should happen.

As for communication about waiting lists and the waiting periods for surgery, it should be the administrator allocated to the waiting list department. It should not be a clinician, whether a doctor or nurse, and the reason for that is it takes up clinical time to speak to families. It has a significant impact on the mental health of medical care professionals to have to be constantly saying sorry to families.

On communication that beds are not available, again it has to be part of the management structure, not us. I will hold up my hands and say I am a poor communicator with families because I do not have enough time to ring everybody during the day. There could be a better communication structure between me and the family by appointing either a physician assistant or a clinical nurse specialist. The latter is the structure we have at Cappagh. Ms Anna Wade, who won an award for nurse of the year for very good reasons two years ago, will every Monday morning pick up her mobile phone and return every message to those families. You can ask any of those families about the communication standard from that nurse.

As I said, we have not received the plan for Cappagh but we will seek it now and take it up in whatever way we can with the Minister and the Department.

Mr. Connor Green

Thank you.

I am curious to know, and I imagine parents are as well, about the prioritisation system for the waiting lists for both surgery and outpatient appointments. Is there potential for better streamlining of those waiting lists? Parents do not know how long the waiting list is for one surgeon compared with that for another and there seems to be no movement between waiting lists. Is there potential for a clearer prioritisation system, with more transparency regarding individual surgeons' waiting lists?

Mr. Connor Green

With regard to developing another system, I was previously involved in hospital integration, although I have stepped aside from that. Ms Kelly is now our clinical lead. There was a waiting list trial in regard to how to prioritise children differently. At the moment, as Professor McCormack said, we are in charge of our own waiting lists and that is our responsibility. Thankfully, we still have clinical autonomy in this country to decide who should be put on a list first. Currently, I prioritise based on a child's need. I cannot give the Deputy a list of the criteria but they relate to whether kids have sores or are in pain, for example. It cannot be chronological. That is the system we are in at the moment.

I appreciate that but parents do not seem to be aware of how lists are created and what the prioritisation system is.

Mr. Connor Green

In the hospital, a child will be put on either an urgent or a routine waiting list; there is nothing in between at the moment. Their cases are listed chronologically. For those who are chronologically at the top of the urgent waiting list, the hospital will tell them where to go. As Professor McCormack outlined, most clinicians, including him and me, will try to prioritise those children on the list whom we feel need the surgery most. That is the way it is at the moment.

I thank Mr. Green and Professor McCormack. Their statement was very honest and candid. I read it last night before going to bed and was struck by the honesty in it. We read a lot of statements from healthcare professionals appearing before the committee in regard to our health system, but I was particularly struck by our guests' testimony, honesty and candour in respect of this most serious of issues. There is always a system failure when families are obliged to go public regarding their children's surgical needs. We can immediately tell there is a systemic failure where they have to go on the public airwaves to get surgery. What happens then is their child, their loved one, gets the procedure because of the outcry. If that is the system, that is a complete failure. That is no reflection on our guests but it is the system we live in. I cannot blame parents for doing it; I would do the exact same myself. If you have a child who is in constant pain, you will do everything to get that child the operation and procedure. We have to examine that system and fix it.

Mr. Green stated, "Therefore, the real crisis is not in scoliosis; the real crisis is everything else." What is the "everything else"?

Mr. Connor Green

As I went on to outline, it relates to the children with spina bifida we are trying to look after by maintaining their walking and their being able to sit in a wheelchair, and by keeping them out of pain in order that they can go to school. These children have no sensation in their feet, so if they develop a foot deformity, it will immediately break down into a pressure area and a sore.

We are trying to allow a child to go to school to be educated because these are bright kids. The next group is the cerebral palsy group. These children have sensation all the way down and so when they get a foot deformity, they cannot walk because of pain. Again, these are bright intelligent children who should be able, through their abilities, to help Ireland. I could continue with all the groups of children with additional needs, but there are also the other children who are completely medically well. Normal children are born in Ireland every day and have a silent diagnosis of hip dysplasia because we do not have a screening programme.

We did a review with the Cappagh National Orthopaedic Hospital Dublin, which showed that 40% of people under the age of 50 needing a hip replacement have hip dysplasia. Because we do not have the screening programme, I think the hip replacement cost for an under 50-year-old is probably about €5,000 for implants. I think it is about €10,000. I would not be held to those numbers because I am not an adult surgeon. We do several operations per week and I believe our implant costs €50. Therefore, it is an enormous cost to the State and to the family. Anyone who has a hip replacement by the age of 50 will definitely get one or two revisions before they are finished.

We have not even started talking about children who might just have a bit of a curly toe or a lump that needs to come off. Those children are completely lost. We have not said anything about our trauma service. We are not talking about the children who come in every week with fractured arms, infections etc. If there was a major incident in Dublin today involving children, we do not have the ICU beds for them to go to. We have no beds in Temple Street at the moment. We have no redundancy in the system. We could talk all day about each aspect of paediatric orthopaedics.

I want to be clear in this. I do not blame anybody within the management structure of CHI for the failings in this. We just do not have enough paediatric resources and they need to be put in place. I believe Eilísh Hardiman is a very good CEO who is genuinely trying to help. However, we are really stuck because everybody is focused on the new hospital. Everybody thinks this new hospital will save everything and it will not. We have been talking about a new hospital since the 1960s. The Mater was supposed to happen and was going to save everything. Children keep getting sidelined. Entire generations of children are now grown up. We need to remember that the children are paying for all our pensions and will support the State in the future. If we continue to neglect them now for small investments, it will be a problem.

Mr. Green has answered my second question, but I have one further brief question. What can we say to somebody with a child who has been waiting for years for an operation? There is capacity outside the State for treatment abroad. Obviously, it is a very complicated procedure.

Professor Damian McCormack

I might respond to this. It really upsets me when I hear families doing charitable work to gain money to go abroad to private institutions for treatment, some of which is excellent but some of which is completely bogus. Some tragic things are happening in that regard and it kills me to see it. I have never sent a patient abroad for treatment. We went abroad for years to train and, without blowing smoke, we are as well trained as any surgeon anywhere on the planet. The neuromuscular spine surgery I do in Temple Street is difficult and dangerous. Great Ormond Street does the same surgery but it was stopped, because of its complication rate, for a year and half. It could not do it as well as we do it. Children should not need to go abroad for anything.

Are some children going abroad for operations?

Professor Damian McCormack

Yes. Some are doing so with the agreement of their surgeon but unfortunately, we have a breakdown of trust in the system and therefore patients are going abroad for experimental treatments without the knowledge of their surgeon. This is a real symptom of a sick system, a system that is broken. Ireland, as a nation, should be proud of its health system and we should be embarrassed if a patient is going elsewhere for an operation. We are better than that. It would be a manifestation of a healthy system that no one ever needs to go abroad for anything.

The Deputy asked what the "everything else" is. To my mind there are three elements to this. There is the infrastructural issue, but we have brand new paediatric orthopaedic theatres in the north east. Alone that is not enough. Infrastructure is important, but we need additional staff. We need consultants, nurses and so on. We need sufficient numbers and that needs to be addressed. The third issue is that we need quality staff. One way to ruin any system is to put a bad doctor in, someone who is not confident or comfortable. It is not about bringing in, as has happened, locums from eastern Europe who claim they can do paediatric orthopaedics but who cannot. They last three or four years and they disappear. That has happened and it is not a solution.

We need quality training. I believe we need to train our own surgeons in paediatric orthopaedic surgery. It will take time to get good Irish leaving cert students through an appropriate medical school where they earn their degree and become high-quality surgeons and then incentivise them to do this work. The money is not sufficient incentivisation. It is not about money. We would not do this job for money. No amount of money would make us do this job. There is more. It is a social contract we make with society and with our patients.

There are three elements and if one of those elements is deficient, the whole thing is a waste of time. We can get into the detail of this another time but they need equal attention.

I thank the witnesses for their presentations. The last issue mentioned was that of training. What is the total number of orthopaedic consultants, including paediatric orthopaedic consultants, in Ireland at present?

Professor Damian McCormack

I do not know the exact number of orthopaedic surgeons practising in Ireland. The majority do adult surgery.

What is the number in paediatrics?

Professor Damian McCormack

In terms of paediatrics, we have six - down to five now - in Temple Street and the same number essentially in Crumlin. The point is there are none in the north east, none on the west coast, two in Cork and none in the midlands. We have locums and transient services, but that is a major issue. If we were to say to a young doctor to go to America to train for two years on fellowship, possibly not guaranteed a job because it is a competitive process-----

(Interruptions).

I ask Deputy Burke to put himself on mute as the interference is coming from him.

Professor Damian McCormack

A junior trained to do this level of work who was then put into Galway alone with no support would not last. The last orthopaedic surgeon appointed to Galway lasted a couple of years and has come back up to Crumlin, leaving Galway with nobody. It is not about fixing one element; it is about a systemic fix and an intelligent approach to this. We are significantly deficient in skilled appropriately trained paediatric orthopaedic surgeons. We do not have trainees in the pipeline. I am aware of one person who might decide to do it but of 60 or 70 trainees, the majority will just do adult surgery because it is easy. They can go into private adult surgery, which is even easier. That is not a competitive process; they can wander up to a private hospital and get a job. We are competing against our adult orthopaedic colleagues for trainees and for resources. We are coming out now for the first time saying that we need to compete for this. We need to change some of the models of training so that we can train our own people and populate paediatric orthopaedic units around the country.

In the context of consultant posts in other areas, there was a programme where a clear plan for training was set out. Is a clear plan now being proposed to deal with this issue for paediatric orthopaedics?

Professor Damian McCormack

An issue is that for junior doctors to train in paediatric orthopaedics, they have to train in adult orthopaedics first, which is a five-year programme. A very small number of them then go on and do what is, in my opinion, the most difficult sub-speciality within orthopaedics, namely, paediatric orthopaedic surgery. It is a difficult and technical area, so the majority of doctors do not wish to go into it. The solution to that issue is to separate from the adult training programme and train a small number of elite surgeons who will do this work around the country and support each other as a small elite group. We do not have that in Ireland, and it is telling.

Is it possible to team up with a hospital outside Ireland such that junior doctors would do part of their training in Ireland and then automatically have a place here and there would be structured training over, say, a five-year period so that when-----

Professor Damian McCormack

Precisely. The Deputy is speaking my language. In fact, that is exactly what has happened. Having trained in Ireland, I went to Texas Scottish Rite Hospital for Children in Dallas to train for two years. Most people would agree that is the best paediatric hospital on the planet. I was privileged to be accepted to it. My junior colleague, Mr. Paul Connolly, followed me and trained there, as did Mr. Green. We have a strong relationship with that fantastic North American stand-alone paediatric orthopaedic hospital and, of course, we could send people there, but that requires junior doctors who are willing and able to bring their families to spend two years in Texas or a similar place. That is in hand. The problem we have is that we are competing against a more lucrative and comfortable lifestyle as an adult orthopaedic surgeon doing hips and knees. In a private setting, such surgeons can potentially make millions of euro a year. Who wants to deal with spina bifida patients or cerebral palsy patients? It takes a particular type of individual to do it and we need to find those people.

I refer to the issue of access to theatre. Obviously, in the context of complex operations such as these, it is not just about having the consultant and the back-up support team, it is also about having access to beds once the operation is completed. I refer to efforts to attempting to fast-track dealing with some aspects of waiting lists, as has been done in Cork in respect of day procedures, though I acknowledge it is far easier to do with day procedures. For example, if there were 4,500 people on a gynaecology waiting list in Cork and the consultants could not get access to the theatres in Cork University Maternity Hospital, they rented space in the Mater Private Hospital, Cork, and did all those procedures there. These were all public patients. Is there capacity to get space in the private hospitals such that consultants would have that space and the theatre, beds and back-up support staff to deal with some aspects of the lists?

Professor Damian McCormack

On paper, it sounds like a good idea. I have significant problems with engaging the private sector for children and I have not done so. I could have done it but I have not done it. Mr. Green and I have spoken about this at length. As we have not engaged the private sector, we have been forced to create another solution in our locality, and that solution is Cappagh Kids, which is a sustainable and brilliant public development. We are not at the behest of the private sector. I remind the Deputy that all of the private hospitals are not really hospitals; they are vehicles for speculation. I have a big problem with that because they are potentially transient. They could be sold by the French power company that owns them or by Denis O'Brien, etc. They could be gone overnight. They are not sustainable and they are extremely expensive. Frankly, I could make a fortune doing private paediatric work on a National Treatment Purchase Fund, NTPF, system in a private hospital but, as I stated, paediatric orthopaedics requires a particular type of individual who has a social contract and a social conscience. We are not doing what the Deputy has suggested, but we might be forced into doing it.

I am not suggesting providing treatment on the NTPF. I am talking about what was done in Cork. The procedures were not done on NTPF, it is just that the consultants got access to the theatres and the facilities-----

Professor Damian McCormack

I understand. On paper, it is-----

It is not the NTPF.

Professor Damian McCormack

I understand exactly the point the Deputy is making. I understand also that the private sector would like us to do this because it would make it look good as children would be being treated in those private hospitals. However, that establishes a private route and that could change because the private hospital could decide that we are dependent on it and put the fees up or whatever. It is not a sustainable public process and I think-----

I accept what Professor McCormack is saying but the reason I am raising this is because there is a waiting time for the new children's hospital to be opened and this is about filling the gap for that short period, rather than having young people waiting so long and families getting very frustrated with delays. It is just a suggestion. I am sure Professor McCormack has considered it. It is one of the options.

When the children's hospital opens, whenever that will be, will there be sufficient support there in terms of staff? Is Professor McCormack satisfied there will be sufficient staff there? What additional numbers will be required in order to help improve the service once the facilities are available?

Professor Damian McCormack

I am sure Children's Health Ireland has detail on that. I will not speak to it. I do not really know and, as I stated, I do not really think about it because I would rather focus on the health service today, as if that hospital were not being built. Today we have Cappagh, Temple Street and Crumlin hospitals and what the issue I would analyse is what staff are missing in those hospitals. There is also Cork, which could do much more but it was designated a second-level hospital, so it does not do primary-level paediatric orthopaedic surgery. Those seeking such procedures have to come to Dublin. That could change. I do not see why it could not. It is just a matter of getting quality surgeons down there who are willing to do the procedures. I am hopeful in respect of the system because, with the application of rational thought and the exclusion of some of the interference - and the private sector is one of the things I would say is interfering; in some ways useful and in other ways not useful - in the context of this chaotic system and slowing it down, taking some of the chaos out of it and dealing with individual items one at a time, I would be quite hopeful that we can get through this and sort it out, always focusing on the next child in the theatre. It is a chaotic system.

I was following the proceedings from my office, but I like to come into the room for direct discussion. In reply to one of my colleagues, Mr. Green stated that he and his colleagues tried to advance plans during the Covid lockdown when prices were cheaper. What blockages were faced back then? Where were the blockages? Why was it not possible to advance the plans?

Mr. Connor Green

For accuracy, the answer to that question should be given by Ms Angela Lee, the CEO of the Cappagh National Orthopaedic Hospital Dublin. The reason I say that is because she was present at the meetings with the HSE in Dr. Steevens' Hospital and she has sent the emails on behalf of the hospitals. I am there as a clinician, supporting her. If I could give specifics, I absolutely would do so.

I accept that. Another interesting observation Mr. Green made which is very telling relates to the amount of his time that is taken up with advising and engaging with families, and that it is having an impact on the mental health of some of his colleagues. What type of supports are needed but lacking in that regard?

Mr. Connor Green

The supports we need certainly include a psychology service.

We do not have adequate psychology services in Temple Street and none in Cappagh. We need more psychiatrists in Temple Street. At the moment, we only have one psychiatrist on the site and psychiatry services in Temple Street have not been taking on new patients since March of this year, or that is my understanding. We need more nurse specialists because the nurse specialist is there, working with the team consistently. The doctors in training are transient, so they come in under our service for a while and then move on. The consistency is with the nurse specialist, who can answer the clinical questions around things. We need a clear place for families to call with regard to the administrative issues and we need administrative support as well. There is not one aspect. I want to speak to families as well, so let us be clear about that.

Mr. Connor Green

I want to spend time building a relationship with families. We are not treating a child as a once-off condition and then they move on. It is an entire childhood that we treat. Further to the questions in regard to outsourcing care, this is where that becomes impossible. We have built a relationship with these families. These children, unfortunately, have a morbidity and a mortality risk around the time of surgery, and these are complex cases of children who cannot go out of the State for care.

With regard to trying to speed things on in that regard, the public sector has to be the beachhead. We have to have a sustainable public service before we try to clear the waiting lists in the private sector and overseas. There is no point in clearing a waiting list which then re-accumulates. We must resource it.

In terms of the children's hospital and the question of staffing, it is important to understand that the plan is that while Temple Street and Crumlin will no longer exist in their current form, Cappagh will continue as part of the paediatric group, and both the board and the executive in Children's Health Ireland, CHI, have had this presented to them. Ms Hardiman has been a consistent supporter of that. Let us be clear that any capital investment in Cappagh National Orthopaedic Hospital Dublin will still be there and it will not just be a short-lived solution.

I want to highlight the comments Mr. Green made earlier about us having the best clinicians in the world and the best expertise in this country, which is correct. I do a huge amount of work with the eye care teams, particularly in the Mater hospital, including a lot of advocacy work. In the whole area of eye care, we are the best in the world, and we are the best in the world in a whole series of areas, particularly when it comes to children's care. It would be great to see the blockages that have been discussed this morning cleared. It is a small investment in what is our future and the future of our country.

In response to Deputy Colm Burke, Professor McCormack made reference to the private sector sometimes interfering. Would they like to expand on that?

Professor Damian McCormack

For instance, when the NTPF started, some of my consultant surgeon colleagues in the public sector switched contract because they made so much money from the NTPF. They went to the private side. We are competing against the private sector for nurses and for consultants. They are the competitors. For the national public body, the private sector and the few individuals who are involved in that system are the competition, yet they have free access to the Department of Health, they advise the Department of Health and they have free access to the HSE. If I was a businessman, I would deal with a competitor as a competitor. I would not let him into my boardroom. I would not allow individuals to wear six or seven hats so that, today, they can be in a committee in this hospital group, tomorrow, they can be on a committee in this private university and, the next day, they can be on another committee. This is going on. The system is pretty broken in that sense.

It is unethical, I would suggest.

Professor Damian McCormack

It depends on how we define that, but absolutely. I made reference earlier to the latest developments in education. The Minister for Education and the Minister for Further and Higher Education, Research, Innovation and Science need to be involved in these discussions because training is an educational thing. How is it possible that someone can buy a PhD without doing any prospective supervised research? Yet, it is possible.

Professor Damian McCormack

It is crazy but it is the law and it is supported.

Perhaps this committee could do a body of work on that.

Professor Damian McCormack

I would love to speak to the committee about my experience over 20 years of how privatisation and profitisation is interfering with the health of children in this country, absolutely.

Mr. Connor Green

To add to that, the President wrote an excellent article about academic inflation earlier in the year and it all goes around that academic promotion of individual institutions. When the Senator talks about the standard of care in Ireland and supporting that, I am delighted to hear him say it, but we need to continue to be able to keep ourselves at that standard of care and, therefore, we have to be able to track people back to this country and encourage people to go away and train. Genuinely, there will always be talk about remuneration for work and salaries, and we are never going to get away from that. However, as medical professionals, we find that the hardest thing is coming to do our job and not being able to do it. I would much rather be sitting in the lab right now, doing research with the additional time that I have, trying to advance care rather than trying to promote my specialty. If we are given the time to research, educate and train, we will have happy physicians who want to work. It is not that hard to keep us happy.

I thank the witnesses for their time.

I thank Professor McCormack and Mr. Green for their evidence, their advocacy, their expertise and their work. Professor McCormack mentioned the situation 20 years ago as it pertained to having theatres and consultants in Galway, Limerick and Sligo. Was there a conscious decision to consolidate positions elsewhere and to move to Dublin, did people retire and were not replaced or was there an inability to fill positions? Professor McCormack mentioned the changes and the fact of change for change’s sake within the system. Was it a planned policy decision, a case of people retiring and not being replaced or an inability to fill positions?

Professor Damian McCormack

It was a mixture of both. There have been policy changes, and Mary Harney sticks out because, at that time, things started changing for the sake of change, to quote her, which created chaos. There were also people, for example, surgeons, retiring and not being replaced by like, that is, by equally skilful surgeons. That creates a problem. For instance, I know the HSE sent money to Galway to fund a paediatric orthopaedic post maybe ten years ago but the surgeons in Galway chose to use that money to hire a spine surgeon. They are autonomous and what they do is not my business, it is their business, but what they did was to hire a spine surgeon, not a paediatric orthopaedic surgeon. Therefore, they had one paediatric orthopaedic surgeon, who then retired and was replaced by a young surgeon, who was not happy and left, and who has come back to Crumlin for various reasons, some of them personal and some of them, I think, professional. To do this job alone in a place like Galway, which is so busy with the whole west coast feeding into Galway, is virtually impossible. This evolution has occurred but it has been a devolution, really, for the past 20 years.

We need one or two really good, solid surgeons working and incentivised for the right reasons, resourced with good quality people around them. We do not need a huge glass building. I am are aware of some really excellent, probably the best, trauma surgeons on the planet who are operating at the moment in a tent in the West Bank. We do not need a huge building. We just need quality people who are motivated in the right fashion, obviously, but the motivation cannot be financial because that does not work. It has to be more. It has to come, from the very beginning, from how these people are educated and taught. They have to be working in good faith, in good spirit and they need to be authentic and honest people. That is not a big ask. Ireland is full of such people but there is interference stopping them from progressing. I think we can clarify that.

How do we maximise the time of Professor McCormack and his colleagues in the public system, in the theatres, doing the jobs they were trained for? Professor McCormack talked about the training model and privatisation but what is the quickest fix?

Professor Damian McCormack

Okay, here is a quick fix. Hip dysplasia is a big problem. Two years ago, over the summer I suggested to Temple Street hospital management that if they gave me a theatre on a Saturday, I would work for nothing. I asked them to pay the nurses to work for the Saturday morning so we could work on ten or 11 kids. It took a good chief executive officer at the time, Ms Mona Baker, to say "yes" and it happened. Every Saturday over the summer I went in and operated on what I think were nine children each morning. It was as many as we would do in a month otherwise. That little bit of a waiting list was dealt with. The nurses loved it because they were incentivised and that incentive was very simple. The nurses were paid until 5 p.m., along with the anaesthetist. If we worked hard and cut out all the bullshit, we would get the work done by 2 p.m. and that is exactly what happened. Everybody was delighted and went home at 2 p.m. having done a good day's work.

This was amazing because in the public sector for the first time in my experience in Temple Street hospital, on a Saturday morning we cut through work just like it was a private operation. For a second year I asked the same for the summer months and we did it but there was some resistance. Nurses were given vouchers. There was some detail about not being able to pay nurses extra or whatever. The bureaucracy hit us in the face but we did it. For the third year, which was last year, it did not happen. There was too much bureaucracy. The chief executive was gone and there was a layer of managers so it just did not happen because of the bureaucracy. That is a quick fix.

Another example is that of the four theatres available in Temple Street hospital, three close on a Saturday and Sunday. We have all this intense debate all week but on Friday afternoon people just go home and it is the weekend. I stopped believing in Santa and God a long time ago and I have no problem working on Sunday all day. Why not? We have the infrastructure but it is closed two days from seven. For God's sake - if there was a God - could we not just open the theatres and let us do some work? It should not take that much but trying to get that through the bureaucratic management structure is impossible. Maybe members could help with that. We could give people working over the weekend Monday and Tuesday off or pay them a little extra. It would not cost €2.5 billion to use those two or three theatres over a weekend.

Professor McCormack has proven there is a solution that worked for two years.

Professor Damian McCormack

Yes.

It can work again.

Professor Damian McCormack

Everybody loved it and was proud of the work. They still talk about it because people were motivated to do their best. They were not under the cosh or being clocked in and out. They were incentivised and not just by money; they knew if they worked hard, they could get out. The entire country needs that kind of incentivisation. It is being inhibited but we can identify those inhibitions and deal with them rationally, I am sure. For that reason I am hopeful for the health service. If it does not happen, I would be very pessimistic about everything.

I thank Professor McCormack.

I thank the witnesses for being here today. I apologise as I have just come into the meeting in the past few moments. Since moving back to this building, we often dart between the Dáil Chamber and here. I have been following the meeting and reading the opening statements.

I will begin where Professor McCormack left off just a moment ago. We heard there are theatres available and fully kitted out, ready to accept patients, but they are closed. That is pretty damning. I am glad he spoke so frankly here this morning. Many parents of kids with scoliosis in particular contact our offices and it seems there is an endless wait for that all-important surgery. The witness just spelled out a solution and he very clearly asked for our help a moment ago. Loud and clear messaging must come from this committee that we want to see such bursting through the bureaucratic red tape. We want to see the theatres operating on a Saturday and Sunday so we can start eating into these extensive and long waiting lists. That must be a key outcome of the work we are undertaking this morning.

We have all received quite a number of emails in recent days. One that caught my eye was a mother who referenced metallosis and she went into quite a bit of detail about various rods that were implanted in her son. She did not name the particular type of rod but she mentioned that in recent months it had its CE safety mark removed. On top of that it is now under scrutiny by the Health Products Regulatory Authority. I know the product and its name but I cannot reference it. How prevalent is the problem after surgery and implanting? How often does a case appear in theatre that must have rods extracted and replaced, or where problems are caused right up to metallosis?

Professor Damian McCormack

I have never used that device and would not allow it to be used in Temple Street hospital. That is from the very beginning. A large part of my practice is specifically the type of scoliosis mandating these little growing rods. I have a certain expertise in the area over 20 years but I have never used that particular implant. I was sceptical about it from the beginning.

Please do not mention the name.

Professor Damian McCormack

Yes. It is an American implant. The problem with surgical implants in this country is they are not regulated. Medical regulation is very strict in this country and the people doing it do a superb job. Surgical regulation is based on market activity. In other words, individual regulators look at how well something is selling; if it is selling well, it is a "good" implant, which is ridiculous.

That particular implant was tested and invented by a surgeon. The surgeon sent it to his friend in Hong Kong and it was tested on two patients. That was absolutely not sufficient to get Food and Drug Administration approval in the United States, where it was made, but the Americans were quite happy to let it be used in Europe. Having been tested on two patients, a paper was written to say it was great, and that was ridiculous. It got European CE approval and it was used in Europe. With marketing, it became-----

Could Professor McCormack estimate how prevalent its use is in Ireland?

Professor Damian McCormack

It has only been used in Crumlin. I might refer the question to Ms Paula Kelly.

It is important because not only are a number of young individuals grappling with scoliosis but when they got the magical treatment and underwent the implanting, they found a secondary problem leading to metallosis. It is extremely worrying. We are here to speak about surgery and how to get through the backlog. The medical professionals are doing fantastic work and are facing Mount Everest. They have all our political support. It bothers and concerns me in a major way after reading the evidence from parents in the past few days that some of the products in Ireland are-----

Professor Damian McCormack

It is not just with scoliosis. There was a hip product and it is costing the State millions of euro. It comes down to regulation and we do not have regulation of surgical implants that is meaningful in this country. It is a huge problem. I would love to speak at length and in detail about it again. It involves not just orthopaedic implants and takes in cardiac implants and all kinds of stuff. Reading the financial statements of international companies from America, Ireland is noted to be a soft touch state where a surgeon would use an implant.

My time is almost up but I thank Professor McCormack. A body of work must be done on this, although I realise it is tangential to what we are discussing today. It relates to scoliosis and is relevant for anybody who faces any form of orthopaedic surgery. There is a need to look at a regulatory regime that sounds very weak now. I suggest in future weeks we undertake a body of work on this and perhaps we could have Professor McCormack and Mr. Green to speak further on the matter. I am sorry I took us on a tangent but it is very much linked to what young people are experiencing.

I commend Professor McCormack and I am really impressed by his clear analysis of the nature of the problem. It is very refreshing to hear somebody speak so frankly about problems within the system and the putting forward of solutions. Is there any forum in which that analysis can be considered or inputted? Does such a forum exist in Children's Health Ireland or the orthopaedic community where there could be some meeting of minds on the scale of the problem and what needs to be done?

My second question relates to Cappagh hospital. The witnesses set out clearly the difficulty with regard to putting newly trained surgeons, on their own, into Galway hospital or some other hospital and how unsatisfactory that is. Given the size of the country and the scale of the problem we face at the moment, is there a case to be made for making Cappagh hospital the centre of excellence in relation to this?

Earlier, I asked if in six months' time we would observe a sizeable impact on the erosion of the waiting lists, the answer to which was in the negative, but I would like to put it again. In order to do our job as a committee, we need to know what length of time it will take to put in place what is required from the witnesses' vantage point, utilising all of the services and facilities.

My final point is in regard to clearance by the authorising body here of implants. Does that body evaluate implants in the same way as it evaluates drugs, or does the European Union authority evaluate implants in the same way as it evaluates drugs? As I understand it, the answer to that question is "No".

Mr. Connor Green

I will respond to the question on Cappagh hospital and the waiting lists in six months. On the waiting lists, in my opinion, and as discussed today, there will be no difference in six months' time. I am speaking only for Temple Street hospital and Cappagh hospital. We have an issue with respiratory viruses at the moment and, therefore, the ICU system has no further capacity. I have had three spinal surgeries cancelled in recent times. Those patients are now pushed out further. It is possible that the waiting lists will have increased further in six months' time, in my opinion from my practice.

In terms of meaningful change at Temple Street and Cappagh hospitals, if we get the investment for the expansion, ten months from that time it will be built and then we can start to talk about meaningful change. That is as accurate as I can be, genuinely. All I can do is look at the patients in front of me. There are 224 on my list for inpatient surgery in Temple Street hospital and 282 on my list for inpatient surgery in Cappagh hospital. On average, I get one done per list in Temple Street hospital. That only happens if the list has not been cancelled. On the basis of my list of 224 patients and an average of 40 lists per annum, depending on bank holidays and so on, I cannot in all honestly say that there will be meaningful change in that regard.

On Cappagh hospital and the number of surgeons that are required to be appointed, Cappagh is already the national hospital. We accept referrals from all over the country. We can continue to accept those referrals. We are in discussions with regard to surgeons from Crumlin hospital coming to Cappagh hospital providing we get the adequate resources to support them. If we had two paediatric orthopaedic operating theatres running per day, we would fill them with our existing surgical staff. The surgeons at Crumlin hospital have access to the national orthopaedic hospital. We also have access. It is already the national orthopaedic hospital. In my opinion, that is where investment should be go because it will always be there.

That concludes this session. If there are issues which were not covered this morning on which the witnesses would like to come back to the committee, they are welcome to do so. We appreciate them giving up their time to be here. I am conscious that they both missed clinics this morning in order to be here. It has been a very useful discussion. We have got a sense of the challenges facing the witnesses and their patients. We really appreciate Mr. Connor and Mr. McCormack giving of their time and we hope they found this a useful opportunity to express their frustrations. Hopefully, the committee will be able to recommend some actions.

Sitting suspended at 11.05 a.m. and resumed at 11.15 a.m.

I welcome Ms Eilísh Hardiman, chief executive, and Ms Paula Kelly, consultant paediatric orthopaedic surgeon, from Children's Health Ireland, CHI. From the HSE, I welcome Mr. Liam Woods, national director, acute operations, and Ms Helen Byrne, assistant director, acute operations.

Witnesses are again reminded of the long-standing parliamentary practice to the effect that they should not comment on, criticise or make charges against any person or entity either by name or in such a way as to make him, her or it identifiable or otherwise engage in speech that might be regarded as damaging to the good name of the person or entity. Therefore, if their statements are potentially defamatory in relation to an identifiable person or entity, they will be directed to discontinue their remarks. It is imperative that they comply with any such direction.

I call Ms Hardiman to make her opening remarks on behalf of Children's Health Ireland and the HSE.

Ms Eilísh Hardiman

I thank the members of the committee for inviting us to attend this morning. I am joined by Ms Paula Kelly, who is a consultant paediatric orthopaedic surgeon at Children's Health Ireland at Crumlin, as well as being a clinical speciality lead for orthopaedics across CHI. Mr. Liam Woods, national director of acute operations, HSE, and Ms Helen Byrne, assistant national director of acute operations, HSE, are also in attendance. I also acknowledge our colleagues, Mr. Connor Green and Professor Damian McCormack, for their advocacy and support, for working with us to try to resolve this issue and for their honesty in the previous session.

We are here to brief the committee on scoliosis services and to outline the progress made in 2018 and 2019 to stabilise this service, which has been eroded in the past 18 months, primarily due to the impact of Covid-19 and the cyberattack. Most importantly, I will outline what we are proposing to do about this situation.

We are extremely aware that behind every number is a patient, a family and a team in CHI that wants to provide treatment. I reiterate, on behalf of CHI, my apologies to all patients and their families who have experienced increased waiting times and delays in accessing paediatric services. We do not, in any way, underestimate the impact that this has on them, and our intention is to correct this situation as soon as we can. As the committee will appreciate, we are not in a position to discuss individual cases in the public domain.

Timely and increased access to our services is the single greatest operational challenge in CHI. We are operating within old and constrained infrastructures, and we have recently experienced extremely high levels of accident and emergency department and urgent care activity. We have a plan in the form of the new national children’s hospital. It will be amazing and will address many of our current challenges, but we cannot wait for two and half years to improve access to our services. What we must do is to support paediatric orthopaedic services to operate more than in their pre-pandemic levels to address the backlog caused by what has happened in the last 18 months. The committee's focus today is on scoliosis. We must point out that there are other children with time-sensitive orthopaedic and other conditions that we equally need to prioritise. We are trying our best to manage all these service demands.

To contextualise the situation, at the end of October, CHI had 2,876 children on inpatient waiting lists, 2,686 children on day case waiting lists and 43,844 children on an outpatient waiting list. As part of CHI paediatric orthopaedic services, the most complex scoliosis cases are treated in Crumlin and Temple Street hospitals, with the less complex cases being dealt with in the national orthopaedic hospital at Cappagh, known as Cappagh Kids. Scoliosis treatment accounts for 17% of orthopaedic inpatient activity in CHI.

Through investment in 2019, CHI stabilised the service and achieved delivery of a target of 382 spinal treatments. This was the projected annual number of treatments required to practically manage timely access within our current infrastructure. This annual target of 382 spinal treatments was decimated in 2020 due to the impact of Covid-19, with 60 fewer spinal treatments undertaken. A total of 322 procedures were undertaken. We made progress in early 2021 to recover some of this activity, but the cyberattack in May really impacted services in CHI. We anticipate that this year we will undertake a total of 335 spinal treatments in CHI.

To address the impacts of Covid-19 and the cyberattack on performance, we have developed specific proposals for HSE funding approval to increase capacity at Crumlin and Temple Street hospitals and to expand the paediatric services at Cappagh hospital. That means more operating theatre capacity, additional beds, new MRIs and additional staff. As of today, 203 patients are on the waiting list for scoliosis-related procedures in CHI. These include active, pre-admittance planned procedures but in keeping with national waiting list standards, it excludes suspensions for clinical and other reasons. The vast majority of these patients need their surgery to take place in Crumlin or Temple Street hospitals, with Cappagh hospital offering the opportunity to undertake less complex elective procedures.

With this new investment, we will deliver sufficient additional orthopaedic activity to substantially eliminate long waiting lists for scoliosis treatments on a sustainable basis. In activity terms, this means increasing our annual funded target for spinal procedures from 382 to 430 in July 2022, which is an additional 48 spinal procedures in 2022. Plus 438 in 2023, which is an additional 56 spinal procedures. This will improve the waiting times and we are committed to the following. By the end of 2022, all scoliosis inpatient waits will be below six months unless clinically indicated, and by July 2023, all scoliosis inpatient waiting lists will be below four months unless clinically indicated. These targets are subject to securing the required investment and no uncontrollable events like a pandemic. The private sector capacity might be able to help accelerate these targets but we do not expect this to materialise due to the constraints in securing specialist paediatric staffing.

To conclude, waiting times for scoliosis services have deteriorated in 2020 and 2021 primarily due to Covid and the cyberattack. This is unacceptable. Again, we apologise for the distress and strain that any lack of timely access causes to children, adolescents and their families. We appreciate that families want to know when their child will have surgery. This is also impacting on our dedicated and professional staff who are working diligently through challenging and difficult times.

We have demonstrated that we can improve services when investments are made in CHI. Despite the infrastructure and serious challenges faced on a daily basis, we remain committed to improving services. I can assure the committee, patients and families that on securing the required investments everyone in CHI is fully committed to making timely access to our services better for children needing treatment for scoliosis. I am happy to take any questions.

I thank Ms Hardiman. I thank all of the witnesses for agreeing to participate in this morning's session.

I welcome Ms Hardiman and thank her for coming before the committee again.

From the earlier discussion, it appears that we have a completely unacceptable situation in terms of scoliosis treatment. The matter needs to be dealt with, as a matter of urgency. Covid has been deemed to be a factor. However, we have evidence to the effect that Covid was not a factor from one of the earlier witnesses. Also, that we can, and could, utilise facilities that are available in the downtime of theatres to deal with the urgent waiting lists. I ask Ms Hardiman to comment.

Ms Eilísh Hardiman

I concur with my colleagues, Professor McCormack and Mr. Green. We continued, and they continued, to work during the pandemic and during the cyberattack but a lot of focus was on the emergency, urgent and time-sensitive cases. Unfortunately, during that time we had to cancel elective surgeries for a period but that was for safety reasons on both occasions. We can clearly demonstrate and acknowledge that when we received the investments in 2018 and 2019 we made a difference. We increased the staff and reduced the waiting list for scoliosis treatment, and managed the situation an awful lot better. That was the position in January 2020 but, unfortunately, it has deteriorated since.

We have developed proposals for funding to provide access to care, and to increase the capacity of theatres in both Temple Street and Crumlin hospitals because that is where the majority of these cases need to be dealt with. We are also identifying how can we utilise that capacity at weekends. To make it sustainable it must be something that we are not just doing a few weekends at a time. It needs to be something that is built into Temple Street and Crumlin hospitals, and will expand the services over in Cappagh hospital before we move to the new children's hospital.

From our perspective, we can progress if we get funding. In fact, the funding has been approved and I assume that it will come through the service plan for 2022. We hope to have the fifth theatre open in Temple Street by July of this year. We can start, at the same time, trying to extend the theatre times in Crumlin but that requires us to recruit staff.

Do the CHI's plans for the current year involve the kind of things that we were told about the utilisation of the downtime in theatres, etc? Is that part of the plan for 2022?

Ms Eilísh Hardiman

Yes. My point is that it is fine for some short initiatives but it is not sustainable on a continual basis. We would have to be significantly staffed to work a seven over seven roster. We propose to extend the hours of theatres.

Why is not possible to do this on a continual basis if this is effective for a time? We have an urgent situation on our hands, and have had for some time so why is not fortuitous to do that now on a continual basis until we work our way out of the crisis?

Ms Eilísh Hardiman

Today, our hospitals are at 100% bed capacity because we are dealing with emergency cases. We have had the highest number of attendances to our emergency departments and urgent care centres. There has been as much as a 36% increase compared with the same time in 2019. We cite 2019 as we do not view 2020 as a normal year. I know that the Deputy will understand that the solution is not just about theatre times and that it is about making sure we have beds. Therefore, we need to expand the number of beds and increase theatre times to be able to accommodate this. If we stopped working on the weekends then some elective procedures will not be accommodated on a Monday and Tuesday. Our plans have identified that we should expand the number of beds, MRI scanners, staffing and theatres together otherwise a block will be created elsewhere in the system.

We agree that it is good planning. I have another question that arose from the earlier discussion. I want to learn about the availability of appropriately trained staff to deal with the situation that arises. Is Ms Hardiman satisfied that the requirements will be met?

Ms Eilísh Hardiman

It takes time and planning to get highly specialist consultants. The comments made about the efforts to train is the reality in paediatrics. We have found that when we plan ahead we can encourage clinicians to plan for and engage in their training so they are identifying the posts and clinicians for the future.

From a nursing perspective, we have only two vacancies in our theatres at the moment and that is a good position to be in. We need to recruit more nurses to expand our theatres but we are in a relatively good position.

I am happy to confirm that we have a fully staffed eight-bed ICU in Temple Street and 23 beds fully staffed in Crumlin for which we are funded. We have surge plans, if necessary, during an emergency and that is done an overtime basis.

Once we get approval to proceed, we will do an active recruitment campaign and our nursing leaders are quite strong on that. Nurses and anaesthetists, predominantly, are the other key staff that we need. My clinical colleagues are quite right that it takes longer to fill psychology and nurse specialists posts. We have demonstrated with the investment that we got in 2018 and 2019 that we can attract high calibre staff. We must now get the infrastructure that will allow staff to do the job that they came to do with us and treat children as speedily, and as timely, as possible.

This morning, we heard honest, sobering and heartbreaking contributions from two colleagues of Ms Hardiman who are consultant surgeons in this area. Was she present to hear the presentations or has she listened to them?

Ms Eilísh Hardiman

Yes, I have listened to them.

I will start by referring to a number of comments made by Mr. Green. He said that the care of children with scoliosis in this country is absolutely inadequate. Does Mr Hardiman agree with him?

Ms Eilísh Hardiman

We actually are challenged. We would like to be able to achieve better and more timely access.

We are restricted by the infrastructure situation.

Ms Hardiman accepts that the-----

Ms Eilísh Hardiman

We need investment to deliver what we see as the standard of care to which we aspire.

Ms Hardiman accepts that the service is inadequate. He also said that it would be "dishonest", to use his word, to claim that the cyberattack and the impact of Covid-19 are the main drivers of a worsening situation. While he accepted that those events would have had an impact on longer waiting times, he said that the problems predate the onset of Covid-19 and the cyberattack. Yet Ms Hardiman, in her opening statement, mentioned on three occasions the impact of the cyberattack and Covid-19.

Ms Eilísh Hardiman

Yes, we had to cancel all elective treatments across the three children's hospitals in CHI. We closed Tallaght hospital for four months during the Covid-19 crisis. We supported our colleagues working in adult medicine by moving some of our staff over to work in those services during that crisis. Therefore, I can clearly demonstrate the significant reduction and impact that this had-----

That is in Ms Hardiman's opening statement. My point though concerns this situation where we have people at the coalface treating children, such as the surgeons who are doing the procedures, saying that it would be "dishonest" to claim that the cyberattack and the impact of Covid-19 are the main drivers of the current situation, a worsening situation and the inadequacy of the service. Would Ms Hardiman accept that is a reasonable position for those people to hold, from their perspective?

Ms Eilísh Hardiman

I can see it from their perspective, because, as surgeons, they were still working. We still continued with emergency, urgent and time-sensitive surgeries during that time and we made some impact in those areas during Covid-19. However, we had material amounts of time where no elective surgeries were being done, because it was considered unsafe to carry out such procedures. I might add this was more particularly the case during the cyberattack, because Crumlin and Temple Street hospitals were severely impacted by it, more so than many of the other acute hospitals. We have, therefore, had these periods whereby it has-----

I get that. The problem, though, is that in 2017, the Ombudsman for Children's Office produced a report.

Ms Eilísh Hardiman

That is correct.

We had many statements then from the then Minister for Health, and others, and plans and strategies were put in place. In her opening statement, however, Ms Hardiman still referred to more operating theatre capacity being needed and coming. She also spoke about additional beds being needed and coming, and I assume that she is talking about paediatric ICU beds. She also then referred to new MRI scanners coming and additional staff being on the way.

I was given a statement to read by the Scoliosis Advocacy Network, SAN, which I will not have time to do, and I have also met the parents of many children who have scoliosis. The reasonable point they would make in this regard is that those plans and strategies were put in place five years ago and it is now 2021. Yet, we are still here talking about the provision of more surgical theatre capacity, which may be on the way, and for which there are plans down the road, more staff, who may also be on the way, with plans again for that to happen down the road, more beds, which once again might be coming and for which there are again plans down the road. Why in God's name was all that not done during the past five years? Why are we still here and still hearing about all these aspects?

When Ms Hardiman responds, she might also spell out more detail in this regard, because her opening statement was quite scant on detail. When she refers to more operating capacity, what exactly is she talking about and when will that be provided? Equally, concerning the reference to more beds, how many will there be and when will they be in place? Regarding the new MRI scanners, as well, how many will there be and when will they be in place? Ms Hardiman also talked about additional staff, as did my colleague, who referred in particular to the need for more nurses to open beds. How many such staff will there be and when will they be in post? That is the type of detail that parents want to hear. They want to know what actions are to be undertaken, what is happening in that regard and why that was not done over the last five years.

Ms Eilísh Hardiman

I am happy to give that clarification and any further details needed. The Deputy is absolutely right that we did get investment in 2018 and 2019. If I was to take the position in January 2020, therefore, which for us was the last normal period in our provision of elective services, we then had 147 children on the waiting list for scoliosis treatment. Of those children waiting, 70% of them had been waiting for less than four months. That was the target we were aspiring to achieve. Some 30% of those waiting had been on the list for more than four months, and some of those had been waiting for clinical reasons. That is the position from which we have deteriorated.

What we have seen since that time is that the numbers have been increasing, because we have been unable to get elective surgeries done. The length of time that people have been waiting has also increased. Those are the facts. When we did get investment, we made some progress.

I would like to support my colleagues-----

My time is up, and I still have not heard what additional capacity will be put in place.

Hold on there, Deputy Cullinane. A series of questions have been asked, and I ask the Deputy to allow the witness to answer. He can come back in then.

Ms Eilísh Hardiman

I thank the Chair. I concur. This is not just a matter concerning scoliosis treatment, as our clinical colleagues have said. This is about orthopaedic services overall. In that context, we are trying to expand the paediatric orthopaedic services we provide in CHI. To give some specifics, and I am happy to send on the details in writing if we have run out of time, we have identified that we need a fifth theatre in Temple Street. We have plans ready to go for that endeavour, and we anticipate that we will have that facility open by July 2022, subject to approval in 2021. We have also identified that we are going to open unfunded elements of and expand the theatres in Crumlin. We can move on those in the first six months to get the staff in place to extend the hours. An MRI scanner will begin operating in Temple Street in July 2022 as well, and, subject to funding, we will have a second MRI scanner in place in Crumlin by the end of 2022.

Turning to the situation with beds, eight beds will be opening in Temple Street at the end of November. Those are short-stay beds to deal with emergency issues, and that is intended to address the situation regarding some of the cases, from the huge numbers being seen in our accident and emergency department, being admitted up into the inpatient beds. Those extra beds will allow us to try to decompress the pressure on those inpatient beds. We have a plan to also put four more beds into Temple Street, subject to funding, and we can put a further ten beds into Crumlin. Those beds will be put in place by the third quarter of next year, because they are subject to some building work being done. We have identified the revenue and capital costs required for these investments over the next two and a half years. We hope these developments will allow us to address the situation with orthopaedic services in general and not just with scoliosis cases, although we are of course keeping a close eye on our scoliosis waiting list.

I will finish by saying that there is a great deal of frustration about this issue because of the impact it has on children. I make no apologies, therefore, for the robustness of my contribution. We must see the details and timescales for everything that Ms Hardiman has outlined.

Ms Eilísh Hardiman

Yes.

I say that because parents and children have heard all this before. Five years on, we are still hearing about more capacity that may be on the way. I do not doubt anything that Ms Hardiman has said about the commitments but we must see action in this regard and these commitments delivered. We must also see the details of all these undertakings in writing, including the beds, the staff and the surgical theatre capacity, the numbers involved, respectively, where they will be in respect of each hospital and when these developments will come on stream. When these additional resources will be in place is the crucial point. I would like to have details of these timescales involved and if Ms Hardiman could send that detail on to this committee as soon as possible, that would be very helpful.

Ms Eilísh Hardiman

I am happy to do that.

I thank Ms Hardiman. I call Deputy Cathal Crowe.

I welcome Ms Hardiman and our other witnesses. We had Professor McCormack and Mr. Green with us a short while ago talking about their analysis of the waiting lists and the one thing they both said was that Covid-19 and the cyberattack cannot be blamed for the mess we are in regarding the long waiting list for scoliosis treatments and surgeries. One of the points that I homed in on was that the surgical theatre required for scoliosis surgery two days a week is not used for scoliosis surgery. It sits idle. Could Ms Hardiman account for why that is the case and why the theatre cannot be staffed and opened, as suggested by Professor McCormack and Mr. Green?

Ms Eilísh Hardiman

I ask the Deputy to clarify whether the situation he is talking about concerns Cappagh hospital.

I believe it was in CHI.

Ms Eilísh Hardiman

No. We are engaging actively, we have theatres and list spinal cases every week. I do know that over in Cappagh, they are seeking an extension of theatres.

Okay. I am sorry. My apologies then-----

Ms Eilísh Hardiman

We support that extension.

The point stands, but I am sorry. I understood that the situation was as I outlined it, but that is fine.

Moving on, is Mr. Liam Woods with us as a witness?

Yes, he is.

My next question is linked to what we are talking about here. The Chair had a different view in the last session, but I ask for his forbearance now. In July this year, the Food and Drug Administration, FDA, in America issued a notice alerting patients and healthcare providers to the potential risk posed by MAGEC, that is, magnet expansion control, rods. The key concern referred to by the FDA is that the end cap can separate from the device and that these have not been fully tested for-----

Deputy, you do not need to mention the specific names of products.

With the greatest of respect, I think every global media outlet has named this. I am not maligning any outlet.

I am just going by the instructions as Chair.

I understand that.

We read out at the start of every session that we are not supposed to name individuals or entities.

I understand that and I would like to proceed because I will not be defaming anyone. I guarantee the Chair that. I will not be abusing privilege.

You do not need to mention specific names of products. Go on.

Can I proceed, because I am referencing something that is crucial to parents and patients here this morning?

I know you are. You can reference without naming the particular product. That is all I am asking you to do.

I will continue because everything I am saying is already in the ether and has been covered by global media. This is a fact and it can found on Google in a matter of minutes.

Again, I am working under instructions as Chair. Bear in mind what I am asking.

Would you adjust the clock, Chair?

I will adjust the clock. I am just saying to you in future we do not mention names or entities. We read that out at the start of the meeting. They are the instructions I am under.

I will restart my question to Mr. Woods. There is a device that is manufactured in America. The FDA has in July of this year issued strong caution about it. It has alerted both patients and healthcare providers of the potential risk of this device. One of the key concerns it flagged is that the end caps of this device have a tendency to detach from the rest of the device. They detach from the rod itself while it is implanted. It has also been referenced that these have not been tested for biocompatibility. Basically, they detach when within the body of the person. We do not know what potential harm that causes. The scientific world is investigating this. Currently, however, there is a suspension of the sale of this device in all 33 countries that require a Conformitè Europëenne, CE, mark. On top of that, there is a voluntary hold on shipments of the device in other countries. I understand that the device is still used in Ireland in scoliosis surgery. I understand that 51 patients may already have this device implanted in them. It is continuing to be implanted on so-called compassionate grounds on the basis that the need for surgery and the need for this device outweighs potential risks that other regulatory bodies on the other side of the Atlantic have already flagged. I do not expect Mr. Woods to have all the answers. It is a bit of a curve ball question. If nothing else, I want it on record here today that we have major concerns about this device. The world’s scientific community has major concerns about it and surgeons have major concerns about it. The CE mark has been withdrawn from the device. The FDA has written cautionary notes to all in the sector. Yet, in Ireland, we still continue to implant this. It is essential that we slow down a little bit here and that we look at global scientific studies. If this device needs to be suspended, which other countries have done, we should follow suit in that and not become the outlier in potentially putting patients, particularly young people, at risk.

Mr. Liam Woods

I thank the Deputy. I heard the question and I heard the debate earlier. I would have to refer to the Deputy in writing about the detail of the question. I am not sure if CHI can make any comment at the moment. I might hand over to Ms Kelly who might make a comment.

Ms Paula Kelly

Before I answer the question I would like to thank the committee for the opportunity to be here. We are grateful to be given this arena to advocate for our patients. Specifically related to this question, we only got the email this morning from NuVasive that says that the CE certificate has been reinstated for the PRECICE nail. I probably should not mention the name. The patients that had implants are being monitored. Levels are being measured in London. The families have been informed of this. This is to give the Deputy the clinical context.

That is breaking and welcome news.

Ms Paula Kelly

It is really reassuring for everyone.

It is. I want to conclude by thanking Ms Kelly for clarifying that. There are 51 patients who have been very worried about this. It would be no harm if Ms Kelly and the surgical team in the hospital could write out to patients explaining this, as well as that any scientific analysis is to be published and to be put in the public domain. It is bad enough to have scoliosis. We have heard from many of the children in recent days. Their parents have emailed us. Some of these children are close to paralysis. They are in wheelchairs and they are awaiting surgery. On top of that, those who have had surgery have had this added risk, health concern and potentially a metallosis or a detachment of end caps. It concerns me. I am glad that we have clarification this morning. However, we have been outliers in continuing to implant this when other countries pulled right back from it. Ms Kelly’s clarification is welcome here, but it needs to go beyond what is said in the committee this morning. That needs to be issued in a communiqué to all families of patients who are either waiting for or who have received this implant.

Ms Eilísh Hardiman

Chair, may I please have an opportunity to respond?

Ms Eilísh Hardiman

Thank you. Deputy Crowe is right that assurances should be given to families. I know that the clinician has personally contacted all of those families, has reviewed any of them that have required review and has formally written to them. We are happy to continue with that communication and to update them with the new information just received today.

Deputy Shortall is next.

I thank all of the witnesses for their attendance and for the presentation. My question is to Ms Hardiman. In the course of her responses to a number of members and in her presentation she talked about plans for a fifth theatre in CHI at Temple Street, additional staff, additional beds, and so on. In relation to each one of those, she put in the proviso of "subject to approvals". Can she explain exactly what that means? When will the issue of approvals come up? What is delaying her getting the necessary approvals?

Ms Eilísh Hardiman

I might have to defer to my colleagues on this. The access to care programme is the funding that has been identified to address the better access and the waiting list challenges. CHI has made submissions across all of our services that need better access to care so as to improve them. We have some changes with some investments we have got already into particular initiatives. I will ask Ms Kelly to elaborate on those that are specific to orthopaedics. We have made those submissions. They are under consideration. I am expecting that part of the allocation in 2022 and confirmation before that. We should hopefully get confirmation of what has been funded and approved to progress with.

When are decisions due on that?

Mr. Liam Woods

Can I come in there? Very briefly, not to waste the Deputy’s time, we are doing a service plan of the HSE right now based on the recent budget. All the decisions for 2022 are in the context of that service plan. Some proposals that Ms Hardiman has referred to that have already been signed off under the access to care programme. They are already commencing. Others are a matter for the service and capital plan of the HSE, which has to be completed by the end of this month and submitted to the Minister. That is the approval process. Within that, there is also further funding of €200 million for access to care programme-type projects. Paediatrics, scoliosis, and indeed paediatric orthopaedics would be high priority within that.

Is that €200 million right across the board for all services?

Mr. Liam Woods

Correct.

This year, the Minister and the Department approved the service plan very late in the day. I certainly hope we will not be waiting as long this year. Could I ask, and I do not expect the witnesses to have the information today, about waiting lists? They provided some details on that. The number of patients waiting for inpatient and day case procedures is over 5,000. A further 44,000 - an incredible number and quite a scandal - children are waiting for outpatient appointments. The key thing in this is the waiting times, as opposed to the waiting numbers. Could the witnesses provide the committee with a breakdown of the waiting times within each of those three lists?

The next issue I want to raise is the earlier session, which the witnesses said they saw. Personally, I thought Professor McCormack’s analysis of the nature of the problem was to the point, clear and impressive. Do the witnesses accept the case that Professor McCormack was making about the nature of the problem, which is the competition from the private sector, the competition from adult paediatrics and the general dysfunction and chaos that he referred to?

I was certainly very impressed by his analysis of that and of the steps that needed to be taken to bring about systemic fix, as he called it. Is there a forum to listen to what practitioners are saying about this and the steps that need to be taken? One gets the impression that there are administrators on one side and practitioners on the other and there is very little meeting of minds. Is there interaction between those two groups and is there a shared understanding of the nature of the problem and of what needs to be done?

Ms Eilísh Hardiman

I thank Deputy Shortall. Would she like me take that question from a paediatric prospective, if I may?

Ms Eilísh Hardiman

To be clear, the Deputy is completely correct in that for paediatrics to be delivered to the standards that we all want and expect, it has we done as part of an integrated network across the healthcare system. It is a little bit like the cancer system as it cannot be done just in Dublin but has to be developed in the regions. We are really strong in Children’s Health Ireland, CHI, on the need to support and work with the regions to ensure that in the model of care, while we are consolidating what needs to be consolidated in the new children’s hospital, as much as needs to be kept local and convenient is. I would like Ms Kelly to come in and talk about those regional elements and discussions with our colleagues. We have a paediatric network lead who is discussing with the regions how we should develop that in an integrated, networked way, with CHI clinicians working and supporting that as much as possible.

Does Ms Hardiman actually sit down with people like Dr. Green and Professor McCormack, people with experience, to discuss solutions?

Ms Eilísh Hardiman

Yes. I was going to discuss what happens inside CHI also. We have regular meetings with the orthopaedic team. Ms Kelly is across CHI, which is Crumlin, Temple Street and our colleagues in Tallaght hospitals. I have meetings with Angela Lee also. We do sit down because we know that this is going to require efforts over and above to move this investment because it needs to be moved. A task force is being progressed to ensure that we implement it. That is what we did previously when we got the investment; we ensured that there were target times and the clinicians are the key to the solutions of what is intended. That is our commitment within CHI.

Is Ms Hardiman saying that there is a task force that is made up of both sides?

Ms Eilísh Hardiman

Yes, and it is within Children’s Health Ireland.

Who is representing the surgeons on this task force?

Ms Eilísh Hardiman

Ms Kelly is our clinical lead for the surgeons in CHI.

Okay. I thank Ms Hardiman and I have just a few more questions.

Mr. Woods is also looking to come in and has his hand up, Deputy Shortall, as is Ms Kelly. Does the Deputy want to allow these witnesses to respond to the previous question?

Sorry, but to clarify, is Ms Kelly the clinical lead on that? Yes, that is fine.

Part of what was proposed earlier on as to solutions was the whole question of the plan for the National Orthopaedic Hospital Cappagh and its funding and that that could be brought on stream within a ten month period. Where does that stand at the moment and when will a decision be taken on the funding of that?

Mr. Liam Woods

Perhaps I will take that question. We have a number of proposals on Cappagh but the proposal that was referred to was the larger one. We have one with a quantum of €88 million for over 70 beds at Cappagh including ten high dependency unit, HDU, beds. That will also be considered in the capital plan for the HSE and in reality is relevant to the elective hospital discussion in which I am not directly involved myself but is moving forward. There are other and much more immediate proposals around Cappagh which were referred to. Ms Hardiman referred to one of those around Cappagh Kids which is using two more days in theatre in Cappagh. That is something that will move in the service plan this year.

Okay, but on the bigger proposal to designate Cappagh as the elective centre for paediatric orthopaedics, is there support for that proposal?

Mr. Liam Woods

There is support for paediatric orthopaedics within the model of care and I will defer to some extent to Ms Kelly here. We need to recognise that the most intensive work is done in Crumlin and Temple Street hospitals. Cappagh is a very good base to do a significant volume of work, both age and acuity-adjusted, if the Deputy follows my meaning here. Yes, we are very supportive of doing work for children in paediatrics in Cappagh as we are indeed for adults. It is an excellent centre.

Does the proposal for that major centre also have to await the service plan?

Mr. Liam Woods

Yes, everything we are doing in 2022 will come from the service plan.

Okay, I thank Mr. Woods. My final question is-----

Ms Paula Kelly

Could I answer the Deputy’s question, please?

Ms Paula Kelly

I thank the Chairman. I took up the clinical lead in February of this year. We have a very clear vision across the orthopaedic department which includes all the surgeons, nursing and anaesthesia. We work with a very large team which looks after all of these children. We have a very clear vision of what we want to do and number one is that by a particular time we want to have no children waiting for surgery and, more specifically, not just in terms of numbers, we want to be in a position where children are not suffering, be that in pain or from a psychological point of view in not being able to play sports and all of those things. That is the situation we want to be in.

I and our team believe that this is the first time in Irish history that this is achievable. For the first time we have an infrastructure in the new children’s hospital, albeit it is down the road a little bit, that will allow us to have four orthopaedic theatres running for children and will have 23 protected beds which will not be affected by the emergency department. That will allow us to have a dedicated spinal theatre. There is also a dedicated trauma theatre which will continue our trauma service. We have a management structure which is listening, is actively engaged and is open to our discussions on a regular basis. We have a Government that that has given a commitment to fund what is needed. I really believe that this is an opportunity and if we get this wrong we have no excuse.

I appreciate that.

Ms Paula Kelly

We will hopefully have four theatres.

Hopefully we will see all that coming on stream. My questions are on what is going to happen immediately and how quickly can the many, many children who are on that waiting list be seen?

Ms Paula Kelly

Absolutely, we will need four theatres running across Dublin.

But that is not sufficient. The point has been made that those theatres are lying idle at the weekends. Why can we not open up those theatres and do what Professor McCormack has suggested and what he did himself, two years ago? Why can we not take that kind of can-do approach in maximising the use of existing theatres rather than all of this talking about building projects for the future? Can we produce an immediate response to the immediate crisis that is there for children who are in agony?

Ms Paula Kelly

Certainly, we have 14 paediatric surgeons now and we talked about numbers earlier. Every one of our surgical group are keen to work, be that Saturdays or Sundays, there is no issue and we do not need more surgeons.

How can they be facilitated to work on Saturdays and Sundays?

Ms Paula Kelly

Yes.

What is Ms Kelly going to do to make that happen?

Ms Eilísh Hardiman

Part of the proposals is to look at what can be done at weekends. Our challenge is that it is not sustainable. We will do anything that is short term but something for two and a half years needs to be sustainable because staff will not continue working overtime. In addition, we have to understand that some of these patients are highly complex and would be best done during the week when we have all of the other supports that are actually there. We have absolutely no problem moving but when we go to weekend working, we tend to do that with some of the less complex procedures to reduce the waiting times. We are happy to take that as part of these proposals and it will involve people working overtime on additional payments, and such matters, to actually do that. These are things we can do.

There would be an interest in hearing from our witnesses precisely what they are going to do about that and the timescale involved. We would welcome more detail on that.

The Deputy is out of time now but she may go on.

This is my very final question, Chairman. Many parents have said to me that because of the chaotic nature of the waiting lists and of course the fact that we have a two-tier health service, they have to borrow or get money somewhere in order to see a consultant privately as an outpatient in order to get on the public inpatient waiting list. Is this the case and what are our witnesses going to do about that?

Ms Paula Kelly

I will answer that question. That is completely wrong as every child in this country should have access to care and that should be provided in the public health sector. We strongly support that. Yes, there is a two-tier system where children can access care privately, for sure, where they bypass and get a quicker service in the private sector.

We do not support this. We need to build a future for paediatric orthopaedics which is public-based and where every child, irrespective of where they live or what their parents' income is, has equal access to care. That is what we would strive towards.

Will that not continue as long as there is a shortage of consultants? It is estimated we are about seven or eight consultants short of what we need for a standard ratio.

Ms Paula Kelly

We have 14 consultants in Dublin. We need an additional ten or 11 to support the regional centres. We need regional centres in Limerick, Cork and Galway, as has always been clearly mapped out, with a network to link to CHI so we do not have consultants independently operating on their own and we have the support of the CHI group.

Sure, but that is not happening. How will the witnesses make it happen so we have more paediatric consultants available to provide these critical services?

Ms Eilísh Hardiman

We are engaging with the regionals and doing some joint planing on that. We have met with our colleagues in Cork, Limerick and Galway again this year as part of the service planning and investments required to identify posts that can be developed in the regions with us, putting in a joint proposal and how we can support this. For Children's Health Ireland, as a national integrated network, it is part of the regionalisation of health to ensure we are working and planning with them----

Is the issue not training?

Ms Eilísh Hardiman

We work with the training bodies and have examples where consultants work with us before they move down to the regions. We are willing and able to work with the training bodies and do the workforce planning needed to support----

You are not training enough.

Will the Deputy let the witness finish answering?

Ms Eilísh Hardiman

The national training body for doctors in the HSE has identified the workforce plan. We are committed to working on it. We accept that paediatrics requires additional training. We are working now to a standard in CHI that is comparable to the training they could get internationally. I see the training assessment reports that come in for CHI. We can offer to plan this but it needs to be planned. We started, let us say, five years ago on planning for some of what we knew was in the pipeline and are able to demonstrate that, for example, a huge number of people are applying for general paediatrics. It is the same in paediatric emergency medicine and paediatric anaesthesia. It takes that length of time. I support Professor McCormack concerning the need for strategic planning around these posts. There are not many of them so trainees need to identify the potential future.

I accept what Ms Hardiman is saying about planning but why are we only talking about it now?

The Deputy is way over time.

When will the additional training posts be available?

Is that the last question because you are way over time?

That is the last question.

Ms Eilísh Hardiman

I will have to come back with the other specifics. I do not have the details unless Ms Kelly wants to add anything.

Ms Paula Kelly

As Professor McCormack said, our training in orthopaedics - it is one of our strengths as well as one of our weaknesses - is such that we all train in adults and then sub-specialise in paediatric training so every paediatric orthopaedic surgeon in the country has a two-year paediatric fellowship training. It means every adult orthopaedic surgeon has the skill set to look after paediatric trauma and it is key at a national level to continue this. If our adult surgeons are not trained, the paediatric surgeons will need to do all the trauma, and that is not option. We have eight SpRs coming off the training programme each year. The problem, as Professor McCormack said, is attracting those people to paediatrics. People do not go into paediatric orthopaedic for money; they go into it because they want to look after children with disability. That is-----

I just do not know what we are doing to attract those people. That seems to be where the logjam is.

Ms Paula Kelly

The only way to attract paediatric orthopaedic surgeons is to have resources and theatres. The new children's hospital will do that.

We cannot wait that long, unfortunately.

I thank the witnesses for their presentations. Ms Kelly said eight specialist registrars come off training each year. Can some adjustment be done so that an automatic number comes into paediatrics? My understanding is they have to do a further two years in paediatric orthopaedics once they finish the five-year training. Can that be adjusted to make it attractive for them to commence paediatrics? Can that be planned for?

Second, we were talking about theatre nurses earlier. There is huge competition for theatre nurses who have the skills and experience. Hospitals in some countries are training theatre specialists, in other words, theatre assistants. Is there any plan to introduce a programme for theatre assistants, whose job from one end of the year to the other is working in theatre only? Is that being planned now or, going forward, for the new children's hospital?

Ms Paula Kelly

I will answer the first question about trainees coming through. The number is not always eight; it fluctuates a little bit. Unfortunately, the SpR depends on what they want to do. Every orthopaedic surgeon who comes to the end of training picks a sub-speciality. If they are doing adult arthroplasty, they would do a two-year fellowship in that. Every sub-speciality does a training of one year or two years. Nobody goes into a job unless they want to so we could not specifically have two or one paediatric slots. It has to be the surgeon who wants to do the sub-speciality.

We do manpower planning and five years ago we aspired to having 14 surgeons in CHI. We have achieved that, which is fantastic. We need to look at that on an annual basis as surgeons may leave or retire. It is part of our orthopaedic development goals to look at manpower planning. Our biggest issue at the moment is nursing. We need many more nurses specialised in paediatric orthopaedics.

Mr. Liam Woods

On the Deputy's second question, the model of care for orthopaedics, which is on the HSE website, identifies the need for operating department assistants, the theatre assistants he referred to. There are already some theatre assistants working in the country and there are plans to increase that, within and outside of paediatrics.

What timescale are we talking about? What level of training will we provide? When will we have a structure of training for that type of post?

Mr. Liam Woods

To some extent it is already happening. I would need to come back to the Deputy with a written answer to address the full detail.

Mr. Woods might also outline the number of people it is proposed to train per annum.

Mr. Liam Woods

Absolutely.

Going back to Cappagh, Temple Street and Crumlin hospitals, it is three or four years down the road, but what percentage of the work being done at those hospitals will transfer to the new children's hospital? What will be the level of transfer of staff from there?

Ms Eilísh Hardiman

We are planning the opening of the children's hospital because it is two and a half years out and it takes that level of planning to do something that significant from a change perspective. All of Crumlin and Temple Street and all of the inpatient services in Tallaght will transfer to the new children's hospital. The issue of elective work and, specifically, Cappagh is something we are waiting to explore and is being outlined.

We have a detailed activity and capacity plan developed for all the activity in the new children's hospital and are moving to the plans to open it, prepare to transfer those services, close those hospitals and consolidate everything. We will have the children's hospital with everything consolidated and two outpatient and urgent care centres: one at Connolly Hospital, which has opened, and another at Tallaght hospital, which is opening this weekend.

The next step is to ensure, as an integrated network with the regional hospitals, we are supporting as much paediatric medicine and surgery as can and should be in the regions. Those services should be as local and convenient as possible.

I will deal with those regional issues. I have a report here from Cork University Hospital which includes a cost-benefit analysis. At a recent meeting, it was indicated to me that nothing is going to be done to upgrade and provide the necessary facilities in Cork for at least another five years. What is the plan? We have now developed outpatient services at Tallaght and Connolly hospitals but nothing has been done in the regions. We are now very much on the back foot in Cork. What is going do be done in that regard?

Ms Eilísh Hardiman

I might let Mr. Woods expand on that but I assure the committee that Children's Health Ireland has been actively engaging with its clinical and management colleagues in Cork University Hospital and the South/South West Hospital Group. We have had joint meetings, one of which related to orthopaedics. A specific element of that was that we identified we can work collectively. I understand there is a plan and proposal as to how to develop paediatric services and ensure they are developed locally, within the region, to ensure that services required in Cork remain there. Mr. Woods may wish to add to that.

Mr. Liam Woods

I thank Ms Hardiman. I will respond to the point the Deputy made about Cork University Hospital, which is a matter for the South/South West Hospital Group, as he rightly said, and not CHI. There is a proposal, as the Deputy probably knows, from that hospital group to develop a paediatric facility. That is under consideration under the HSE's capital process. It is a significant proposal and it is already under deliberation.

In fairness, there is also a proposal for a new elective hospital for Cork which has not progressed by a single inch in the past five years. We are focused very much on the capital side, and rightly so because there is a need for development and a new children's hospital. However, everything else appears to be parked. I am concerned now that paediatric services in Cork will also be parked and we will not get what we require. We will be unable to keep consultants if the facilities are not there. We will not keep the nursing staff and we will not have the facilities we require.

Mr. Liam Woods

In response to the Deputy's point, no, it cannot mean that everything else is parked.

That seems to be the message.

Mr. Liam Woods

CHI must develop facilities for the future of the country. To be clear, 60% of children are not in Dublin. The proposal for Cork can run in parallel with the development of the new children's hospital. There is a significant national development programme published, which provides significant resources for capital spending in the health service. It is in that context it would be considered. It is not in any way parked because of any developments happening around CHI.

Those in Cork have not received an indication as regards whether we are talking about 2022, 2024 or 2026. Surely at this stage some indication can be given to them in that regard. We must go through a planning process. We have not even gone through a design or planning process. Can that be started at this stage?

Mr. Liam Woods

If it would be helpful, I will come back to the Deputy directly with the detail of where that project is at. As he rightly says, there is at least a 12-month lead-in time for design and planning for any major proposal and this is a significant proposal, as I understand it. I will revert to the Deputy in writing with that detail, if it would be satisfactory to him.

I will ask a final question that returns to the issue of scoliosis and the opening of theatres. I know there is a number of components to any operation. There is a need for staff, a consultant, support after the operation is completed and beds. An issue arose around theatres not being opened at weekends. How serious are we about trying to deal with that issue and to identify beds that would be available if operations were done on a Saturday and Sunday? Is it possible to have beds available so that patients can get the necessary support after surgery?

Ms Eilísh Hardiman

I am quite happy to lay out the details clearly. The commitment is there. We have identified how we can practically progress this and increase the capacity within both Temple Street and Crumlin, and support the expansion in Cappagh hospital for scoliosis. As I said, we already have eight short-stay beds opening in Temple Street at the end of this month. The new facilities are opening in Tallaght at the weekend. There are short-stay beds in that unit to prevent admissions. These are all developments to try to ensure that patients in the hospital are inpatients who need to be there. We have plans, the detail of which I am happy to go into. The commitment is that we have a task force. I am happy to demonstrate how those plans can actually be progressed and developed once we get approval for funding. We have a lot of things ready to go, subject to our progressing them. We hope to hear positive news about them in the next few weeks.

It would be helpful for the committee if we could get that back in writing.

Ms Eilísh Hardiman

I am happy to do that.

Is Ms Hardiman saying the issue thereafter is funding?

Ms Eilísh Hardiman

We appreciate there is an approvals process, the national service planning process, which involves the HSE and the Minister. That is the process under which this will be considered.

I thank Ms Hardiman for her presentation. Many of the technical questions have already been asked so I will not go through them again. We have all had a considerable amount of communication from parents of children who are suffering from scoliosis. I was struck by the situation of parents who contacted me. They ended up leaving the country because they were concerned about the care their son was going to get. I do not think they are the only ones. They were able to do that. I was really struck by that case. They were comparing the care they get in Ireland and abroad. Their son was preliminarily diagnosed with scoliosis in the womb and all these different things. They moved to Finland. I was struck when they told me about the comparison in the care they were getting in another country. I was struck by how far we are from where we need to be, which has very much been highlighted here. Those parents are confident they will get the surgery when it is needed. In Finland, all the medical files are available online for parents to see whenever they want. I will not even ask our guests to get into medical files and how they are made available online because I know there is a whole issue around that here in Ireland. We need to get there at some point. The hospitals in Finland are well staffed, modern and all of those things.

The technical questions having been asked, the main question I wish to ask is whether our guests think we have simply failed in our approach to children's healthcare in Ireland. Have we failed in our approach to scoliosis treatment? Is that a reasonable thing to say? From all the communication I have received and all of the frustration I have heard from parents, the overwhelming sense I get is that we have simply failed. Can our guests comment on that?

We are talking about specialist staff. During the previous session, it was mentioned that a particular kind of staff member is required. Those are people who are willing to work in a system. I worry about the best laid plans to get the specialist staff in an area when we cannot compete with what they would get in the private market. I was struck when it was said in the previous session that a very particular kind of person is required. How are we going to do that? How are we going to get away from what we have, which, as parents are saying, is a failed system? That was the case before Covid-19 and the cyberattack. I know there are plans and everything is laid out, but what comfort can we give to parents? I cannot comprehend the suffering parents are going through. They are listening to all of these plans and different things but their children needed care last year and two, three and four years ago, or before they left this country.

Ms Eilísh Hardiman

I will start and Ms Kelly might come in. It is heartbreaking to hear that people think they have to leave the country because their child's condition will not be dealt with. We have excellent physicians and many patients who come through our systems are treated very well and very successfully. When we got investment and addressed this issue we made a significant impact. We will never have zero but we had 147 patients on our waiting list in January of whom 70% were waiting less than four months. That is not bad considering the constraint we still have, which is far less infrastructure than what we will have in the children's hospital. At a high level, we currently have 13 theatres; we will have 18 in the new children's hospital. That takes time to develop.

We have a very good plan and the way to attract colleagues is how we have gone about it already. The Deputy heard Professor McCormack talk about colleagues going away to the people they know and then coming back. Our 14 physicians and surgeons are very clear about how they can develop the future trainees who are coming up. They support, identify and work with them and we in CHI do what we call proleptic appointments. We are even willing to appoint a surgeon to finish off his or her fellowship and then come back to us. These are the all the measures we are putting in place and people are attracted to the posts because of what we do. It is quite correct that those working in paediatrics are not driven by the private market. We are driven by trying our best to put the child at the centre and working with each child as much as we can. We have constraints because, as the clinicians quite rightly said, this is part of orthopaedics, which is a bigger area we have to address and a big factor in the numbers I read out earlier for children trying to access paediatric services.

Credit has to be given to some of the clinicians for being quite innovative about some of the ways to address the waiting list. From a global perspective, our outpatient waiting list is going down. It is long but is going down because of the initiatives we are putting in place. Our day cases are also going down although our inpatient numbers are not. That is the area that has been impacted to a major degree. It is one of the challenges I outlined along with the fact that our hospitals are pretty much full of infectious disease and respiratory syncytial virus, RSV, cases, in which we have experienced a major surge. It is quite complex. I will ask Ms Kelly to talk about some of our initiatives to try to give assurance that we are trying to be as innovative as possible before we get to the new children's hospital.

Ms Paula Kelly

I have one comment on this. It is heartbreaking to hear that parents get to a point where they feel they have to leave the country because I can attest we now have 11 paediatrics final surgeons who are trained. They are fellowship trained and are from all over the world, including North America, Canada, Australia, New Zealand and Europe. They are the most highly trained spinal surgeons possible so it is heartbreaking to hear that parents feel they have to leave the country for treatment.

On initiatives, every crisis creates an opportunity, as they say. We tried to do a lot of work during the Covid pandemic. One of the initiatives we got was the active triage clinics where consultants actively triage a patient, ring them beforehand and then see them face-to-face. To put some numbers on that, and I know it is not all about numbers, Crumlin hospital staff saw more than 1,000 patients in Citywest. The conversion rate of those 1,000 children to surgery was just 5%, which is reassuring. Those children were the ones who were waiting longest and that is a reassuring figure. That initiative worked outstandingly well. We need more initiatives and we need support from management and the Government to continue them.

We also brought in virtual fracture clinics. That initiative really transformed how many patients we needed to see in the actual clinic. It did not discommode parents and patients' families by having them come into a clinic when it could be done over the phone.

To clarify, parents felt they had to leave. It was not about the quality of care they would get but the time they would wait to get it. These parents had their diagnosis before their son was even born. There is no question about the quality of care; it is about the fact that people are waiting so long to get it.

Have we failed in our approach to children's healthcare and scoliosis healthcare up until now? The witnesses have outlined all the things that are being done and the proactive work that is being done to try to tackle the backlog, but do they think we have failed up until now in our care, especially for children with scoliosis?

Ms Paula Kelly

No, I do not. It is very easy for any group to look at the negatives, but looking at it in context, approximately 168 spinal fusions are done every year by CHI. That number represents 168 individual children, their families and the ripple effect for those who have had successful treatments. Our morbidity and mortality rate is very low compared to international standards. When children do get treated it is a very high-class treatment. I support that position. I do not think we have failed. There is definitely more that can be done. The cyberattack and the Covid pandemic over the past 18 months has affected treatments but we can fix that, given all the correct supports.

Ms Eilísh Hardiman

I will add that the communications have been challenging. That is something we have identified that we could improve on. I totally understand a parent wants to know when their child will have surgery. Clinical nurse specialists were referred to and while they are conduits, when there are many people on a waiting list we have to support those specialists. They cannot spend all their time communicating. There are things we need to look at in order to communicate a little better and be clear about our patient management system. Patients come onto waiting lists, particularly for scoliosis, but there are significant staged elements of pre-assessments and other assessments because some of these cases are very complex. That is normal and is about safe patient care. We need to be clear about when the decision for surgery is made, even though there could be a lengthy period before that where people are on a waiting list in preparation for that decision point. Those are the sort of complexities. One of the things we will look at, and we offered this through the advocacy groups we meet with on a regular basis, is to get better at communications.

I have a couple of questions on some of the matters that came up, which I may direct to Ms Kelly. In the earlier session, Dr. Green and Professor McCormack talked about having a system to outline their concerns. In her experience, is there a system whereby such surgeons can outline their concerns? More important, are those concerns acted on? Is that her experience? If surgeons have positive suggestions that might improve the situation, are they listened to and are those suggestions acted on? Is that Ms Kelly's experience, broadly?

Ms Paula Kelly

With the creation of the new hospital we have tried to create that system. I am clinical lead and we have regular meetings within the orthopaedic group trying to integrate the two or three hospitals. We have that system in place. I strongly believe, however, that no surgeon should ever get to a situation where he or she has an unmanageable waiting list. That is just not fair on the surgeon and it is not fair on the children, predominantly, and families attending that surgeon. There should be a system, and we are seeking to introduce it, whereby once the waiting list goes over a certain length of time, the surgeon has to essentially say "I am temporarily full" and deal with those children on his or her waiting list before taking on more patients, which is just not fair on anybody.

Somebody brought up the issue of looking across the group of surgeons. If a surgeon is really good he or she will attract more patients, which is understandable. Patients need to be able to make the choice of who they go to. We need to look across the board - if one surgeon has a very long waiting list and somebody else has one that is shorter - at how we can implement access to care for those parents quicker. There is a lot that can be done before the opening of the new hospital for sure.

From any experience I have ever had of talking to surgeons, they want to be in theatre as much as possible.

I heard the frustration this morning of getting perhaps one day per week and dealing with one case when the same people could, if they had the opportunity, deal with half a dozen cases on a Saturday afternoon. We can understand the frustration arising from that.

Ms Eilísh Hardiman

Absolutely.

I know it is difficult to get the skill sets and everything lined up. I have spoken to surgeons and they are frustrated because they might be ready to go into surgery when one member of the team does not turn up, which brings all sorts of difficulties. If people have a couple of minutes, perhaps they could indicate how we could shorten these waiting lists, particularly for those families. There has been mention of respiratory syncytial virus and the challenges facing the system. Could we say something here to families indicating a system could be put in place and that within the next six months their children will be seen? It might be within a particular period that the lists could start decreasing significantly in length. I know there is a question of funding and theatre time, etc. When will the parents who are listening today see that this is starting to work?

Ms Eilísh Hardiman

There are infrastructure issues that cause rate-limiting factors. There is also the reality that hospitals are responding currently to many emergencies and the winter surge around respiratory illnesses. Every week we produce the numbers on the waiting list and share it with advocacy groups. We are willing to sit down and look at our plans, as outlined, as well as the timing. We have no problem communicating those and we share them in updates. We already publish, tweet and make the information publicly available as to how many are on the waiting list and being treated. We want to be open and transparent about these numbers and communicate as much as possible around this. We have had meetings with advocacy groups to see how we can improve on communication and we know we can do more on that. We are happy to engage with those groups and the committee to get any feedback needed to demonstrate the progress we can make in treating and reducing the numbers and length of time that people must wait.

The treatment abroad scheme was mentioned. It is understandable that parents are looking at their children in much pain or even agony in some cases and want to go abroad. There was some criticism of people going to certain countries for surgery thinking they might get a cure or some sort of treatment. I imagine families in that position would ask a consultant in Ireland if they would recommend surgery elsewhere and so on. For the families where it has not worked out and there have been difficulties, they have said the only way to get access to a consultant is through the accident and emergency department, particularly if the procedure abroad has not worked. Could we consider a system for such families, who through no fault of their own took that route thinking it would be quicker or the best one for their child? Could we look at a system for those particular families?

Ms Eilísh Hardiman

We assume such people go to a GP and contact the team. The teams constantly review the referrals to see if they are urgent or routine. If there are changes, people are advised to let us know. Again, in our communications we have contact numbers for services in Crumlin and Temple Street for engagement. We must improve that. Our clinical nurse specialists are busy trying to do clinical care with inpatients and support patients post-operatively. I advise that if there are changes, people should go to their GP and get a referral back in. That is instead of going to an accident and emergency department for consideration. If it is an emergency we advise parents to come to our emergency departments.

I get a sense that if people get questionable treatment they may seek repair work or whatever. It is about getting people back into the system in Ireland.

Ms Eilísh Hardiman

We expect people would work with clinicians if they are part of that process already. They would come back to them if there are any issues.

Mr. Liam Woods

On the point around continuity of care in the event of further care need, it would of course happen whether in primary care or a hospital space. For the committee's information, there are two options. The treatment abroad scheme is based on a clinical recommendation so there is potentially a level of safety about that in that there is a double clinical sign-off. The cross-border directive arrangements within the European Union are more flexible and patients or their parents may go directly abroad using that scheme, and that may not involve a clinical engagement. That, of course, could give rise to the kind of concern the Chairman is flagging. Continuity of care and reapproaching the health system in Ireland is open and based on need. There is no question of a disconnection there.

Professor McCormack made the point that some sites are excellent centres for this. Of course, our ambition is to provide adequate services in the public service in Ireland. That is our objective.

It may be a broad question but is there best practice from other countries that could be introduced in Ireland? Are there schemes or systems operated that work and which we could possibly adopt in Ireland? Are we happy with the current structure?

Ms Paula Kelly

Clinically, we are strong because all our surgeons have trained abroad. When they train with a fellowship, they continue links with the group. We have a very strong almost global network of advice so if we need advice from someone, we will contact them. We would certainly like to get to a position where parents do not have to go abroad. Parents looking after children with a disability have enough on their plate without feeling they must advocate through the media or political forums so we would definitely like to get to that point.

Does anybody wish to sum up?

Ms Eilísh Hardiman

I acknowledge the clinicians, nurses, psychologists and physiotherapists. We have a great team and they are engaged in research, education and innovation, not just clinical care. They go beyond that. To reassure the committee, there is a sense within the team that they are as good as anywhere else. The infrastructure must be sorted out. The team is good and the vast majority of patients engaging with the team have a good experience. I acknowledge that even despite all the constraints and challenges, they are still striving to develop around research, education and innovation. They have demonstrated this with some of the initiatives they have developed.

After the first ten minutes of this morning's meeting, I wrote down three or four times the need for a plan. It was an obvious point. Reference has been made to the regions and it is proposed to address that. Cork, Limerick and Galway have been identified in this respect. There has been no reference to the midlands or the north west, including Donegal, Sligo, Mayo or such areas.

Due to the trauma for the parents and the patients, is there a necessity for a plan B which might be added to the plan? There is a plan to address the issue, but it will not clear the waiting list no matter how bad things get. Could we append a plan B to that, which might address the seriousness of the situation in a way that the patients and their families will recognise is there for them in the event of something terrible happening? We all have emails which we could read out. I will not go into that because it is too traumatic. I emphasise that there is a necessity for that plan B to be added on.

Would anyone like to respond to that?

Ms Paula Kelly

We can come back with the details of the actual plans. However, clinically we have to acknowledge that some of these scoliosis cases can only be done in Crumlin and in Temple Street. That is the reality of it, and that is what the plan is going forward into the new children's hospital.

The plan for paediatrics is for Galway, Limerick and Cork to be the regional units. When we talk about the west and Galway, that is the Saolta Group at the moment. We also have an all-island approach to paediatric healthcare. We are already demonstrating that with some of the sickest babies, the cardiac surgery babies. We are engaging and certainly have planned the new hospital to look at how can it work on an all-island basis, because of that helps with the Border regions.

What we would like to identify, with Cork, Limerick and Galway as the regional units, is the roll out of that regionally-supported way of working. That is part of what they want, and part of what we want as well.

I am happy to come back with details of how we can demonstrate in detail the 200 patients who are on the list at the moment and the details of the timing of when we anticipate the increased infrastructure so that it is more manageable. We will never be at zero; that is not our intention. Our intention, as we outlined, is to shorten the waiting lists and ensure people are not waiting more than six months. That is our objective, and that is keeping with the policy around Sláintecare. Obviously, it is subject to investment, but that is the commitment we are giving here and the assurance I would like to give to the families and children and to our clinicians who really just want to come in and treat patients.

Thank you very much. Let us end on that positive note and acknowledge the positive work being done by clinicians on this issue. I thank the witnesses for taking the time this morning to help the committee and answer questions.

The joint committee adjourned at 12.43 p.m. until 9.30 a.m. on Wednesday, 17 November 2021.
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