Joint Committee on Health díospóireacht -
Wednesday, 22 Mar 2023

Health Service Executive: Engagement with Chief Executive Officer

An Cathaoirleach

Before we get to the main item on today's agenda, the minutes of the meetings of 7 and 8 March 2023 have been circulated to members for consideration. Are they agreed? Agreed.

The purpose of today's meeting is for the joint committee to engage with Mr. Bernard Gloster, the newly appointed CEO of the HSE, to learn about his strategic priorities for the position. I welcome Mr. Gloster and congratulate him on his important and challenging appointment. The committee engages with the HSE on an ongoing basis by means of direct meetings and written correspondence. The committee members and I look forward to a productive collaboration with Mr. Gloster.

All those present in the committee room are asked to exercise personal responsibility to protect themselves and others from the risk of contracting Covid-19. Witnesses are reminded of the long-standing parliamentary practice that they should not criticise or make charges against any person or entity by name or in such a way as to make him, her or it identifiable, 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 and it is imperative that they comply with any such direction.

Members are reminded of the long-standing parliamentary practice to the effect that they should not comment on, criticise or make charges against a person outside the Houses or an official, either by name or in such a way as to make him or her identifiable. I remind members of the constitutional requirement that they must be physically present within the confines of the Leinster House complex in order to participate in public meetings. I will not permit members to participate when they are not adhering to this constitutional requirement. Therefore, any member who attempts to participate from outside the precincts will be asked to leave the meeting. In this regard, I ask any members participating via Microsoft Teams to confirm, prior to making their contributions, that they are on the grounds of the Leinster House complex.

I invite Mr. Gloster to make his opening remarks on his strategic policy as CEO of the HSE.

Mr. Bernard Gloster

I thank the joint committee for the invitation to appear and for the opportunity, having taken up the position of chief executive officer of the HSE two weeks ago, to outline my priorities. I am joined by Mr. Ray Mitchell of our parliamentary affairs division and Ms Níamh Doody, my executive business manager. I thank the many stakeholders in our health and social services space for their warm welcome for my appointment to this role. It is one to which I was very privileged to have been nominated following an open public competition process. I extend my thanks to Mr. Stephen Mulvany. He has been interim CEO of the HSE for the past five months and his efforts in one of the most pressurised periods for our hospital and community services deserve recognition.

I am conscious coming to this role that there are many challenges. However, there has been a significant improvement recorded in recent years in the overall health of the population. Reduction in mortality rates and gains in life expectancy are important markers of the improvement in population health and underline the importance of the services in place to promote and protect their well-being, as well as services that treat people when they are ill. Overall, there are more people in Ireland and we are living longer than before. The life expectancy of the Irish population has made the strongest gains among western European countries and is now above the EU 27 average. In 2021, life expectancy was 84.4 years for women and 80.8 years for men. Those are increases of 1.4 years and 2.2 years, respectively, in the past decade, compared with increases of 0.1 years and 0.5 years for the EU 27 in the same period. Gains in life expectancy have been driven by sharp reductions in mortality from major diseases. The leading causes of death in Ireland include circulatory system diseases - like stroke and heart attack due to ischaemic heart disease - cancer and respiratory system diseases. In the past decade, the age-standardised mortality from these causes of death has reduced by 33.5%, 18.2% and 33.4%, respectively. Infant mortality rates in Ireland are low, as is the case in most European Union countries, and fell by 14.3%, to three deaths per 1,000 live births, in the decade to 2020.

I recognise that I come to the HSE at a time when all of our staff have been through several years of additional and demanding periods. These have been due to the need to respond to a pandemic, cope with a cyberattack and work through one of the most challenging winters on record for health services. The success of our combined community, acute and public health teams in mitigating the impact for so many cannot be understated. Bringing together large parts of the workforce in crisis times, as was evident in the response to the recent fire at Wexford General Hospital, is a pointer to what can be achieved by that same integration in normal times.

It is an enormous privilege to have been appointed to this position. The confidence of and mandate from the board of the HSE, the Minister, the Secretary General and the Department are very reassuring as I begin to provide the management and leadership for a period of extensive change and improvement for the HSE. I come to this role as an experienced senior public servant with more than 34 years of service, from front line to CEO, in the Irish public health and social service system. Most recently, I served as CEO of the Child and Family Agency, Tusla, which is an organisation coming through progressive growth and reform. I value the experience I gained there in my approach to the role I have now taken up. I am a former professionally trained social care worker and I hold master's degrees in business administration and management practice. In my various roles, I have either worked in or managed every operational part of the statutory healthcare service, including both community and acute operations. At times, I have done both. I have held local, regional and national roles.

I bring significant regional experience at a time of HSE restructuring aimed at giving effect to a more decentralised model of decision making. This 18-year-old organisation has been through several iterations of change, be it in policy or structure. It is the summation of and learning from that history, combined with the potential of an enormously dedicated workforce and the overarching guidance of strong Government policy, that creates the opportunity to make substantial improvements. A clear understanding of the guiding policy context for the HSE over the next period is the combination of the programme for Government, Sláintecare and the various subsequent action plans resulting from it, and the priorities of the Minister set out, from time to time, in his various directions to the HSE. Arising from this, the Minister has emphasised and set a number of issues to be prioritised in 2023, most notably improvements in direct experience of the public in terms of access to healthcare and in urgent care. These come in addition to the critical focus on issues like outcomes, affordability, capacity and effectiveness in care delivery.

Against this backdrop and my own assessment of the current state of play, I have highlighted three headline challenges to which I intend to respond during my tenure as CEO. The first is access and performance. The second is timely implementation, and the third is public confidence. The organisation requires attention and significant step change on several fronts in responding to these challenges.

The organisation has many dedicated and talented people across all disciplines. It is, however, important to accept that while responding to many issues over the years, it is an organisation that has become a top-heavy structure with many cumbersome processes. The opportunities presented by Sláintecare and the programme for Government priorities will assist in tackling some of these issues. Structure itself, however, is not an answer on its own.

While there are well-evidenced capacity and demand issues to be addressed, and there are good plans to do so, there are also process issues to be improved and with decisive management and leadership, these can and will be tackled ahead of structure changes. I will, with the board of the HSE, be positioning all changes in an integrated framework focused on care, culture and governance. If we do not pursue changes in all three together, we will have completely missed the opportunity to be the best health and social care service we can be for the people we serve.

While there is enormous good to report in and about our services, I do not accept that as we work through 2023, with a budget of some €21.6 billion revenue and a workforce approaching 142,000 whole-time equivalents, that we are yet near to being that best we can be right now. The well-documented experiences of the public and our front-line staff must be enough motivation for that position to improve.

In setting early priorities, it would be impossible within the scope of this statement to list all areas of focus and I have grouped some together, noting the exclusion of any part of the service here does not reduce its value and importance to me as CEO. This committee, in its work on Sláintecare progress and updates, will be familiar with the many components of the current action plans. All of those can be taken as read in being central to my future work and I am currently being briefed on the detail of each part. Among these requiring attention in pace of progress are elective care reform, e-health and digital health combined, regional and centre structures, enhanced community care pathways, the consultant contract, waiting list plans, and adding capacity both in staff and infrastructure.

Ahead of the regional health area, RHA, proposed changes, I have taken direct management responsibility for the HSE part of this change. To ensure that we do not wait for that alone, I have also introduced some significant interim management changes in the management processes, to take effect from April.

I am conscious that the HSE has a brief far beyond the projects listed in the Sláintecare programme and in this regard, both the programme for Government and my own assessment of issues require that I also emphasise and devote attention to some specific issues. I specifically want to refer to women's healthcare, mental health, disability services and care of older people. Care measured against regulatory and best practice standards for people in these groups must be the priority in any improvement plans. The HSE cannot, in its social care system, allow for any avoidable delay in responding to access, quality of service or safeguarding issues for people who experience vulnerability.

In a post-crisis period, there is little doubt as to the many challenges faced by the public in how they experience health and social care services from the State through the HSE. With those challenges are also many opportunities. Strong and robust plans are there, and it is the implementation of those that the HSE must remain focused on, and look for every opportunity to shorten the timeline for the benefit to accrue for the public. That is where my time as CEO will be directed to, and I look forward to working with and updating this committee over the next period. I thank the Cathaoirleach.

An Cathaoirleach

I thank Mr. Gloster. On behalf of the committee, I would like to be associated with those remarks with regard to the interim CEO, Mr. Stephen Mulvany. He was very helpful to the committee in its deliberations during that five-month period.

I am going to head straight to members and to lead us off is Senator Kyne.

Senator Seán Kyne

I welcome Mr. Gloster and wish him congratulations on taking up what is, I am sure, a very onerous task. I join in the tributes to Mr. Mulvany on his stewardship over the past five months.

In his opening statement, Mr. Gloster stated, "It is, however, important to accept that while responding to many issues over the years, it is an organisation that has become a top-heavy structure with many cumbersome processes." Does Mr. Gloster therefore envisage realignment of front-line and non-front-line staffing or what does he envisage based on that statement?

Mr. Bernard Gloster

There has rightly been a lot of focus, in the context of the discussions about Sláintecare, on regional health areas and regional structures and on moving an appropriate level of capacity and decision-making to improve the timeliness of decision-making to that regional and local level. That is a balancing part of that. However, a fundamental part of that change is also to deal with the centre of the HSE; not just the size of it, but its purpose and function. There will always be a centre of some type, and it is coming to what the appropriate size and structure for that is. At the moment, because a lot of the decision-making and prioritisation has been centralised - understandably, for a period of years - the centre has grown into that very significant, what I would call top-heavy, system. I have made some changes to try to rebalance that in order that we can start to get to some regional inclusion in decision-making, even ahead of the RHAs.

Senator Seán Kyne

I thank Mr. Gloster. He has mentioned the need to add capacity in both staff and infrastructure. Obviously, we have capacity issues probably all year round, but it is particularly acute during the winter periods. We have seen in recent years the winter plans, which are sometimes criticised for coming too late. A number of us met recently the Private Hospitals Association. Private hospitals have capacity, but they would argue that there needs to be more engagement, a longer period of engagement, and advance notice, rather than contacting them in January looking for immediate beds.

Regarding additional capacity, we obviously want to see capacity added in the public sector but where there is capacity in the private sector, how does Mr. Gloster think that could be harnessed more efficiently?

Mr. Bernard Gloster

There are two parts to that. In the context of winter plans, it may be a necessity for 2023, given the period of time that I have arrived into the system. My preference is that we have an all-year round capacity management plan. Winter plans have perhaps passed their usefulness in that context, and that is because we experience pressures right throughout the year in the system. The acute hospital system operated at full tilt in periods last summer. If one looks at the evidence, one would find it hard to distinguish between parts of the summer and parts of the winter.

Whether or not there will be a winter plan for 2023 is something I want to discuss with the board of the HSE, the Minister for Health, Deputy Stephen Donnelly, and the Secretary General of the Department of Health. My preference would be that by the time we get to 2024, if not sooner, we would have a capacity plan for the year as part of the service plan, and that we all know from the start of the year what we are doing about capacity, be it in May, August or December. Enough of a period can be allowed in that plan for fluctuations to happen. That is just a general comment on plans.

With regard to private hospital capacity specifically, we are in a phase where we can anticipate, with pressure, for the next period of time that we have to use what capacity is available to us to use in the best way that we can. Personally, I think there is more capacity benefit from the private hospital system in the context of elective work, responding to waiting list initiatives, and picking up some of the pressure and slack there. The use of the private hospital system for what we might call more general medicine, which is a predominant part of the pressure in emergency departments, is much harder. It is not necessarily the core work of a lot of private hospitals.

I could not agree with Senator Kyne more, however. If we are going to use capacity in the private sector - and I need to look at what that will be for the balance of this year, with the Department - for the rest of the year, then that is better dealt with, and dealt with well in advance as distinct from short notice engagements, and trying to buy capacity at short notice. We either have capacity to be bought and used for the public interest while we are building and developing for the public capacity, or we do not. It is not beyond all of us to identify and call out what that is, and nail it down more quickly.

Senator Seán Kyne

I thank Mr. Gloster. Community neuro-rehabilitation is obviously an important area and a vital support for people living with neurological conditions. I understand that only 15% of people have access to community neuro-rehabilitation teams, and certainly in community health organisation, CHO, 2 they do not.

How does he plan to tackle these issues and ensure there is a roll-out of teams across the country?

Mr. Bernard Gloster

There are two ends from which one approaches that. The first is that if we come back to the principles of some of what we will try to achieve in a regional context, we would try to achieve a balance of evidence-based resource allocation as opposed to the historical models that have been used heretofore. Population needs assessment, population analysis, public health analysis and health intelligence all feed into that. There are no quick solutions to populating the rehabilitation in all the places we would like to provide it. Apart from the obvious issue of resources, there is the issue of the available skill set. Community neuro-rehabilitation is a multidisciplinary intervention. It is very effective when it works well but an entire focus in the rehabilitation strategy as part of the overall response to the population in each of the proposed six regional health areas would, perhaps, be the mechanism by which we can fully call out what the deficits are and then, at least, see what the plan is to address them.

Senator Seán Kyne

I presume Mr. Gloster accepts that for people with multiple sclerosis or Parkinson’s disease, access to these teams can help in terms of preventing disability and reducing admissions to hospital.

Mr. Bernard Gloster

Yes, of course. Not only do they need that access, they can benefit greatly from it. There is a balance between the expertise to rehabilitate those neurological conditions and what one might call the use of general therapy to help people. For example, there are the enhanced community care interventions of which the committee has heard in the past 15 months, with some 2,000 extra staff coming into community network teams in the context of chronic disease, primary care and older people. Many of those staff are therapists. The fundamental question I would be asking the delivery system is whether there is anything in that construct that can be done to help people who have a range of other needs for therapy without crossing the lines of what the specialisation might be for that. There is potentially some benefit to respond better but I would not want to give the impression it is an easy fix. Given the prevalence of disease, incidence of illness and age profile of the population, rehabilitation must be one of the key components of reducing the dependency on the acute-centric system.

Senator Seán Kyne

To return to the issue of adding capacity, capital programmes are very important, as is engagement with the Department of Health on delivery of those programmes. The Department of Public Expenditure, National Development Plan Delivery and Reform is carrying out a review of the public spending code in the context of the delivery of projects. Will Mr. Gloster have an input in that regard in terms of trying to speed up key projects? I refer to the proposal for a new emergency department and a maternity and paediatric centre for Galway, for example. Detailed designs were prepared in 2018 for delivery of that project. The strategic assessment report has just been agreed or sanctioned by the Department of Health. It is necessary to go through a convoluted process of preliminary business cases, design brief and so on. Will Mr. Gloster have an input in terms of trying to speed up that process?

Mr. Bernard Gloster

For significant capital expenditure and capital projects, there are two component parts; there is the part that can be controlled within the HSE and there is the part that is external. The latter is the capital plan, which is the determination of the Government, the Minister and the Department of Health. The Department of Public Expenditure, National Development Plan Delivery and Reform has a significant role in the governance of significant expenditure and the flow thereof. Only yesterday, I met members of the executive management team of the HSE and have asked for a specific view on this. My view is to identify the processes within the HSE either from the time of initiating a concept or carrying out an approved project that is funded and to determine what is the best we can do to reduce the timeline of those processes. There are steps we can take to reduce those timelines but there will still be many other factors in the approval process. There are significant balancing issues with major capital expenditure and development in Irish public services in general because of the fear of expenditure going out of control or timelines being missed and so on, and those are legitimate fears. I need to see what are the steps within the HSE and how many of those we can reduce. That might cause pressure for other parts of the civil and public service but I can only control the bit that is within my gift. There are certainly steps we can take to improve that.

Deputy David Cullinane

I welcome Mr. Gloster and wish him well. If he is successful in his role, the health service will be successful. Obviously, the committee wishes to work with him as the new head of the HSE. I commend him on his work in Tusla.

Mr. Gloster rightly referred to the enormous amount of talent working in the healthcare system. We have to harness that talent in the best possible way but we must also acknowledge, as Mr. Gloster did, the significant challenges in healthcare. The current context or backdrop is the ongoing challenges in hospitals and emergency departments, with people waiting too long and waiting lists too high. That is what people see. In the context of confidence in the health services, patients and others look at daily news reports, such as the reports that there were 660 people on trolleys yesterday. It is becoming a year-round problem. The Irish Nurses and Midwives Organisation, INMO, has threatened strike action. I understand nurses in Cork are being balloted today. What is the response in the short to medium term to dealing with those challenges in hospitals? I am not just focusing on hospitals; we need to look at all the problems that are leading to overcrowding. What is Mr. Gloster’s message to the INMO and nurses who are concerned about unsafe staffing levels and what is happening in emergency departments? Will he meet the INMO, given its concerns? Has he pencilled in an opportunity to meet the INMO?

Mr. Bernard Gloster

I will take the questions in reverse order. I met the INMO last Wednesday night at its request. To be fair, it was not a scheduled meeting. The INMO asked me to meet it at short notice, given its concern regarding trolley numbers last week. I was happy to meet with it. I had a good engagement with Phil Ní Sheaghda, the general secretary of the INMO, and her officials last Wednesday night. The meeting related to both the national context and particular concerns in respect of the situation in Limerick on that day. I look forward to meeting the INMO again. I am due to address its national conference in the coming weeks. I do not dispute that we need to pay attention constantly and consistently to the issue of an appropriate and safe environment for patients. That includes the physical infrastructure of the environment as well as the staffing levels. There have been significant growths in the numbers of nurses being recruited but there is no doubt there is a difficulty and challenge on the retention side. That is a matter on which I am very anxious to speak to nurses, as well as all the other disciplines-----

Deputy David Cullinane

At the moment, there is threatened strike action. How can Mr. Gloster, as the new head of the HSE, play his part in averting strike action?

Mr. Bernard Gloster

I can do so through an honest and fair dialogue that calls out the challenges the INMO has identified, finds the solutions to those challenges and, of those solutions, selects the ones that can be responded to now. Regardless of the number of approved posts, when it comes to addressing staffing levels there is a limited number of graduates who can be recruited at any particular time. My head has to go not just to today but to resourcing into the future and how we can grow the numbers. Based on the basic projections, we need to significantly grow the number of training places across the higher education system for all health disciplines. I will do everything possible in the short term to alleviate and respond to the pressures that all the disciplines, including nurses, are identifying.

Deputy David Cullinane

An issue that was not addressed in Mr. Gloster’s opening statement is that of workforce planning. It should be one of his key priorities. The committee has identified it as central to any changes in healthcare. We need more staff and we need to be able to train more professionals. When Mr. Gloster is setting out priorities, workforce planning and working with his counterpart or colleagues in the Department of Further and Higher Education, Research, Innovation and Science needs to be one of them.

Mr. Bernard Gloster

That is a fair comment. I have done one public press interview since I took up the job. In that interview, I spent a significant amount of time speaking about the difference between a workforce plan and an entire people strategy. I hope the INMO, the Irish Medical Organisation, IMO, the Irish Hospital Consultants Association, IHCA, Fórsa and SIPTU will participate in all of us collectively owning the plan in the short, medium and long term for the staffing of the health service into the future.

Deputy David Cullinane

Mr. Gloster certainly will have our support in that.

Regarding winter plans, our experience over recent years is that they have been window-dressing, giving a sense, when there is an emergency, that things are being pulled together and additional resources made available. There are different views on whether they work. We are now dealing with an all-year-around problem in emergency departments. Mr. Gloster referred to an all-year-around plan. We need rapid decision-making. We see it in some hospitals, Waterford being one example, with decisions being made very quickly. That is good management. However, we are not seeing that right across the board.

We also need capacity. One of the issues that is raised with us constantly by hospital managers and representative bodies, including the Irish Medical Organisation, IMO, and the Irish Nurses and Midwives Organisation, INMO, is the lack of bed capacity. In the past two budgets, there was no additional funding for new beds. In budget 2021, there was a funding allocation for 1,147 beds, some of which are still undelivered but may be delivered this year. Looking to the challenge for next year, we see there is no allocation for additional beds in the most recent budget. How are we going to meet the challenge we face next summer and winter? We had a trolley crisis last summer. From where will the additional beds come? Will Mr. Gloster be seeking extra funding to put in additional capacity during the summer months, by way of modular build or otherwise, to ensure we have more beds in the system next winter? If we have the same number of beds, we will have the same problems and challenges.

Mr. Bernard Gloster

The first point to make is that I will never shy from asking for additional approval to add capacity, given where we are at right now. To be fair to everybody, including the public, the remaining balance of beds from the total provision from 2021 and 2022 of some 1,228 will be delivered in 2023, amounting to some 200 or whatever is left. The first thing I have to do, which is in the control of the HSE, is to deliver those beds that are already approved. To be fair to the public and all sides of the Oireachtas, there is not much point in my asking for more if I am not able to show form for being able to deliver what I have been given. That is what I talked about earlier-----

Deputy David Cullinane

Mr. Gloster talked in his opening statement about culture and accountability. It seems clear that he understands he is coming into a very difficult job in a context in which people are waiting far too long in emergency departments. The representatives of the management of University Hospital Limerick who came before the committee told us they need more beds. I and other members of this committee have travelled across the State meeting hospital managers, all of whom tell us they need more beds. However, it is not the only solution. We also need more investment in community care and so on.

Mr. Bernard Gloster

It is a big part of it.

Deputy David Cullinane

Yes, it is a big part of it. I am saying that we cannot arrive at a situation next winter, and, indeed, right through this year, in which people are asking us what additional bed capacity beyond what was previously funded has been put into the system. If the answer is zero, that is a failure of the system. If we are talking about changing the culture and building public confidence, the way to do that is by having a multi-annual plan, not going big on numbers in one year and then doing nothing for years after that. Yes, the remaining beds must be delivered, but the ambition has to be higher than that.

Mr. Bernard Gloster

Parts of the multi-annual plan have to be about getting to the end game of achieving the desired reform under Sláintecare. The elective strategy for three elective hospitals is a capacity issue that equally requires a stepped change in the planning this year to get them through the various approval stages and get them done. As I said, I do not have a magic wand. The beds I have been approved to build are the balance of the 1,228 from 2021 and 2022.

Deputy David Cullinane

We have been hearing from Ministers, heads of the HSE and Secretaries General for years that they do not have a magic wand. Nobody expects Mr. Gloster to have a magic wand. What people expect is that hospitals are properly equipped and have the bed capacity they need. It is not beyond us to put in the capacity. Magic wands are in nobody's gift but we can plan and we can put in the capacity.

Mr. Bernard Gloster

Sure. On the other side, the Deputy mentioned Waterford and-----

Deputy David Cullinane

Before we get to Waterford, I am tight on time and I want to ask Mr. Gloster about the regional health areas, RHAs, which is a really important issue. What is the first step to put those areas in place? We had a number of meetings as members of the committee with all of the officials, but we are still waiting for the plan and the roll-out. Mr. Gloster is now in charge and I assume he can give direction on this. What is the first step in establishing the regional health areas?

Mr. Bernard Gloster

There are three quick points to make on that. I am in my job two and a half weeks. By next week, I will have finalised with the Department my view of the proposed implementation pathway to RHAs. That is how quickly I intend to move on this. That is the first point. The second point, which will be no secret or surprise to anybody, is that driving integration is not just about the structure of the HSE but also about the single point of accountability, the single line of sight and giving the appropriate authority to that person. We would achieve a fundamental step change if we had six regional chiefs in place, without all the rest of the design being perfectly worked out. Six people integrating and running the totality of the existing service, with responsibility and authority around things like budgets-----

Deputy David Cullinane

When will they be in place?

Mr. Bernard Gloster

I am certainly proposing and hoping that they be in place for the start of 2024. However, there are factors outside my control. I do not have the final say in the approval of those posts. When the request is made to the Department of Public Expenditure, National Development Plan Delivery and Reform, there are approvals to be gone through because these are senior public sector roles. I certainly hope to have my part of the implementation plan finalised and agreed with the Secretary General by next week. I have already had really good discussions with him about that. Obviously, the Minister will have a view on the totality of the implementation plan and whether it is consistent with his priorities and objectives.

The third point relates to why I do not want to lose the value of the reference to Waterford. I appreciate that the Deputy's time is limited. I have heard lots about Waterford and I visited it last week, walked the hospital and met the members of the management team. Apart from the enormous good work they do there, they are currently providing the additional response to the people of Wexford following the horrendous fire at the hospital there. Ahead of the implementation of the RHAs, the most important people in the delivery and running of services today, who can alleviate a little more pressure on hospital emergency departments and waiting lists, are the hospital chief executives and the chief officers in the community. From 4 April, albeit in very big size and structure, I am bringing those 15 people together with the centre of the HSE in a management process chaired by me. The principal objective of that is to take the exemplars of good process and good, solid management and hold them up for everybody else. It is not just about holding them up for everybody else to say they might think about using them; it is about me as CEO mandating that and then inquiring, if it is not happening, why it is not happening. That is how we can at least start to get some consistency of approach across the country and take the benefit of the best of what different parts of the service have to offer.

Deputy David Cullinane

I want to be associated with those remarks about Waterford. We want to see managers being held to account. Going back to the RHAs, the committee has been briefed a number of times. Can a briefing session be arranged for members in advance of whatever developments happen on this issue? We have had two very good meetings with the staff working on the delivery of the RHAs. A briefing session in the next couple of weeks would be useful.

Mr. Bernard Gloster

In terms of the HSE component of that, as I said in my opening statement, it is such a significant milestone change that I am taking direct personal management responsibility for it.

Deputy David Cullinane

I thank Mr. Gloster.

Deputy Róisín Shortall

I welcome Mr. Gloster and congratulate him on his appointment. I wish him very well in the role. No pressure but the whole country needs him to do well.

I will stay with the issue of the RHAs. Notwithstanding the need to keep the health service running, it can be argued that Mr. Gloster's main job in regard to the reform programme is to devolve power and responsibility from the centre, and from himself, to the regions. What is his view on that?

Mr. Bernard Gloster

I must first admit what is perhaps a bias in my background in that I was never part of a centralised structure. I came from a regional structure in the health service and I think I understand both components very well.

That was the premise on which I restructured Tusla into six regions, with six regional chiefs and a reduced and redefined centre with a redefined role. There is always going to be some element of a centre. There has to be for things like consistency, allocation and performance of systems and so on. My view is perhaps best contained in the comment I made about the fact that while we have very good people doing lots of different jobs in the HSE, the centre is just too top heavy. We have to call it out. Part of that is about the shift in the balance of power and decision making to an appropriate level regionally, so that people in the regions can make timely decisions. Equally, we must be careful that there is consistency across the six regions, or we just end up with six very different entities and quite similar problems for people locally. The governance piece is a complex environment, but it is not as complicated as we can sometimes portray it to be. My view is that we need to move to the six regional administrative entities within the HSE, with significant and reasonable authority, and with appropriate accountability.

Deputy Róisín Shortall

Picking up on the point of accountability, it has been this committee’s view and it was certainly the case in the Sláintecare recommendations, that accountability is critical for those people who will be leading each of the six regions, and that such accountability needs to be legally underpinned. It seems that that proposal was not fully accepted by the Government in the business case it adopted. Increasingly, this committee is of the view, and the thinking within the group dealing with Sláintecare and the RHAs in particular, that legislation is required to provide for that accountability. Has Mr. Gloster come to a view on that as of yet?

Mr. Bernard Gloster

I do not believe legislation is required to underpin the RHA and to give it either the authority or accountability that is required for it because that accountability ultimately rests with me as the CEO. I believe the potential deficit that people have identified can be mitigated. First, I do not believe the six regional health leaders should be put into a stepped process of a big gap between me as the CEO and them. That should be a direct reporting relationship, so accountability can be achieved in that way.

Accountability processes generally in civil employment cases are always open to significant challenge because the disciplinary procedures and other accountability mechanisms are not underpinned by legislation. I do not think the structure needs to be underpinned by legislation to achieve that.

Deputy Róisín Shortall

No, I am not saying the structure, I am saying the terms on which those six leaders will be appointed, and the terms of their employment will surely require legal underpinning of that accountability piece.

Mr. Bernard Gloster

I would have thought that could be dealt with by contract, given that they are administrative entities within the HSE, which is itself already a legal entity.

Deputy Róisín Shortall

Mr. Gloster talks about the accountability resting with the CEO. That is part of the problem, that everything comes back to the CEO. Not only does that remove the proper level of accountability from the regions but it also disempowers the leaders in the regions. Does Mr. Gloster accept that?

Mr. Bernard Gloster

I think part of the legislative underscoring of that is in the delegation to those six leaders. Under the Health Act I can delegate the functions that I have. I can formally delegate them in law, and a specific order was signed to do that. That is where we can attach the accountability mechanism. I do not necessarily think there is a silver bullet in legislating the specific accountability of six regional people, given that we are within the same legal entity as it is.

Deputy Róisín Shortall

It will not be on the individuals solely. It should apply to senior administrative people and clinical people as well.

Mr. Bernard Gloster

I do not doubt that regardless of RHAs or not, there is a significant way to go to clarify and implement appropriate accountability mechanisms across the public sector and, in my case, across the health sector.

Deputy Róisín Shortall

I would just point out that Professor Tom Keane, in speaking to the Committee on the Future of Healthcare said the most significant thing that we could recommend is for there to be clinical accountability across the system. That is a huge gap in the RHA framework at the moment. I will leave that with Mr. Gloster.

I want to move on to workforce planning. Mr. Gloster speaks about the need for additional places in third level colleges. There are two other elements to that as well and I would like to get his views on them. The first is the shortage of clinical placements within the HSE, which are essential if we are to up the numbers in the colleges. Is Mr. Gloster across that issue as of yet?

The other issue is the question of retaining staff. Retention is arguably as important as recruitment because we are training very large numbers at very high expense and very large numbers are leaving the system. Is Mr. Gloster familiar with the work of the consultant, Niamh Humphries, on the reasons why hospital doctors are leaving the system? If he has plans at this stage, what are they on the retention piece?

Mr. Bernard Gloster

I agree entirely with Deputy Shortall on the clinical placements. We cannot ask the further and higher education system to develop more capacity if we are not prepared to provide the practice supervision for the students. I do not think it is the case that we are maxed out on that yet. I think we require a different approach to that.

If I take the allied health professionals, for example, in physiotherapy, speech and language therapy and occupational therapy, we have now put just over 2,000 additional people in those posts into the community. I would expect a substantial portion of those should be able to provide supervision and clinical placement and learning for the students that are coming on. I do not think we are without capacity but perhaps our model is not as strong as it should be. It certainly is not as consistent as it should be. It has tended to grow up in arrangements between individual universities and local HSE areas and it just needs to be more consistent.

Retention is an enormous challenge. The first point I must accept is that our workforce is now a very global, young one and people like to move for lots of reasons. I do accept that people also move or leave because they find the experience too difficult, challenging or just very hard to keep going in. We have to start from the point of hearing that and acknowledging it rather than just denying it, as it were.

In terms of a retention strategy, I am particularly focused on the next round of a HSE-wide staff survey, which I hope people will participate in. I am specifically looking at that to see what it tells us we need to do for people. I will not overcook it but one of the things I am told may help goes back to what I said about the RHAs and bringing chief executives and chief officers closer to the centre even before I get the RHAs is the processes. People find it very cumbersome to do things in the HSE - to get approvals for different things, for a local initiative to have the freedom to proceed or to use a post in a particular way. People find the environment very strictured and then when you add that to an exceptionally busy, demanding shift after shift, that can become quite demoralising for people. I must look at the opportunities to improve the work experience of people and at the same time recognise that there is a long way to go and we cannot make that perfect.

Deputy Róisín Shortall

I thank Mr. Gloster. I have two specific questions for him. We are almost at the end of the first quarter and we have not yet seen the HSE's 2023 service plan. Service providers all over the country are waiting for details of their allocation. It is incredible that it is so late. What are his intentions in regard to the service plan and when can we expect to see it?

I note from his opening statement that Mr. Gloster says he wants to devote specific attention to mental health services. Is it his intention to reinstate the national director of mental health and, if so, when does he intend to do that?

Mr. Bernard Gloster

On the national service plan, I have met with Minister. I have also met with the chair of the HSE board and discussed it with him several times, including last weekend. I am due to meet with the Minister, the Secretary General and the chair of the HSE board tomorrow. I hope to receive clarification in that context. The Deputy will appreciate it is for the Minister to make the final determination, but it is imminent. I will also say that we are working operationally to the details of the service plan drafted before my arrival. We are not waiting for the finalisation of the plan when it comes to getting on with day-to-day business. I hope it is imminent. To be fair to the Minister, I do not want to speak for him beyond that.

On mental health, I believe it requires serious attention at every level in the healthcare system, be it nationally, regionally or locally. I hold the same view when it comes to the experience of children and adults with disability. Events like the pandemic and other things, and successive years of challenge, have meant those two groups have sometimes become secondary, albeit unintentionally. The demands are ever increasing for them. The difficulty with a national director for mental health as a construct for running mental health services is that one is immediately taking one part out of the integrated system, intended for the RHA. At the most senior level possible, within the new centre I propose to design in the HSE, I intend having a dedicated focus on mental health and disability, which would be part of a smaller centre reporting directly to me and driving the improvement system. We need to put our hands up and say, notwithstanding all the good work done, that the experience of people with disabilities and people in the broader mental health system is an area in which we have a way to go before we can say we are content and happy and doing the best we can. That is not without recognising the good work being done.

Deputy Róisín Shortall

I thank Mr. Gloster.

Deputy Gino Kenny

I welcome Mr. Gloster and wish him well in his new job. It is a mammoth task to say the least, but I wish him well, and I think I can say that on behalf of every member of the health committee. The health service is one of the key issues when it comes to reform and accessibility. I have some practical questions first of all. How long is Mr. Gloster's contract for?

Mr. Bernard Gloster

Five years, less two and a half weeks.

Deputy Gino Kenny

Okay. Hopefully he will see it out.

Mr. Bernard Gloster

That is certainly my intention. I do not have my sights set anywhere else.

Deputy Gino Kenny

How different will Mr. Gloster be to his predecessors? No disrespect is meant to his predecessors, but how different would he like to see his tenure as CEO?

Mr. Bernard Gloster

The Deputy should have been on the interview board. To be fair, through circumstances I have had the privilege to have done some work with all of my predecessors - Brendan Drumm, Cathal Magee, Tony O'Brien and Paul Reid. I think that, without kicking the can down the road, each manages in their own time. I am not somebody who retrospectively looks back to say that something was terrible and I am going to be better, or something was great and I am going to be even greater. The job and the task are more complex. I am coming to the health service at a different time to my predecessors. Mr. Reid was here in wartime, if one wants to use that phrase, in terms of the pandemic. I recognise what he did in that period. I am coming in the post-pandemic period with the cumulative impact both of history prior to the pandemic and that of the pandemic period on the health service, both in terms of opportunity and challenge. If anything will mark my time as different, as opposed to me being different, it will be achieving in a complex environment, more simple and easy decision-making processes that will directly benefit people more quickly while at the same time doing the job to the highest standards in terms of corporate governance and other things. However, simplicity of process is ultimately no good if it does not benefit the 690,000 people on waiting lists at the start of this year. If the experience of people who today are in any of the country's emergency departments is not better, then I will not have done a good job.

Deputy Gino Kenny

That is very honest. That was my next question. We have a situation where almost 1 million people have been on waiting lists for far too long. People in emergency departments are waiting so long to be seen. That is no disrespect to the front-line staff, but that is just not acceptable in a wealthy country. Hopefully under Mr. Gloster's tenure, and with the help of all the front-line staff, that can be addressed, because that is not acceptable.

Mr. Bernard Gloster

Some strides were made last year, and I hope I can make more this year. The Minister has approved the 2023 waiting list action plan. We are hoping this year to have a multi-annual plan, rather than having to do that every year. I know some people have criticised this year's plan as perhaps lacking in ambition. The volume of waiting lists at the start of the year versus the end of the year in totality is less 10%. However, I made this point with Claire Byrne when I was doing a fairly extensive interview with her. We sometimes forget the number of people who come on to waiting lists, and leave in a year. Some 1.56 million people went off waiting lists last year, and 1.53 million people came on. That is a huge volume of activity. I know this is the Minister's priority, and he has left me in doubt as to his view of it. Rather than getting caught up in the number of people on waiting lists, my focus is the length of time people are on them. The drive this year is to really reduce that. With that, we have to be accountable. That is what we have signed up to do for the people. It is extremely challenging, because part of our capacity to respond to waiting lists is in our hospitals, and our hospitals are repeatedly cancelling elective work because of the overflow in the emergency departments. There is a huge competing pressure there. We will have to improve our process, to be the very best we can be, and to be accountable to people. At the same time we need to recognise that by the end of 2023 people will still experience challenges in their waiting times, be that in emergency departments or on waiting lists. A part of this is about effort, and a part of it is about integrity in our relationship with the public about the reality of what we can do and the limitations of what we cannot do right now.

Deputy Gino Kenny

In his statement Mr. Gloster said something about the organisation being top heavy. We can perceive that in many ways. There is a perception out there that there is too much bureaucracy in the HSE when it comes to decision-making and accessibility for people who want to get healthcare. How is Mr. Gloster going to change that in his tenure as CEO?

Mr. Bernard Gloster

The top heavy and cumbersome processes sometimes go hand in hand. Sometimes they do not. There are processes of decision-making that are important for reasons of probity, because this committee or the Deputy's colleagues on the Committee of Public Accounts would have people like me before them if we did not have probity in terms of the allocation and management of resources. However, I will return to the point the Deputy picked up on in my opening statement. I think local and regional services even today, ahead of RHAs, are slowed down by a significant amount of process that is probably not as necessary as people think it is. I will bring them closer to me to speed up decision-making for them while we are waiting to get there. I will also redesign the centre of the HSE with the board of the organisation and with the approval of the Minister. Redesigning it does not just mean redesigning the size of the organisation or the number of people in it. It means redefining its role to simplify some of those processes the Deputy is talking about. Every system with which the public interacts in the Irish public service needs to hold a mirror up to itself, and not just once, or to do a strategic review or evaluation.

We must constantly hold a mirror up to ourselves and ask whether the process by means of which a person is getting a service is as simple as it can be for that individual. Even if we are caught up in things that are necessary in the context of corporate governance, that is not something the public should see or experience or that we should hold up as a reason for any delay. Improving speed of access is as important as many other things in the approach taken to waiting lists.

Deputy Gino Kenny

On the very topical issue of health and safety issues in the working environment for nurses, doctors and so forth, and the INMO has continually stated that the working environment is not good for its members or for patients. How can the HSE address that matter? If nurses and doctors are saying that their working environment is not good for their health, then something has to give. The latter is already happening because people are not staying in the health service. These highly trained staff are extremely well motivated but they feel the need to say that they cannot continue to work in such conditions and that the stress caused by their working environment is obliging them to either leave the health service or emigrate. If we can keep people who are highly motivated and trained in our health service, it will be in much better shape. Proper working conditions constitute one of the most important issues that to be dealt with during the CEO's tenure. He needs to take into consideration the statements made by the INMO and the IMO about health and safety issues in places of work.

Mr. Bernard Gloster

There were many parts to that. I will comment on the two or three issues that come to mind immediately. Safety is not always about the numbers involved. It is about many of things. It is about the working environment, the space and the pressure. I have to exploit every opportunity to make improvements to the environments in which people find themselves. I have to make improvements, if I can, in the working patterns and conditions of people in terms of how they are rostered and the amount of time for which they are rostered. Unions will quite often advocate in that regard. At the same time, we have to roster in a way whereby it will allow us to run the service.

I hope we can go beyond the impossible. Let us take it down to the individual. If I walked into a hospital today and a nurse, doctor or member of the administrative staff, ward staff or clerical staff put their head in their hands and said that they cannot do this anymore, what I need to understand from that person, and the entire workforce, is what they think is within our gift right now to allow us to change the environment even a bit better, as distinct from saying that 100 more staff are needed, which is going to take two years, or more beds are needed, which is going to take three years. I need to know if there is anything we can do right now in the context of how we manage and support people.

I wish to refer to a safety issue that presents in a number of parts of the service, not just emergency departments but also in the community, where we have lone workers. Again, I addressed this issue in the media recently. I am very familiar with it from both my time in Tusla and my previous careers. I refer to the violence, harassment and aggression that staff experience. The one thing the HSE, as an employer, can do is support staff 100% in terms of physical infrastructure, resources and the processes that are designed to support them fully, not only with their health, well-being and in the context of employee assistance but also in respect of their personal dignity and safety. As a public servant, I must be on the side of the public. I must side with the public first, but staff come very close behind. When it comes to the violence, harassment and aggression being experienced by public servants, and in my case by health and social care professionals, then I draw the line. There is no justification for violence, harassment or aggression in any circumstances. We can do something to help in that regard. Ultimately, I am very focused on what staff tell me I can do right now to improve their lot.

Deputy Gino Kenny

Is Mr. Gloster very hands-on?

Mr. Bernard Gloster

Completely.

Deputy Gino Kenny

That is good to know.

Mr. Bernard Gloster

It would be nice to say that, strategically, I would focus on all of the major changes that I need to make. I need to do that, and I need to devote a lot of my time to doing it. Given where matters stand, the health service needs a more hands-on, closer-to-the-point-of-local management, decision-making CEO than perhaps current circumstances might suggest I am. That is why I will be changing the management team process in its entirety on 4 April next. I will talk directly to the nine chief officers in the community healthcare sector, the chief executives of the six hospital groups and the chief executive of the Children's Health Ireland. It is in the context of that process that the hands-on piece will come about. Some people may not like that, but that is where it will come about.

Deputy Bernard J. Durkan

I welcome Mr. Gloster and wish him well for the future. Without doubt, he has a mammoth task ahead. However, there will also be opportunities. Mr. Gloster indicated that he is prepared to meet the challenges and overcome the obstacles that exist in so far as that can be done.

I want to know, if possible, the degree to which Mr. Gloster has identified the main issues that afflict the health service. In other words, the first meeting that the patient or the individual has with health services usually determines their reaction and degree of satisfaction afterwards. Has he identified the areas that need to be dealt with? If so, how can quickly can they be dealt with? I am thinking about issues like access to accident and emergency units. I am mindful that we do not have a sufficient number of GPs at the moment. Changes are taking place. There is a greater reliance on accident and emergency units than there was in the past, but maybe we have to embrace that situation. Also, instead of trying to do all things at the same time, a decision must be made to do something but to do it really well.

Mr. Bernard Gloster

The Deputy made a fair suggestion. In terms of identifying the most pressing matter, I refer to my opening statement. To be fair to the Minister for Health, I had several discussions with him before and since I took up this job. He has made it categorically clear that the two things we are not making enough progress with are access and the entire management of the experience of people who use urgent care services. We are making progress in the context of outcomes, as I outlined earlier, in areas such as cancer care and cardiovascular care. We are making progress in affordability albeit I accept that we have a long way to go to reach where we want to reach. We are making progress in some of the strategic parts around elective care reform and the consultant contract. Much progress has been made. Ultimately, for the experience of the patient and the public in general, the parts of the system in respect of which we are most challenged are those that have completely buckled at times. I refer here to urgent care provision in emergency departments and waiting lists. Our focus must be on those two areas.

In terms of the patient experience, regardless of process, timelines and access, we cannot take our eye off the ball when it comes to our culture as an organisation and how we interact with people at an individual level and what their experience is of us. Even if people go away knowing that they are on a waiting list or will have a wait time of three weeks, three months or whatever, we need to know about their experience of how they were supported and interacted with by health service staff, their experience of the HSE and how they felt afterward dealing with both. An important part of an organisation that is under pressure is its culture in terms of its openness to accepting and recognising for people that the service is not as good as we want it to be.

Deputy Bernard J. Durkan

A number of issues have repeatedly arisen at meetings of this committee over the past number of years. I refer, for example, to overcrowding and a lack of capacity in the south west, particularly Limerick. Does Mr. Gloster have in mind a short-term plan that will deal with the situation in a way which will ensure that it will not have to be dealt with again next year or the year after? I ask that because I believe that the cause of many of our problems is that we leave situations half resolved. I wish to say, without reflecting on anybody, that half doing the job does not solve the problem.

We need to bring matters to a conclusion. Does Mr. Gloster have a plan in that regard?

Mr. Bernard Gloster

I do. There are two parts to it. On those services waiting for additional capacity to help them meet the demand they are experiencing, as I said, my job is to make sure that whatever the HSE part of the process is, I speed it up to the greatest extent possible without, obviously, being reckless, because that would not be any good either. There are steps we can take to improve significantly on that. I have discussed these with the Secretary General and the Minister. That will put other parts of the system under pressure to also speed up their parts of the process. It is about improving the realistic, informed hope of the public on the delivery of that additional capacity. We talked about the bed situation; 1,179 have been delivered already with 200 more beds to be delivered this year. Rather than talk about the X hundred other beds that somebody might think needs to be there, I have got to deliver on that. I have to shorten the process to do that. That is on the practical capacity side.

On the process side - Deputy Cullinane mentioned Waterford, and there are examples in other parts of the country - Deputy Durkan is right. When we tend to focus on something, we see a little or quick improvement for a day and then it is either back to normal or other priorities take over. That is the piece where I can take it up a level to a more consistent focus every day. I will say to the Deputy that apart from the medium- to longer-term planning and change work I have to do as CEO, already a significant part of my time in the first two and a half weeks in the job has been focused on changing our entire approach to improving those processes as much and as quickly as we can, in addition to sustaining and staying on top of them. I have been having conversations every day for the past five or six days about the number of people who are delayed in hospital in respect of their transfer of care out of hospital.

Deputy Bernard J. Durkan

One of the things I have noticed over the years relates to the building programme. We have certain elements of the building programme, including the children's hospital and the new national maternity hospital, for which I presume plans are ongoing at pace. I was told something a number of years ago regarding the very current issue of housing. I went to Ministers, Secretaries General and various people who were in a position to help who all said, regarding every proposal, that it would take about five years to get it going. Would it not then be a good thing to make a start on the issue that immediately comes to mind to those of us who have to deal with the public on the ground?

I will put a final series of questions. In the context of the hospital building programme, the hospital in Naas, which is near where I live, has had an ongoing upgrading programme for years. Such programmes take a certain number of years to complete. If a programme does not start some time, planning permission will lapse and so on. We are not going anywhere fast in that regard. We have issues such as scoliosis, and other urgent issues, which were dealt with by the committee, where it was proven to the committee that a consultant along with a surgical team was able to deal with the issue very effectively in a short period, but everything stopped again and we are back to square one.

On the degree to which the HSE is relevant throughout the regions, and this again relates to capacity and so on, there is a feeling the further you get away from the centre, the less influential the patient is. I believe the patient comes first. There is also the question of the structure of the board. How does Mr. Gloster hope to relate to the structure of the HSE board and work with it? He mentioned something along these lines already. We believe that a basic fundamental in Sláintecare was the extent to which the regions saw the board as being relevant to their position and how influential they are. It is a simple thing and is not rocket science. It is a very simple thing to ensure the board is relevant, that it reaches down to the regions, and that the regions reach up to the board and have access. If they do not, no matter how good the organisation is apart from that, it will fall apart.

We will support Mr. Gloster in every way possible. We will be critical but fair. We will try to reflect the views of our constituents. I am not saying constituents are always right but they are not always wrong either. We need to remember that. We wish Mr. Gloster well in the future. I ask for quick answers, if possible, to the questions I posed. My time has run out.

Mr. Bernard Gloster

I thank the Deputy. The overall context of what he said about timing, delay and process goes back to what I said. My job is to try to reduce, in every way I can without being reckless, the time it takes the HSE to do things. Whether that is in the context of a building programme or in response to a surgical demand improvement, such as scoliosis, I have no dispute with the observation the Deputy made.

I will have my first meeting with the board of the HSE on Friday week. I am very much looking forward to working with it. I met every individual member of the HSE board before I started. To be fair to them, they have done enormous work since they were appointed in late 2019 in coming through and guiding the organisation through the pandemic and still guiding a lot of detailed improvement work required for aspects of Sláintecare and other things. On how I relate to the board, I have had significant discussions with the chair and all the members. The one thing I have asked the HSE board to do is to ensure I am appropriately held to account for the job I do. I am already having discussions with the board on matters such as connecting regional leaders and chiefs to it. The board has five subcommittees to do specialist focus on its work. All of the people who generally support that work are from the centre of the HSE. I will have some final discussions with the board regarding bringing some of the regional people into that so the board has direct visibility of, information on, and insight into that real, lived, local, regional experience. I certainly intend to drive and improve that. Ultimately, if we move to six regional health areas with six chiefs, I expect they will have a very active part to play in the board processes of the HSE. To be fair to board members, they would very much welcome that. They are a very active board that is very interested in what the experience of the public is of this big organisation of 140,000 people.

Senator Martin Conway

Mr. Gloster is very welcome. Having worked with him previously, I have no doubt that the HSE is in good hands. We wish him well in his endeavours because it will be challenging. It will not be easy but it will be rewarding because the achievables that are possible are significant and will make a major difference to the lives of the people of this country. I sincerely hope the committee can work with Mr. Gloster constructively in a positive way. When he appears before us and we put questions and issues to him, it will usually reflect what constituents want. I know that is what he would want as well.

On what Mr. Gloster has outlined so far, it is very welcome that his initial policy position with us is to focus on areas such as mental health, women's health and supporting people with disabilities. We have been a First World country for a significant period, despite the difficulties we had from 2008 to approximately 2016. That decade was difficult as regards resources and so on but, by and large, we have been a First World country for the past three or four decades. However, we certainly are not a First World country when it comes to creating the type of equilibrium and equality of access to services and supports for people with various disabilities to ensure they have a level playing pitch and the same opportunities to reach their potential in life that able-bodied colleagues have. The health service has not stepped up to the plate in creating that equilibrium. For Mr. Gloster, in his inaugural visit to the committee, to put that at the top of his agenda is very welcome.

It is welcome that he immediately instigated management change within the HSE. It would have been very easy for him to say that he would wait until the regional health forums were established in a year's time to put that type of structure in place. However, he moved rapidly to try to create accountability and devolve responsibility to the various CEOs of the hospital groups and create his senior management team of 15. It is very welcome that will now happen from 1 April.

Mr. Gloster will not be surprised if I ask him how he thinks it will impact on University Hospital Limerick, UHL, particularly when it comes to the serious problem with the delayed transfer of care there, which is a significant contributory factor to the numbers on trolleys. Given that Mr. Gloster is making that management change very quickly, how rapidly does he think we will see an impact on the trolley numbers at UHL? While he is answering that element of the question, he might also give us his views on whether there should be a model 3 hospital on the mid-west. Is there a case for a model 3 hospital? Given Mr. Gloster’s vast experience working in the mid-west, does he think it is lacking? Does there need to be re-appraisal of Government policy in that regard?

Mr. Bernard Gloster

I thank the Senator for that and his kind words. It is lovely to connect with him again. As he said, we have worked together over many years.

On the emphasis of the issue of people with a disability, I cannot emphasise enough the importance of us changing our approach and our response to that. Recognising many good people are doing good work today, we need to make a step change in that.

On the management process change from 1 April and how that will benefit UHL, it will benefit UHL in the same way that it will benefit the totality of the healthcare system. When I look at regions, geography and counties, I do not just look at the individual hospital, rather, I look at the totality of the health service within that. The totality of the health service in the mid-west, where UHL has its footprint, is UHL, mid west community healthcare, the National Ambulance Service based in that area and all of our functions, estates and so on. It is a totality of a health system. To be fair to the people leading the hospital there, we have to represent and push the entire system as an entire system. That is the first thing.

On delayed transfers of care, I met the senior leaders of the mid-west last Wednesday night with the INMO as it happened. It was my first service meeting in the job. It was not because I happen to be from Limerick – I emphasise that. It is just the way it emerged – I promise, Deputy Durkan. I am a CEO from the mid-west but I am not a mid-west CEO. In seriousness, they have made improvements around things such as delayed transfer of care. To be honest, I have been relentless in the past few days in pushing the entire system. The day before yesterday, we had some 440 people waiting for a bed in hospitals on trolleys in emergency departments across the country. That was only achieved because of a huge pressure coming into the weekend to get discharges and other things done.

On the same day we had 440 people waiting for a bed, we had 600 delayed transfers of care. I cannot accept that this requires buildings, new beds or additional other things. Some of those cases are very complex and there is not always an easy solution. There might be major rehab or a major impact of drugs on the life of somebody. There might be horrendous social circumstances, such as homelessness. However, I cannot and will not accept that. I have told both the hospital chiefs and the community healthcare chiefs that I will not accept it is reasonable even today to have 600 delayed transfers of care. For every one of those delayed transfers of care that we can move more speedily and take solid, quick decisions about, that is one fewer person admitted to hospital waiting on a trolley. I am focused on that.

The process I initiated that will potentially benefit the mid-west the same as other areas is exactly what I said to Deputy Cullinane. It is a way of performance managing the totality of the system. Rather than saying what works in Waterford or Dublin – and there are many good things that work in Limerick that other parts of the country could learn from too, to be fair to my colleagues there – I have to go to a position very quickly whereby if something is working in a particular area of the country, particularly a management process, there is very little room for every other area of the country to say why they are not adopting that same approach. Mandating and performance managing that is probably the piece that might help a little bit. However, it is a long way to go. The experience of the mid-west, as the Senator know, is challenged.

On the configuration of the model 3 hospital and the blue light position, it is a difficult question. I have heard questions and calls about reopening Nenagh, Ennis and St. John’s and so on. Those might appear easy solutions to people in the short term, and I can understand where people might default to that position because of their dreadful experience. The reopening of a blue light entry to a hospital requires not just an emergency department and emergency department consultants, it requires intensive care capacity, advanced life support capacity and all of those things that go with it. We know that if you do not have all of those to that standard, it is difficult. There is not an easy answer to that. I could not give the Senator a simple answer and say “Yes” or “No”. There are other things we can do first and that is where my focus has to be.

In the case of UHL, which already has planned 96-bed additional capacity, my job is to see how I can drive the entire system that builds, staffs and configures that to shorten the time.

Senator Martin Conway

On the 96 beds, I know there is one block under construction. However, it is accepted by all parties that there would be at least another 96-bed block. The Taoiseach was in UHL just at the end of February. He gave a clear indication that when the business plan comes to Government, there will be no delay on Government’s side. However, talking about process, speeding up process and unnecessary delays, it would appear that business plan is nearly self-explanatory and should even be at the Department already so it can at least get sign-off. Even when it does get sign-off, as Mr. Gloster knows, between tendering, design and everything, it takes a period of time. I presume Mr. Gloster’s new process, or at least enhanced process for the moment, will deal with those type of blockages.

Mr. Bernard Gloster

They absolutely will. If the technical requirements to configure a business case for additional bed capacity in any hospital that is seriously challenged or any community service meets the basic requirements of scrutiny, there is no reason why we should be vacillating over it for a long period of time. We should be moving it through the process. Eventually, it is dependent on capital funding and the capital plan. I know the Minister is focused on that. As it happens, in respect of the, shall we say, indicated additional 96-bed capacity in Limerick, I met the CEO of the group and the head of estates for that area recently. I had a brief discussion with them and I asked them to consider. They are considering whether it is possible to even get the case ready in building the first 96 to create the foundation base, frame or beginning of the shell for the second, so as to save money, time and process. To be fair, that would require approval, but I asked them to try to get that into the system as quickly as possible.

Senator Martin Conway

That is extremely positive news and the people of the mid-west will be delighted with it.

I have one final question and Mr. Gloster mentioned it. I refer to the engagement that people have initially with the health service. Regularly, we are told once people get into the system, they rarely have complaints about the quality of the service. It is that initial step into the system. Has Mr. Gloster had engagements with the National Ambulance Service in the past couple of weeks? I have come across a situation where somebody had a serious fall and who was waiting for so long for an ambulance that did not come that eventually, that person had to be brought.

While that person's experience within the system was extremely positive, the initial trauma in getting into the system was terrible.

In another case, which occurred not too far from the first, a person had to wait for seven or eight hours for an ambulance. I know Mr. Gloster is not the director of the National Ambulance Service but it is part of the overall offering. I would be interested to get his observations in that regard. How, through working together, can processes be improved to ensure those types of situations can be eliminated?

Mr. Bernard Gloster

I read a report as recently as last week about the concerns that have been expressed about response times, particularly for priority calls. I thank the Senator for recognising that while I am not the director of the National Ambulance Service, I am, to be fair, the CEO of the Irish health service, of which the National Ambulance Service is a component. It is something I take seriously. I talked about changing the management team process and bringing together those 15 people with a few of them in the centre. On my second day in the HSE, I met that entire group of senior people and the one person I ensured will be a part of that process from now on was the director of the National Ambulance Service because, to be fair to him, and in order for him to do his job and get the support he can from the service, and for us to be able to challenge the potential for improvement within the National Ambulance Service, he needs to be right in the centre of the process. The National Ambulance Service is vital. It needs to be at the active centre of what I am doing, and it will be.

Deputy Colm Burke

I thank Mr. Gloster for his presentation and wish him well in his new role. It is a difficult task and I fully understand that. In his statement, he outlined that there are positives in the health service. Life expectancy in Ireland, for example, has increased dramatically. The results in our maternity services are extremely good in a European context. However, the media's focus has been very much on the negative side of the health service. That gives the wrong impression to the public. Consider the number of people now employed in the health service. In December 2014, 103,000 whole-time equivalents were employed in the health service. That figure is now 142,000, or coming close to it. In real terms, between part- and full-time staff, how many people are working in the HSE now? I know Mr. Gloster may be unable to give an exact figure but can he give an approximate figure as to the total number now working in the HSE?

Mr. Bernard Gloster

In December last, there were just over 139,000 whole-time equivalents. Some of those would obviously be made up of part-time-----

Deputy Colm Burke

When we look at it from the part-time-----

Mr. Bernard Gloster

I do not have that head count. I am due back before the committee next week to discuss Sláintecare and I will certainly have that figure for the Deputy. The net figure for whole-time equivalent staff grew by 19,500 between 2019 and December 2022. That is extraordinary net growth when one considers the number of people leaving the service.

Deputy Colm Burke

There has been a growth of 40% in real terms in eight years.

Mr. Bernard Gloster

It is significant. I may have the head count here. Ms Doody will assist me in that regard. The Deputy is quite right that it is an enormously positive story. I said there were three challenges to which I want to respond, one of which is public confidence. That means ensuring that public confidence is appropriately informed. That is people-----

Deputy Colm Burke

Can I just talk about the-----

Mr. Bernard Gloster

Some 157,924 people are employed by the HSE.

Deputy Colm Burke

That is the number of people who are physically working for the HSE.

Mr. Bernard Gloster

That is the head count.

Ms Niamh Doody

That was the figure as of February 2023.

Deputy Colm Burke

I will move to issues around how we operate the service. There has been talk about the fact that nurses are highly qualified. In fact, many nurses are better qualified than many junior doctors. That does not take from junior doctors who are training. We have not expanded the roles of the nursing staff. On the other hand, nurses are doing duties that care assistants could be doing. Some of the private hospitals now have theatre assistants providing back-up support in theatres. We have made no progress in restructuring what the workforce does. There are highly qualified people who are not allowed to do tasks that they are qualified to do but are doing tasks that others, such as care assistants, could easily do. We are prevented from taking them in. Are we going to consider a restructuring in order to get a more efficient service?

Mr. Bernard Gloster

There are two things that can lead to that type of skill efficiency and skill transfer. One will take slightly longer than the other. The significant growth of 19,000 staff members that I talked about from December 2022 is in the context of nursing and midwifery. That is just an indicator. That is not to say, to be fair to the INMO, that it has everything it says it needs. However, that is significant growth. Skills transfer is something that has been talked about for many years.

Deputy Colm Burke

That is exactly the case. It has been talked about.

Mr. Bernard Gloster

I am not sure how well exploited it has been. I very much favour an appropriate skills mix of healthcare assistants and nursing staff where we have inpatient facilities and services, and particularly where we have care services. In the context of the way nurses are now trained and the skill set they have, we must seriously think about the benefit that can accrue from, for example, advanced nurse practitioners, in a similar way to how we approach advanced paramedics. Many of them can do things that were traditionally the remit of junior doctors. That is an observation about overall change.

The other thing we can do to help better use the staff time we have available to us is through the use of technology and digital technology into the future in terms of how we care for and support people.

Deputy Colm Burke

I will move to an issue in respect of elective hospitals. I was recently advised that for the elective hospital for Cork, for instance, there are something like 17 steps that have to be taken within the Department before the hospital is built. Like others, I recently met representatives of the private hospital sector. Representatives of one of those hospitals said they are prepared to build the elective hospital. I was a member of Cork City Council when I was Lord Mayor in 2003 and 2004. The city manager wanted to build an extension to City Hall. He brought in workers from the private sector who designed it, applied for planning permission, built and financed the project, which is being repaid over 25 years. Should we be looking for that type of system to allow for fast delivery of our elective hospitals? The current process means we will be lucky if a sod has been turned in five years' time for a new elective hospital.

Mr. Bernard Gloster

As I said, I will be before the committee again next week to discuss Sláintecare and will have more detail for the Deputy at that point. I can say that the steps to building a hospital are significant. They require a lot of consideration and probity consideration-----

Deputy Colm Burke

The development at Bon Secours in Limerick will take 23 months.

Mr. Bernard Gloster

It will, but to be fair, the Bon Secours group has been considering the project and the background work for a Limerick hospital for quite some time. I absolutely accept we could do better on the time that passes between a decision being made and a spade going into the ground. I had discussions about the elective hospital strategy only yesterday. For two of the three elective hospitals, we will achieve what is required of us by September or October in terms of the grounding business case to move it on to serious decision-making, which will eventually lead to design, procurement and so on. To be fair to my colleagues in the Department of Health and in other Departments, particularly the Department of Public Expenditure, National Development Plan Delivery, and Reform, I would rather wait until next Wednesday's meeting to give the Deputy the detail. However, on the general principle, we should be doing more to shorten the process.

Deputy Colm Burke

I will touch on two other Cork-related matters. One relates to the management structure in Cork University Hospital. I understand that the staff of the hospital must go through a whole series of processes to get any change done, including in respect of work within the hospital etc. The main hospitals in Dublin, by contrast, have direct access to people at higher levels in the HSE and within the Department of Health and can get decisions almost overnight.

However, in Cork University Hospital, CUH, which is one of the biggest hospitals in the country, management has no powers to take decisions regarding the changes it wants to make. Is that going to be reconfigured? As a result of HIQA intervention in community healthcare services, there are 240 fewer community beds in the Cork-Kerry region than four years ago. What engagement are we going to have with HIQA if on the one hand it wants a higher standard and on the other hand, the HSE is not then able to put in place the replacement for what is being removed.

An Cathaoirleach

These questions are probably more suitable for the other meeting we are going to have. The Deputy is going into detail in relation to the Cork area and Mr. Gloster may not have the detail or may have to backup staff with him today. The idea of today was to give an overall vision of how we see the job moving forward. I think it is a bit unfair for the Deputy to be looking for such detail, particularly if Mr. Gloster does not have the details in front of him.

Deputy Colm Burke

Chair, it is about forward planning and how we work with all the different organisations

An Cathaoirleach

In that case pose the question around forward planning rather than specifics about the Cork region.

Mr. Bernard Gloster

I take the general thrust of the question. I am pretty familiar with the impact of regulation on community beds and traditional community hospitals and public hospitals. Senator Conway will recall my travails in Ennis many years ago on the same issue. To be fair to HIQA, it has been given a job in law by the Oireachtas, with regulations and standards rightly focused on the care and dignity of people. At the same time, the capability of the HSE to get its stock up to that standard is a huge pressure. There is always a balance between how many beds one can keep versus how one maintains the focus on the dignity of patients. The loss of 240 beds is an enormous hit. However, there have been improvements in community beds.

Deputy Colm Burke

I accept that and I fully accept that the HSE in Cork has done a huge amount of work in improving all the community hospitals but I am concerned about how fast we can deliver the replacements needed. We also need to remember that the population has increased by more than 170,000, from 410,000 to 580,000 in Cork alone. There is a large demand there. The question is how we respond to meet the demand and how fast can we deliver on it.

Mr. Bernard Gloster

Regarding Cork specifically, I will respond with some more detail next Wednesday when I appear before the committee again. The health system as a whole, the Minister, the Department and the HSE sees the value of community bed capacity as a big part of shifting emphasis away from the challenges that are in the acute hospital system. We also recognise the ageing profile and the volatility in the private nursing home sector. In principle, the answer is "yes" but how quickly is another matter. I will need to get back to the Deputy on the specifics of the Cork position. I just do not have-----

Deputy Colm Burke

In relation to the structural management in CUH, there are more than 320 consultants there so it is a huge hospital.

Mr. Bernard Gloster

Yes it is a very big hospital.

Deputy Colm Burke

My question is about the decision-making process. Hospitals in Dublin have a direct link to the decision-makers regarding the provision of finance whereas in Cork it has to go through a series of hurdles before anything can be signed off on.

Mr. Bernard Gloster

It is a challenge. Earlier I talked about the process and the top heaviness. Cork is the same as Limerick and Galway in that context.

Deputy Colm Burke

No, Limerick has a direct link.

Mr. Bernard Gloster

Yes but Limerick is part of a group, the UL Hospitals Group.

Deputy Colm Burke

CUH does not have a direct link

Mr. Bernard Gloster

CUH is part of the South/Southwest Group.

Deputy Colm Burke

I know but it still has to go through a huge series of hurdles before-----

Mr. Bernard Gloster

In capital terms, I do not think it has to go through any more hurdles than Limerick or Galway. I will certainly check that for the Deputy. If I am mistaken I can assure him that I will be the first to put my hand up. It adheres to the current HSE processes. It is part of a group in the same way as Limerick is part of a group. That is the reality. CUH is not separate from the group. It is part of the South/Southwest Hospital Group that was designed in 2013. In terms of reduced process and equity of access to the decision-making, that would be resolved for CUH the same as for everywhere else with the six regional health areas, RHA, structure.

Senator Annie Hoey

I thank Mr. Gloster for coming in and wish him the best of luck his new role. His success will be a success for patients and the staff under his remit. Today is Daffodil Day and there are things available upstairs for anyone who wants to grab a little treat at some point. The topic of screening for lung cancer and other diseases has come up before. We only have two or three screening programmes up and running in Ireland. Does Mr. Gloster envision the screening programme expanding in the coming years? Lung cancer screening is being introduced in the UK. From pilot programmes, the evidence internationally seems to indicate that screening programmes result in an earlier detection of this cancer. I am interested in cancer screening overall. It is an expensive endeavour but there is now evidence for newer ones that may be successful.

Mr. Bernard Gloster

On the screening services generally, there is an acceptance of the benefit to the population of good screening services regardless of the specific context. I know some of the services have been very challenged. Focus on the recovery of screening services post-Covid was a challenge. I have some information about fairly steady progress in recovery to steady-state for cervical, breast and bowel screening. Rapid access clinics for lung cancer and so on are all part of the bigger mix. I do not have the clinical expertise in this but I would generally favour that in a health service focused on population health needs assessment, that part of the needs assessment would be a prioritisation of the best return and value to the public of the totality of screening services. This would be measured against the prevalence of the diseases we are trying to reduce. Proactive screening and proactive engagement of people in the management of their own health is something I have a passion for. We are talking much more about the preventative and capturing stages to intervene rather than the serious damage that comes later.

Senator Annie Hoey

It is something I am particularly interested in because I think around 25% of lung cancers are caught due to completely unrelated issues. People go in to have a routine operation on their toe or something and the medical staff happen to catch lung cancer at stage 3 or stage 4 at which point the prognosis is very poor. There is real potential with the lung cancer screening given what is happening in the UK and we should keep an eye on it.

The HSE has a fairly robust whistleblower policy. It is something that comes up not very regularly but it does come up. What would Mr. Gloster's approach be to protected disclosures and whistleblowers? When we hear from them they feel very aggrieved and it can be a very difficult process. What is the cultural approach to those people who feel they want to come forward for something that could potentially be long before Mr. Gloster's time? How will he be approaching this in the system as it stands?

Mr. Bernard Gloster

By its very nature, the context of protected disclosure and the connotation of whistleblower would mean that people who would identify themselves in that position would probably start from the perspective of finding it very difficult to trust somebody like me. In their mind, I represent the system or the establishment which they feel they have to go up against, taking personal and professional risks in order to call out what they see as a harm or wrongdoing. I would not want to be patronising to anyone in that position.

I have an absolute view that where people see and believe that there is a significant wrong-doing that is causing harm, or will cause harm to people, they should first and foremost be in and be part of a culture where they can articulate that and put that out there without fear of reprisal or of being isolated or scapegoated in any way. Equally I would say that when it is demonstrated that the system has done everything it can, proportionately, to look at that and try to evidence that concern and respond to it, there must come a point at which the whistleblower and the system have to agree or disagree on what the outcome is. That is where we get into things like independence and independent reviews and so on.

There is an extent to how far that can go and whether we can ever satisfy. I have seen some dreadful working relationships fractured in that very protracted space. My underlying position is, and has to be, that we have to have a culture where people who are in and part of our service and our organisation have the freedom to express that concern, and to have that concern considered reasonably. There are a lot of people who have done that and who have done a service to the public, and at times some of their concerns have been upheld. There have been other occasions where the concern has not been upheld, stacked up or validated and unfortunately the person is still very often left feeling that somehow the system is still wronging him or her in some way. That is where relationships can become intractable and difficult. It is very regrettable and I do not think there is an easy answer to it. I simply want to assure people that for as long as I am the CEO of the HSE if there are concerns there has to be a place for that concern to be heard.

Senator Annie Hoey

Hopefully people will then see that there is a proactive approach and the space for them to do that and that will be an important thing to come out of this. I am a member of the Joint Sub-committee on Mental Health so I might jump to that and have two more questions if that is okay. The sub-committee undertook pre-legislative scrutiny, PLS, of the quite long-awaited Bill to reform the Mental Health Act 2001. We understand this is a priority piece for drafting and will hopefully be introduced as soon as the Minister of State, Deputy Butler, can do so. This will ideally be before the summer. Is any work being undertaken by the HSE in preparation for the implementation and reform piece that will come around that mental health Act? I appreciate that Mr. Gloster has been in post for three weeks.

Mr. Bernard Gloster

In fairness I have not yet had the chance to meet Minister of State, Deputy Butler, and I intend to do that and see exactly what it is she believes the priorities within the bigger picture of mental health reform, improvement and service management are. I need to pursue that. I am shortly due to meet some of the key people in the mental health service and to hear first-hand exactly where it is at. To be honest, my sense of it, and I stress this is my sense of it, is that the system is currently struggling and under pressure to respond to the level of demand to deal with issues such as consultant recruitment. Whether it is in adult or in child and adolescent mental health the Senator will know well the documented challenges we have seen in Kerry and in other situations. Before we get on to major strategic improvement the service is struggling with that. Not unlike the reference to Health Information and Quality Authority, HIQA, with older persons the Mental Health Commission has a function and has presented us with challenges around outdated infrastructure, outdated practices and so on. There is quite a bit to focus on and quite a way to go. My point principally is that in the midst of dealing with the very obvious and urgent need to tackle urgent care and hospital waiting lists which directly impact the health of people today, we cannot forget the significance of the impact on people's mental health and well-being. My focus is on what the next phase of improvement we can make in the service is, regardless of what the legislative framework for that is.

Senator Annie Hoey

One of the areas that might be useful to consider is the discussion around widening the criteria for recruiting authorised officers. I think they are the only group of professionals who are legally entitled to undertake involuntary admissions so it would be removing this obligation from the Garda. There has been very slow progress on recruitment in that area so just to flag that could be a particular area that it would be very useful to focus in on. It is a small group of people but they are the ones who are quite badly affected when the system is not working quite right.

Mr. Bernard Gloster

That is helpful.

Senator Annie Hoey

I have a final question. A huge piece of work was done around the Assisted Decision-Making (Capacity) Act 2015. There was the Assisted Decision-Making (Capacity) (Amendment) Act 2022. There is a cultural shift around consent and a person's will and preference, and how that will be prioritised within the HSE. I think that will be a big cultural shift. Has Mr. Gloster thought about how he will ensure this cultural shift happens and that people are presumed to have capacity? That is what has come out of that piece of legislation - that people are presumed to have capacity. That will take a cultural shift so does Mr. Gloster have any thoughts on how to enact that?

Mr. Bernard Gloster

Starting from the respect for the assumption of capacity, and moving on from the traditional facilities of wardship, which served a lot of people well in its time to be fair, I have said several times when I dealt with serious challenges in the public service that I have been responsible for is that part of our history as public servants and as public service bodies in Ireland has been our tendency, albeit well-intended, to be over-paternalistic. We are and we need to put our hands up and recognise that. It does not mean we are bad people but that is where we have come from. We have come from traditional models of rescue and recovery, protect at all costs, and ironically people do not always get protected in that setting.

Changing that culture will be a big shift but there are enough really strong, modern-day progressive healthcare professionals now across the system who will bring that tide of change and who will welcome that assumption of capacity, but more importantly the cultural piece of allowing people to have self-determination in every aspect of their lives, healthcare and care. I do not think it will be as slow a burner as people think it will be in terms of the culture. People will struggle with the concept initially because there are people who just do not have capacity and experience very difficult and vulnerable circumstances in their lives. We have to be very careful that, for the majority, what is intended means we have to step back from that very paternalistic approach.

An Cathaoirleach

I will make a couple of observations. I begin by welcoming the fact that there was an announcement this morning relating to the drug Kaftrio, which is a life-changing drug and one of the issues the committee raised. The committee received a lot of correspondence on it and realised the importance of it being approved.

One of the things that came up at the committee was that the slowness of change in that area, particularly the approval of new drugs, was something that probably needs to be looked at. Mr. Gloster's opening statement mentioned the positive work health organisations are doing throughout our State, and it is important we remind ourselves all of the time about that. He mentioned the fact that people are living longer, the low mortality rate among children and the challenges that creates.

We know that in our hospital system there has been quite an increase in the number of people who are part of the older population having to stay longer in the hospital. That is a challenge in itself. The population is growing which again is a challenge. I welcome the fact that we heard that Mr. Gloster has taken on his role seriously and is starting to meet key players in his organisation and particularly meeting many of the unions. We have had the unions here and they talked in terms of the challenges they face as regards bullying at work, the problems of racial abuse, assaults on staff and on patients and so on, so there is the importance of fixing that.

Some of those at the meeting spoke about the pandemic payment. It is small money given the overall package of money that we are spending. It was mentioned time and again that it was a goodwill payment and many organisations are still waiting for that payment. The committee will look at this as a possible body of work for us in future. I ask Mr. Gloster whether there is anything that can be done. Fórsa said it was looking for a simple meeting with the HSE and that it had not had a formal meeting on the payment. This is something that could be done straight away. It has created frustration and resentment. It was a goodwill payment. It was not a huge payment given the amount of work that people did but it was recognition of that work. When people are left out it has an impact on morale and how staff feel.

The biggest challenge we are facing has been mentioned by most contributors this morning. This is the slowness of change and how cumbersome change is. We have heard about the importance of establishing the regional health authorities. They could be key. Everyone who comes before the committee speaks about the slowness of change. Where positive things are happening in the health service we do not replicate them. Mr. Gloster has mentioned meetings with the hospital CEOs. The committee has heard from witnesses who have come before it how important Pathfinder is and the number of hours and lives it saves. The Reeves day surgery centre that was developed by Tallaght University Hospital is a model that is working and clearly needs to be replicated. How can we build on these positive models? I presume this is what the meetings with the CEOs of the hospitals will be about. Where things are working in the system how can they be improved?

Mr. Bernard Gloster

I thank the Chair for his acknowledgement of the drugs decision yesterday. It is significant. Albeit the number of people involved is very small they are a very important small number of people. I was delighted to see it come forward. To be fair, I want to recognise the roles of the chief clinical officer, Colm Henry, and his team in this.

I said that I was taking on three challenges and the second of these is timely implementation. I do not believe the health service is short on plans. I certainly do not believe the HSE is short on plans. We are challenged by our capacity to implement them in a timely fashion. We can implement them but it takes us too long. This comes from a history long before the HSE was born in 2005. We come from various historical local structures. Convincing people that what is working in Cork is good for the people of Mayo can be a bit of a challenge. I picked these two counties only as an example and we could say the same about any other two.

The greatest challenge for a public service organisation is to have a sense of equity. We cannot have everything standardised but there should be a sense of equity and appropriateness. I often say that people in Donegal, Dingle and Dublin should have a reasonable chance of experiencing the same type of public services. This only comes with consistency. We have made this overly complex. We have failed to take the steps to identify quickly what works and to mandate it to happen across the system. We will still probably come up 20% short. It is the old 80:20 rule. If we got to 80% we would be an awfully long way down the road.

We have become risk averse. We want to think about a decision for a very long time. We want to study it and to analyse it. Sometimes this is good. We cannot just make decisions flying by the seat of our pants. We do have to reach a point of doing things in a timely manner. We have not been strong on this. To be fair to Deputy Cullinane, and particularly to be fair to the manager of University Hospital Waterford, it is being headed up in a particular way. Whether it is in Waterford or anywhere else if something is working I am obliged as the CEO to find out why it is not working everywhere else and why it is not happening. This is my job. If I do not do this I am not doing my job. These are the basics of accountability, sound management and strong governance. If I spend my life looking at what is not working then I will just looking at what is not working. Very often we have the answer and we are fearful for many reasons of scaling that answer quickly. I share the frustration of the committee. Something I openly discussed during the period in which I was being recruited to the job was that my potential weakness is perhaps my potential strength as a manager and that is that I am very impatient.

An Cathaoirleach

The important thing is that we do not plan to fail but many times we do. We plan for now rather than for the future. We need to plan for now and also for the future. Every second week we speak about the crisis in University Hospital Limerick. If we do not put in the number of beds that are clearly needed in the hospital system there we will fail again. If the plan does not cover a sufficient number of beds now and we are speaking about building then it will take another two years. However, two years later we will realise that we still do not have enough beds. We are not planning for the demands of the future. This is the big challenge that we face.

Mr. Bernard Gloster

It would be good if the revision of the 2018 capacity review could be done quickly and does not take an inordinate amount of time. To be fair the Minister has been quite supportive of it. I absolutely agree that we must plan for the future. We have to get on with the 96 beds if that is what we have decided. If we decide to have another 40 beds somewhere else we have to get on with it and see whether we can shorten the process. Public sector capital projects are by their nature slow.

What I would equally say, and I have to hold onto this as being important, is that just building extra capacity is not the only part of the solution and is not the only part of the problem. We do have process and practice challenges in most parts of our system that require a significant step change in how we deal with them. If we hold onto and keep all of the processes and practices that may not have served us well for years in any part of the Irish healthcare system we can build all the beds we like but we will keep filling them by the same process and we will not necessarily achieve the full benefit of having them. I am not a denier of capacity but for me it is capacity and process.

An Cathaoirleach

I will focus on capacity. Last week the Irish Pharmacy Union came before the committee. Its representatives spoke about a possible role for Irish pharmacists and the fact that polls have suggested they are the most trusted healthcare providers in Ireland. They showed their mettle during the Covid epidemic with regard to vaccinations and more. They spoke about other jurisdictions and the roll-out of strategies to deal with shingles, athlete's foot and eczema. This is done in other jurisdictions but clearly it is not done through pharmacies here. This could be a role for them. In many cases pharmacists are the first step. When people are ill they go to the pharmacist. They may then be able to get a GP appointment and then go to hospital if the system works. Does Mr. Gloster see pharmacists as having an enhanced role, particularly with regard to the capacity element?

Mr. Bernard Gloster

Enormously so with regard to healthcare advice and being the first stop for advice and for medication, medication administration, vaccination and vaccination programmes. These are done very well by pharmacists under protocol. We speak quite often about the central point at which we hold or understand a patient's story.

There is potentially a bigger part for pharmacy to play in that than many people might think. When I think about primary care as the place to which we are trying to shift the emphasis of healthcare for the future, there is a tendency to default to GPs supported by the HSE and allied health professionals. However, when we think about primary care, we must think about the full spectrum, and pharmacy must be right up at the top of that.

Deputy David Cullinane

To follow on from the theme of the last discussion, I had a similar experience to Mr. Gloster when I was appointed health spokesperson for my party. Unfortunately, I started at the height of the pandemic, which was a difficult situation for everybody. I spent about ten months meeting hospital managers, front-line healthcare professionals and people in the Department and HSE. I was talking to as many people as possible to understand what we are doing right in healthcare, and we are doing many things right, but also where we can improve, as everybody wants to improve the health service. That notion Mr. Gloster has of identifying quickly what best practice is and then mandating that it be done is exactly what needs to happen. That is the leadership we need across the health service. There are many examples in community, primary and acute care of good practice not being implemented across the system, so I 100% support that approach. It would be a significant cultural shift at the top of the HSE if that was done at pace.

I want to pick up on some of the themes of Mr. Gloster's contribution and opening statement. In the latter he focused on access, urgent care and used all the right words, including outcomes, affordability, capacity and effectiveness. He then talked about access and performance, timely implementation and public confidence. Mr. Gloster rightly said beds are not the only solution. I did a lot of analysis myself and tried to get my head around what was really driving the chaos, if we want to call it that, in emergency departments. The right care in the right place at the right time that Sláintecare promised stems from the idea that if people cannot get access to a GP or primary care or cannot get support in the community for neurorehabilitation from the integrated care programme for older persons, ICPOP, or community health teams, they end up going to hospital. We therefore need to invest in all those areas.

However, we equally have a problem with capacity in hospitals. If Mr. Gloster is going to bring hospital managers together, that is exactly the right thing to do. It is about holding them to account but also, I imagine, supporting them and enabling them to do what needs to be done. That could be a game changer as well. Those managers will look to Mr. Gloster and rightly say they have been screaming for beds, surgical theatre capacity and diagnostic capacity in our hospitals and it takes too long for decisions to be made and for things to be done.

I spoke to Mr. Gloster earlier about beds. Coincidentally, I only got the parliamentary question reply back ten minutes after we had our contribution, so I want to come back to Mr. Gloster on that one. As he said, it is not just about beds, but they are important. I refer to the budget in October 2020 which was to be delivered in 2021. I remember we had a robust discussion at this committee about the Estimates following that budget. A figure of 1,156 beds, plus 72 from the national service plan to make 1,228, were to be delivered in 2021. A total of 970 of those beds were delivered to the end of 2022 with 207 planned to be delivered this year, so three years in we are still waiting for those beds to be delivered. Today I have found out 49 of those beds will now be delivered in 2024. How in God's name could it take four years to deliver beds? Mr. Gloster is talking about pace and delivery, public confidence, timely implementation and performance. We funded and resourced the HSE to deliver 1,228 beds in 2021 and we now see some of them will not now be delivered until 2024, all while we have people waiting for 12 hours or more in emergency departments. In Cork, elderly people are waiting more than 24 hours on average. It is unacceptable. The hospital managers are screaming out for more beds. Will Mr. Gloster give me some insight into this from his perspective? He cannot be held accountable for any of it yet, but he is the HSE now so he must start answering some of those questions. Will he give me some understanding of why it has taken so long to deliver those beds?

Mr. Bernard Gloster

Sure. I am just looking at the briefing I have. First of all, there are the 1,179 beds delivered and, as the Deputy says quite rightly, 209-----

Deputy David Cullinane

A total of 970 were delivered. I have it here.

Mr. Bernard Gloster

I am sorry; by the end of 2023.

Deputy David Cullinane

In 2022, it was 970. This year it is 207.

Mr. Bernard Gloster

Yes. The 200-odd this year will bring it to 1,179.

Deputy David Cullinane

Yes, and 49 are to be delivered in 2024.

Mr. Bernard Gloster

Yes.

Deputy David Cullinane

Mr. Gloster has talked of pace and delivery. Why are 49 beds not being delivered until 2024? Why in God's name is that the case?

Mr. Bernard Gloster

On those 49 beds, a number of substitute projects are being looked at for other sites because there have been significant challenges with progressing the delivery of the beds. There are to be 25 at Beaumont and 24 in Cork. To be fair to the Deputy, I can sit here and talk about things like supply chains in the construction industry, the war in Ukraine, increased construction costs, and retention and recruitment in the building sector, and I am sure all those things have a part to play in it, but until I understand whether there is a part the HSE played in the process-----

Deputy David Cullinane

I do not want to be unfair to Mr. Gloster, but the last thing people want to hear is excuses. We have been listening to excuses for years. When we say we want delivery at pace and when we say we want timely implementation, I put it to Mr. Gloster that one of the key issues, though not the sole one, is beds in hospitals. The IMO says it, the INMO says it and hospital managers say it. Every time I talk to her, Grace Rothwell, the general manager of University Hospital Waterford, acknowledges her hospital is a success but says it needs more beds and I should keep pressing for them. Given we announced in 2020 we would deliver 1,228 beds and it is 2023 and I am being told 49 of those will not be delivered until 2024, I suggest that is not delivering at pace. Unless we deal with that and unless we are asking serious questions of ourselves at the top of the HSE about why it is taking so long to get it done, we are not going to get the public confidence we need. When Mr. Gloster meets hospital managers, they will ask to see the colour of the money, where the beds they looked for are, where the surgical theatre capacity is and where the extensions are. Managers are forwarding capital plans and they are not being delivered.

Mr. Bernard Gloster

That is why I said I did not want to offer excuses. I could sit here and rattle off reasons. It is great to talk about the 1,173 that will be delivered by the end of 2023, but the Deputy is quite right that my mind must be focused on the balance of 49, what happened with them, how we avoid it happening again and how we get beds at a faster pace. Regardless of the size or percentage of the total beds delivered, I fully accept the 49 outstanding do not represent timely implementation.

Deputy David Cullinane

This was a big announcement. I acknowledged at the time it was a significant number of beds to deliver in 2021. We were then told we would see more in 2022, 2023 and 2024, yet here we are with no additional beds beyond the figure of 1,228. It has taken us four years to deliver beds that were funded in October 2020. That frustrates me because I have a genuine fear we will get to winter next year and the 207 beds that will come in this year, which were funded back in 2020, will not cut it. People will ask where the beds are, what was done in the months from April to October and what beds were delivered beyond what was previously committed. The answer to that last question is "Zero".

Mr. Bernard Gloster

I am not seeking to either justify or stand over that. I have to look at the 49 beds and ask what in the HSE processes and approach contributed to that timeline, that delay or that not happening and how much of that I can take out to avoid it happening with any other development in future. That is where my focus is. I am not arguing with the Deputy about it. A four-year wait is not timely implementation; I absolutely accept that.

Deputy David Cullinane

My quarrel is not with Mr. Gloster at all, because he is only in the door. His vision and everything he has set out is exactly what we need. He has set a clear direction for the HSE that I support and which will serve the health service very well.

I fully support the overall direction of what Mr. Gloster is trying to do, but equally, for him to be a success, those bottlenecks in the system have to be challenged.

Mr. Bernard Gloster

Completely.

Deputy David Cullinane

As mentioned by the Chair, the time it takes to get things done is far too long. We still do not have many of those teams under the enhanced community care model funded and in place. Home help and all of that is still an area in which we have hours funded but we cannot deliver them. We talk about implementation and delivery and that is where the priority will need to be.

Mr. Bernard Gloster

Yes, and subject to capital developments and all of those things. I have to look at what is within the control of the HSE. What I would say about timely implementation, and it is there for a reason, before I commenced in the role, I met with the Minister and the HSE board and that was probably the central point of the discussion.

Deputy David Cullinane

I wish Mr. Gloster well.

Mr. Bernard Gloster

I thank Deputy Cullinane very much.

Deputy Bernard J. Durkan

I come from the generation that was led to believe many years ago that we had far too many hospital beds and hospitals and too much space in hospitals. We argued against this theory at the time for very good reasons which are now obvious to everybody. I am delighted to hear Mr. Gloster's vision for the future in this regard. As a priority, it would be helpful if he were to go down through those sensitive areas, put a deadline on them and put them away once and for all. Otherwise, we are going to be back here next year talking about the same issue. If it is not a winter plan, it will be a spring, summer or some other plan. That is only giving a name to something that is ongoing and has not been dealt with before. We are relying on Mr. Gloster to deal with that. I was told, regarding the housing situation long ago, that the solutions I proposed would take five years to do. Well it will take 20 years if it is never started.

There are a couple of other areas with which I will conclude. I have a couple of experiences in recent times of looking for somebody at the end of a telephone in the HSE, for instance, in the medical card section. There is a dedicated phone line for politicians, but the only thing we ever get to is somebody handling information at the end of a telephone line. It can go on and on. I brought this up before in relation to medical cards for people with serious, life-threatening or possibly terminal illnesses. I have always felt the families are going through enough trauma without the added trauma of wondering if it would be possible to get a medical card. These used to be readily available once upon a time. They are no longer available except when the case has been examined two, three or four times, notwithstanding the availability of the consultant's report and the GP's report, both of which point towards this being a serious situation that needs to be dealt with now. Somebody comes back from the medical card section and says a new application has to be made. Imagine what that is like for somebody who is facing those particular types of trauma. Will Mr. Gloster make an intrusion into that particular department with a view to providing a more readily available response? In a similar mode, reimbursement is one of the things we come up against again and again.

I want to make a point on the building programme. Again, regarding the local hospital in Naas, I remember years ago when it had been discussed for 16 years. That was long enough really and it was time to make a move to bring the discussion to an end and do something. The current proposals for that same hospital are being discussed for an awfully long time. The answer is the same year after year: oncology areas, enhancements, and extra space are needed. We are getting no nearer to what is becoming an outdated response to the questions and that frustrates us. When I used to be a member of the health board years ago, it used to really frustrate us. We were closer to the heat in that kind of situation.

Mr. Bernard Gloster

I can assist the Deputy on the Naas piece specifically. I know he is probably talking about a bigger footprint, but in the 2021 winter plan, 13 beds were approved in that hospital and they are now scheduled for delivery in 2023.

Deputy Bernard J. Durkan

It is, as my colleague was saying a few minutes ago, the year after.

Mr. Bernard Gloster

No; 2023.

Deputy Bernard J. Durkan

I know, but it is after the event that it is coming up again. It is urgently needed.

Mr. Bernard Gloster

I hear that.

Deputy Bernard J. Durkan

The rest of the facilities are urgently needed. Mr. Gloster knows that. I know that. The people who are the potential patients of that hospital know that as well.

I will make another point. I had need to access emergency treatment recently and I was really impressed with the treatment in a public hospital. I drove in and was attended to - not immediately, as there were between 20 and 30 people waiting and obviously everybody cannot be dealt with at the same time. There were some people who were obviously in need of urgent treatment and they were dealt with in good order. There were other people who, to external appearances, were less obviously in need of treatment. However, they were all attended to. All the tests were done, all the bloods taken and ECGs done. They were very thorough. I hope the doctors did not have to wait for the results because it used to be a real bugbear that you would have to wait a couple of weeks for the results. I attended a major hospital in Dublin and I would give it ten out of ten.

Mr. Bernard Gloster

I thank the Deputy for that recognition because in all of the challenge we rightly talk about, there has to be room for and recognition of the fact that it is not all bad. There is an awful lot that is good. The majority, if not the totality, of people in the Irish health service come to work to do a really good job, do their best to care, and go beyond the call of duty. It is important to recognise that, despite all of the frustrations that so many people are experiencing today.

Senator Aisling Dolan

I am based in Ballinasloe as a representative for the Roscommon-Galway area. I congratulate Mr. Gloster on his new role. He has spoken already about equity across the country and mentioned it is one of his key priorities in being able to deliver a health service.

My brief question brings it back to the local a bit. Portiuncula University Hospital is one of our Saolta hospital group regional hospitals. It is a level three 24-7 hospital. Coming from the University Limerick Hospitals Group, Mr. Gloster will be aware of the regional nature of some of these hospitals. We have been very fortunate. There is a 50-bed ward block currently under construction that is scheduled for delivery at the end of 2024. Currently, our emergency department has been under severe pressure. Outpatients has also been converted and we only have 13 single rooms in this hospital. That is where the pressure has risen the past two years, particularly around the lack of dignity for patients within those multi-bed ward blocks. This is a replacement 50-bed ward block that is being brought on line.

The issues around access relate to the emergency department. In the past year and last Christmas, it saw the highest figures ever in terms of trolley counts. There is a proposal currently before HSE estates from the Saolta University Health Care Group around a modular build or at least ten additional treatment bays. We have engaged with HSE estates and I was very hopeful this might be something that could be put in place for this Christmas to tackle the demand at the end of this year. Will Mr. Gloster give his opinion about modular builds around emergency department additional space or treatment bays?

If a build is on the bricks and mortar side, will it take a far longer timeframe? The 50-bed ward block in question will not be on stream until the end of 2024. We are hoping the additional 14 beds and eight rooms that are being converted from outpatient facilities in the hospital will be on stream in the coming months, but there is continuing pressure.

Mr. Bernard Gloster

There are two things in the profile for 2023. There are 12 beds scheduled for Portiuncula. I hope those beds will be of help but I appreciate the hospital has been awaiting them for a significant time. I am not looking for credit in that regard but those 12 beds are scheduled to be delivered this year. Part of the solution to the capacity and infrastructure issue generally across the public service, including in healthcare and hospitals, is to use modern building technologies. Modular builds have proven to be very good in several cases. Whatever about reducing the timeline to getting the service in place, when defaulting to modular build due to time pressure, we must ensure we do not reduce the quality and sustainability in the long term. All present remember school prefabs.

Senator Aisling Dolan

It is very different. Even in the school sector-----

Mr. Bernard Gloster

It is completely different. Modern building technology is fantastic. To be fair to colleagues in the Department, whom I will be meeting shortly in respect of the capital plan, they recognise, appreciate and wish to share in the use of the most advanced technology to shorten delivery time. As regards the situation for Portiuncula this winter, I will have to revert to the Senator. I do not know the answer to her question. I am familiar with the hospital. It is a fine hospital with a long history and it is an important part of the Saolta group.

Senator Aisling Dolan

It is a fantastic hospital with a tremendous team. There has been an increase in staffing at the hospital. We are seeing a fantastic uplift, particularly in the context of the construction under way there. There is a significant amount of activity. The hospital caters for nearly 400,000 people across five counties. It covers all of County Roscommon in terms of a level 3 hospital but it also reaches as far as north County Tipperary. It delivers so much for areas such as Westmeath, Galway and Roscommon. There may be other challenges in delivery but any supports for staffing at the hospital would be welcome. It is the only emergency department within the Saolta group that has not undergone work. Any attention Mr. Gloster can pay to the hospital in his new role would be greatly appreciated. I thank him for his time.

An Cathaoirleach

We have not touched on it in the meeting thus far but how important does Mr. Gloster consider the all-Ireland dimension to be in the context of the roll-out of healthcare? We will have it with the national children's hospital and we already have it in oncology and so on. How important is that dimension, particularly for the Border region and the enhancement of population health there? What are Mr. Gloster's priorities in that regard? How important is that North-South co-operation? I refer to near neighbours, such as Donegal and Derry and so on.

Mr. Bernard Gloster

Cross-Border co-operation in areas such as healthcare, be that in emergency healthcare responses or in primary care and proactive care management, makes perfect sense for the people who live in Border regions. In terms of cross-Border co-operation generally, which works both ways, there is a significant amount to be gained and learned from taking what works in one place and reproducing it elsewhere. All those relationships, such as the traditional relationships and so on, are extremely important. During the pandemic, we saw the relevance of the connection between the population of Northern Ireland and that of the Republic. It is an obvious consideration.

An Cathaoirleach

Disease does not stop at imaginary borders. I thank Mr. Gloster. I very much appreciate him coming in. It is exciting times in terms of the programme he outlined and his priorities in that regard. He can rest assured of the co-operation of the committee. We look forward to working with him. He will shortly be appearing before the committee to discuss Sláintecare. I look forward to that engagement. Unless there are any other matters, that concludes our discussion. I thank Mr. Gloster for taking the time to discuss his strategic priorities for the HSE. The committee and I again wish him all the best in his new role and look forward to ongoing engagement with him and his officials.

At our meeting next week, the committee will be joined by the Department of Health and the HSE for a regular consideration of the implementation of Sláintecare. Mr. Gloster will be back with us next week.

The joint committee adjourned at 12.15 p.m. until 9.30 a.m. on Wednesday, 29 March 2023.