Mr. Michael O'Flynn:

I thank the committee for giving us this opportunity to share our experiences as members of a non-executive advisory board that supported and challenged from the outside a major health service reform project. As the Chairman has mentioned, l am joined by Professor John Higgins, who is the former director of reconfiguration for Cork and Kerry; and Mr. Gerry O’Dwyer, who is the CEO of the south and south-west hospital group. The project we are discussing today was based on a document, "Reconfiguration of Acute Hospital Services, Cork and Kerry: A roadmap to develop an integrated university hospital network". Much of this statement is covered in more detail in my chairman’s report to the Minister, Deputy Varadkar, which was published by the HSE in December 2014. Everyone in Ireland is aware of the ongoing issues in our hospital emergency departments and the significant waiting lists for accessing some services. These issues remain major national challenges. Unfortunately, I do not bring any immediate solutions. However, I want to highlight a reform process that will bring long-term advantage to hospitals and communities in our region as they tackle health care challenges, while ensuring there are adequate primary care centres with appropriate diagnostics for hospital avoidance. I want to make a few simple but fundamental points, before bringing in my colleagues to assist me in answering the questions that members may have.

The reconfiguration of services in counties Cork and Kerry was a significant health reform project. It brought about real change in the way health services are delivered in both counties. We sometimes lose faith in the capacity of the health service to achieve reform, but it can do so when it goes about reform in the right way. I would like to mention some headline outcomes from our experience. Over 800 staff transferred their places of employment without any major industrial relations issues arising. One hospital changed from being an acute hospital with an emergency department that was open 24 hours a day, seven days a week, to being a dedicated elective hospital with no emergency department. The number of emergency departments and hospitals performing emergency surgery in Cork was reduced from five to two. This was supported by the introduction of advanced paramedics and intermediate care vehicles throughout Cork and Kerry. Local injury units and medical assessment units were established at the other sites to support the two 24-7 emergency departments in Cork city. The local injury units have achieved a 65-minute average time from patient attendance to discharge.

The transfer of the stand-alone St. Mary’s Orthopaedic Hospital to a dedicated elective hospital at South Infirmary Victoria University Hospital resulted in the same quantum of service being provided with a reduced number of staff. The remaining staff were redeployed to open 50 extra long-stay beds in community nursing units and to enhance support services at Cork University Hospital. The new model of care at South Infirmary Victoria University Hospital enabled the achievement of the best figures in the country for length of stay for hip and knee replacements and a 48% reduction in the number of patients waiting to be seen in the first year after service reconfiguration. Reconfiguring services at Bantry and Mallow by ceasing emergency and inpatient surgery and developing strong day surgical services, with visiting outreach consultants from Cork city hospitals, has provided safer and more sustainable services that comply with the recommendations of the small hospitals framework and the relevant HIQA reports.

The provision of cardiology services was consolidated from multiple sites to a new purpose-built unit at Cork University Hospital. The provision of pain medicine, plastic and maxillofacial surgery was consolidated from two sites to a purpose-built unit at South Infirmary Victoria University Hospital. The adoption of lean principles for the pain service led to a 49% reduction in the number of patients on the waiting list in the first 12 months following this transfer. The wait time was reduced from three years to nine months. The consolidation of all gynaecology cancer surgery at Cork University Maternity Hospital involved the reciprocal transfer of benign surgery to the South Infirmary Victoria University Hospital. Significant savings in the amount of time spent on call out of hours by non-consultant hospital doctors have been achieved through the amalgamation of services on one site or the introduction of cross-city on-call arrangements. Information technology improvements have been achieved through the roll-out of the integrated patient management and national integrated medical imaging systems and the development and roll-out of electronic referrals from GPs to outpatient clinics. The reconfiguration team provided the executive support and the pilot sites for this national project.

I would like to place it on the public record that my experience with this grouping is that this large-scale reform project achieved significant results over a five-year period with phenomenal commitment from front-line staff, clinicians and managers. However, this could not have been achieved without formal structures for managing the change and bringing people along with the process. I will mention the key elements of this. The dedicated reconfiguration team, which was well resourced, had the singular task of reconfiguring the hospital system. A reconfiguration forum, which was chaired by the director of reconfiguration, met every two weeks and acted as a steering group. This forum, which comprised clinical directors, senior hospital and health service managers, a GP representative and representatives from the UCC college of medicine and health, kept going through thick and thin. It heard presentations, discussed issues, took initiatives such as commissioning lean projects and got medical students to upload data from theatre log books so theatre usage could be analysed. Over 40 clinical subgroups were formed to discuss and feed in the views of specific clinical services. This brought to the table a depth of understanding and a realism that informed all the detailed reconfiguration moves and ultimately resulted in the successful implementation of much of the report.

I had the privilege of chairing the non-executive advisory board, which brought together some of the most senior clinical, financial, legal and educational corporate executives in Ireland. For a period of five years, they gave their time and commitment freely to ensure the project did not fail. They supported and challenged the director of reconfiguration and his team and the HSE south directors. They mediated with the HSE corporate team and with the political system when necessary. Most of all, they gave the director of reconfiguration confidence that he was supported from outside the system by people who knew what was involved in managing and changing large organisations. I will give three specific examples. In March 2010, after six months in existence, questions arose over the respective roles of the director of reconfiguration and HSE south's regional director of operations. Members of the non-executive advisory board engaged actively with the CEO of the HSE and others in the HSE corporate management team to get all parties to agree a document on reporting roles and a series of actions to enhance communications. This was a critical moment in the project. I believe the actions of the board were vitally important in resolving the issues at stake.

In September 2010, the board was asked to advise on the launch of the reconfiguration roadmap, which had almost been completed. It offered a number of strategies to support a successful launch of the roadmap. For example, on 3 November 2010 it brought all reconfiguration clinical subcommittee chairs together to sign off on the draft report. I believe this was a major factor in ensuring universal clinical and institutional buy-in to the final report, which was successfully launched later that month. In particular, it allowed some last-minute issues to be raised and addressed that otherwise could have derailed the consensus. The board was anxious to assist and support the implementation of the roadmap. To this end, it established three subgroups, which met from 2010 to 2012, in the areas of governance and external partnerships; finance and strategic planning; and change management and communications. Membership included senior managers from HSE south and members of the reconfiguration team. Each was chaired by a member of the non-executive advisory board. It is clear to me, as the chair of the non-executive advisory board, that competency-based boards with business, finance, health care, legal and education skills will provide effective oversight and objective support to our health system and challenge that system. All external members of this board gave of their time pro bono. Many of their skills are transferable. People in the corporate world understand the power and pressures that are at play. Most of all, they know that all users of the health service want it to work for ourselves and our loved ones when the time comes.

The implementation of the reconfiguration roadmap is a work in progress. As we approached the end of the immediate implementation phase, we were greatly encouraged when the then Minister for Health, Deputy Reilly, published the report on the establishment of hospital groups in May 2013. This report provided for six hospital groupings, each with its own board and principal academic partner. I was delighted when one of our advisory board members, Professor Geraldine McCarthy, was appointed chairperson of our group board in the south and south west. I am happy to pass the baton to her to finish what we have started. The establishment of hospital groups in line with government policy follows HIQA recommendations that boards should be competency-based rather than representative. From our experience, I would wholly support that conclusion. I encourage the current Minister to appoint the board and enable its work to commence. What is the work we are handing over to the new board? There are four large projects which are well under way to being completed and we may be assured that they will.

These projects comprise the transfer of ophthalmology from Cork University Hospital, CUH, to South Infirmary Victoria University Hospital, SIVUH; the consolidation of paediatric services at CUH; the development of a regional gastroenterology service at Mercy University Hospital, MUH, and development of a regional laboratory service.

There is one which is complex and difficult and probably the issue which the board is most disappointed about not having seen delivered, namely, the reconfiguration of general surgery and a single on-call surgical rota for Cork city. One project was largely overtaken by events. However, it has become a great deal more likely now that the academic health care model has been accepted as a valid form of relationship between hospitals and universities. It will see the development of a memorandum of understanding between the HSE and UCC leading to an academic health care centre arrangement linking health and higher education in a single governance model.

The last project involves finding the location of a site for a new elective hospital for Cork which would, in time, replace the city centre sites of SIVUH, MUH, and the dental hospital and to allow the expansion of all diagnostic services as appropriate. What is needed is a second hospital site in Cork city which would be developed in a modular way over 15 years as an elective hospital with the latest facilities for day surgery, diagnostics and ambulatory care, as well as with a number of elective beds for inpatient surgery, which would replace the three existing hospitals in Cork, namely, SIVUH, MUH and the dental hospital, resulting in synergies in the services.

CUH and this new hospital would be a single hospital on two sites, one specialising in acute admissions and the other specialising in elective and day surgery but both managed as a single entity by the South-South West Hospital Group. Services would be truly complementary. The site needs to be within easy travel distance of CUH, linked by good public transport. The advantages are real and substantial. The new hospital should be designed and built in a modular fashion over time, using financial resources allocated to key reconfiguration projects to commence its development as those resources become available. Capital moneys would not be wasted on piecemeal developments on the existing sites but could be spent in a cost-effective and incremental way. Services at CUH and the new hospital would be complementary rather than competitive, both being managed by the South/South West Hospital Group. UCC, the primary academic partner of the South-South West Hospital Group, would be partner to the planning from the outset, thus creating a teaching hospital in the fullest sense and a flagship for the proposed academic health centre linking UCC to the South-South West Hospital Group. UCC has already indicated it wants to build a new dental school and hospital. This needs to be on the site of the new hospital. UCC really needs to know the location now. Accordingly, the urgency of this situation cannot be stressed enough.

The effect on staff morale and performance would be transformative, making the task of attracting and retaining high-quality clinical staff much easier across the hospital group as a whole. CUH would be enabled to develop as a truly effective level 4 emergency hospital for the city and a provider of last resort care for the region. Outpatient and ambulatory services at the new hospital would serve the city as a whole, planned de novowith full account taken of patient flows, logistics, parking, diagnostics, clinical therapies, clinical teaching, day patients, pre-op assessment, etc. The transformation of acute service delivery on such a scale will have a major and increasing impact on hospital performance reducing average length of stay statistics and waiting lists.

This is a vision that is practical, necessary and urgent. There are no major impediments to delay its realisation. Both SIVUH and MUH are committed to it. The establishment of the hospital group provides the decisive management and governance initiative to facilitate and oversee the development. It does not even require major capital outlay in the initial stages. We are arguing for a staged commitment over ten to 15 years, beginning with site choice and acquisition, followed by concept planning, consultation with local authority planners on transport and logistics, as well as with other hospitals in the group. We are seeking support for a decision in principle to locate and purchase a site for a modern elective hospital in or around Cork city, with ready access to main transport corridors, and to commence planning for the phased transfer of services under the auspices of the South-South West Hospital Group. The new elective hospital would be planned so that it can be built in a modular way as resources become available. We also must future-proof it for the next generation by picking a site which is sustainable.

The past several years have been difficult for the whole country. I have had some well-publicised issues in business. However, while all that was going on, my involvement in this project gave me hope for the future of our health system and for our country. With this in mind Chairman, I commend the efforts of all those I have worked with over the past five years. I ask you and your committee for continued interest and support as we look to secure the future of our reforms with a second hospital site in Cork.