Dr. Paul Burke:

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

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

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

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

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

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

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