Dr. Susan O'Reilly:

I thank the Chair and members for inviting us here today. I will focus a little on the future. I would like to introduce my clinical director, Mr. Martin Feeley.

Our group began less than two years ago and, like Mary Day's group, is a young group in evolution. We serve a population base of 800,000, our expenditure this year will be close to €1 billion and we have approximately 10,000 employees. It is a busy group. In the interests of time, I will not go through all the numbers. They are in the submission.

We have a distinguishing feature from some of the other groups in that 70% of our revenue goes into three large voluntary hospitals: St. James's, Tallaght and the Coombe Women's and Infants University Hospital. We have three general hospitals, Naas, Tullamore and Portlaoise, and we have the specialty three radiation oncology centres in Dublin - the St. Luke's radiation oncology network.

The two big general hospitals, Tallaght and St. James's, have both national and regional programmes. We are the national centre for burns and the national centre for stem cell transplantation. We have some of the national leadership roles in elements of oesophageal cancer, lung cancer, genetics, family cancers, etc. We have regional services for nephrology, renal dialysis, infectious diseases and ageing as key pillars.

Those two hospitals both offer broad general services as well. All five of our general hospitals include emergency department services, general surgery and general medicine. There are challenges. Our governance model is good in that we work collaboratively with voluntary hospitals by means of service level agreements and we directly manage statutory hospitals. However, all hospitals struggle with trolleys and waiting lists for elective procedures. We have a capacity problem that is universal across the country and it needs to be addressed.

In order to add value, a group needs regional leadership and management in order to progress. There have always been regional models, whether it was the old health boards or the RDOs. Some of them were integrated with the community and some were not. However, we work very closely with our hospitals, and particularly with their clinical leaders, in order to develop clinical networks for patient flow and optimal patient pathways. A very good example of that is the Coombe-Portlaoise maternity and neonatology network, which developed after we arrived as a group and which has been very successful in smoothing out where care is delivered. We are very appreciative that this has been such a success. We collaborate very closely with the two community health areas with which we work. Not only do our hospitals collaborate closely but we, the group, meet them very regularly – at least twice a month - to address admission avoidance and also to reduce delayed discharges. With their assistance, there have been very substantial improvements this year in how we manage delayed discharges but it is by no means close to perfect. It remains a problem in terms of bed utilisation.

Our future focus will be on integrated care with the community, with GPs, in particular, and with hospital consultants having more joint appointments. There are a few joint appointments currently and the CHOs in terms of their broad spectrum of activity are part of that plan. However, that is contingent on things we do not directly control. There needs to be a new GP contract, there need to be more GPs and there need to be more resources. I fully endorse comments made earlier to the effect that one cannot simply switch off spend in a hospital and transfer it to the community, one needs a very comprehensive plan that is graduated in order to get to the point where one shifts work and resources. Nobody would argue with that.

For general hospitals, for local reasons of need in the past - historical reasons - five of them are offering 24-hour emergency department, general surgery and general medicine. We have identified significant challenges through the work that we have been doing to show that low volume complex patient services are profoundly difficult to deliver in small level 3 hospitals. In particular, as members have already heard, recruitment is an issue. It is not even a matter of whether there are people or where there is money available. The jobs are profoundly unattractive if there is very little work to be done at the complex level and if there is very great difficulty for people to maintain their skills over time. We are very focused on having sustainable safe models for patients.

The group has been charged by HIQA, as a consequence of its report on Portlaoise hospital last year, and is expected to develop an action plan. We have put a huge amount of work into how we are going to ensure that we are providing safe care for patients in both general and maternity services. I wish to talk a little bit about how we are setting about doing that because it is still a work in progress within the HSE and the Dublin Midlands hospital group. It is not policy as yet. We are approaching the conclusion of all our work, which is being done in a very comprehensive fashion with eight national clinical programme leaders across the spectrum of all surgery, medicine, maternity and infant services in our group. Transportation is also an issue and the National Ambulance Service is involved and the acute hospitals division is very actively involved in co-chairing the process. It is very evident to us that, as members have heard from other speakers, we need to focus on providing complex, low volume but vital services that save lives in big hospitals and we need to focus on providing an increased volume and scope of elective high volume, lower acuity services in model 2 or model 3 hospitals.

That is part of a significant plan that is linked to an implementation plan we have developed, which is largely based on a very effective policy document that already exists, which is the Securing the Future of Smaller Hospitals: A Framework for Development. Implementation planning takes multiple years and capacity development is key. As members are aware, there are national and international shortages across all doctor appointments, junior and senior, and specialised nurses in particular. We need capacity for facilities and equipment to replace small, old unfit facilities. There is a massive shortage of capital at the moment. This will take some time but we will get there eventually. We have to reflect that front-line staff have performed heroically during the recession and the moratorium but we must ensure that for them to deliver services well, and for the staff to grow, they must have thoughtful planning, both in the community and in the hospitals to deliver a new model of care. Some of the models will make some members, individually, uncomfortable, but we must endorse change in order to be able to achieve that. The entire focus is on quality and safety for patients and I should add too, for our staff. We need to be able to give them an environment where they can do their jobs well.

Briefly, what will work is regional leadership and management. I endorse Ms Day's comment that we would need legislative authority and a model extremely similar to the very effective voluntary hospitals. It is a type of accountable autonomy whereby one is accountable but one has flexibility in how one develops one's programmes and one can be engaged and active in being as creative and productive as possible. It is not only a question of capacity, it is streaming patients around the clinical networks and pathways. Clinical leadership is vital at all levels. This was only formalised eight years ago. It has bedded in well and it is something we strongly endorse. Clinical networks and pathways are the sine qua nonacross community and hospital care and between hospitals. That is what we bring, because even the most effective, successful voluntary hospitals struggle to get the networking done in a comprehensive way without regional planning and leadership at the level we are doing it. Consultant-delivered services is the goal, as the national cancer control programme has pushed to deliver. We have evidence-based guidance from our 32 excellent national clinical programmes and the national cancer control programme. We must link to them for design advice and we will do the service delivery. The smaller hospitals framework models provide a very good underpinning.

In conclusion, 21st century medicine takes longer to achieve than a single Government term. My remarks are all based on a ten-year timeframe looking ahead. Change must be planned, agreed and resourced in order to provide staff, equipment and facilities, and implemented. It must not be all talk and then a case of individuals not wanting to go there. That is a challenge we must overcome as we move to get into the 21st century for all of our services. The committee has a great opportunity to do that. We want to be able to brief and encourage the committee whenever we possibly can to achieve that.

I strongly endorse the advice of my predecessor in leading the national cancer control programme - my previous job - Dr. Tom Keane, a colleague and friend, stated that we need collective political support to see our job through. In particular, I strongly endorse the Canadian public health care system which provides public universal access as an excellent model. We are nowhere near to that today.