Ms Eilísh Hardiman:

The group structure is very much drawn for us. We are providing for the greater Dublin area, which is across all of the community health organisations and nationally for almost a quarter of our services. We have to function across whatever structures are put in place. For us, it was about developing pathways around complex care where we need to reach out. I have discussed this issue with my group CEO colleagues, whereby instructing their services within their regions, we work collaboratively. This means, for example, that our clinical lead would work with the clinical director for women and children in Cork on how to develop services collectively.

One of the fears that we have in the Children's hospital group is that if we do not work collaboratively to support services locally, parents will believe, on the basis of the good road infrastructure, that they have to come to Dublin for paediatric services. This is not the case because the vast majority of services are delivered locally. However, there is considerable inconsistency in this regard. If one takes emergency department attendances in paediatrics, which we have measured, the difference in admission rates varies from 8% of those who attend being admitted in two of our hospitals to 48% of attendances being admitted in another hospital. I have been quoted on this previously but children do not fall out of trees differently in Dublin than they do in other areas. We must work collectively on why such a variation is in place.

We have an over-reliance on the acute hospital system. In the next year, as we roll out the model of care, we expect to work with our colleagues in the other hospital groups to reconfigure services in order that they are less dependent on inpatient beds. Resources should be realigned around consultant delivered services to achieve more effective decision making and keep patients outside hospital and supported.

Regarding the flexibility to configure, there is flexibility to work within that because there is consideration of how to make one's existing resources work better. However, this takes time to plan, and some of it requires investment in capital structure to bring it to fruition.

Regarding recruitment and workforce planning and retention, we have developed a workforce plan for the next five years up to 2021. It is a challenge, but we have identified in the plan the supply elements we need to put in place and the changes in roles and positions which heretofore may not have existed in the system but which in five years one would expect to be in place. The changed roles and positions replicate very well-established posts in contemporary health care systems. For example, nursing being an area of common concern, a nursing workforce planner is coming onto our team and we have developed a paper with the nursing policy unit to work with all the universities on increasing the number of nurses going through children's nursing. We are producing nurses, they are all getting permanent contracts with the children's hospitals, and our colleagues in Cork can get permanent contracts with us, but we are not producing enough. During the 12 years in which we have been moved to the degree system for paediatrics, we have not increased the number of students on these courses, so we will present a plan of how and what we need to develop.

I think my colleagues would agree that the other issue is theatres. We see new roles such as an operating theatre department developing. We must create these new roles. They sometimes can be seen by some other colleagues in the system as a challenge, but they are well-established in contemporary systems and are already in place in the private sector in Ireland. They must be introduced as a way of relieving the pressures we find. Nurses generally want to go out and work, but some of these theatre-type roles are very repetitive, so there needs to be consideration of roles in which staff are specifically trained to deliver these services but in a safe way.

We have a huge challenge in the children's hospital in that much of the emphasis has been on the building and too much on the issue of its location. We know and understand the concerns and we would like to work with the families raising them to address them because we believe we can and we know we have a responsibility to do so. However, our focus within the children's hospital group is now increasingly on successfully merging the services. We work very well with the boards. We meet every fortnight with the four CEOs, the four clinical directors and the group management team. We have a structure in place and a plan for our staffing, a plan for engagement and a plan for how we will move from where we are now over the next five years. However, this is resulting in pressure and it requires resources. One does not introduce a change as significant as this, that is, a 473-bed hospital with two new paediatric outpatient urgent care centres in the periphery and a digital hospital, without having resources to implement the change. All our colleagues would probably concur on that. We must keep the ship going. At the same time, many people need to be employed. This week 200 of our staff in the children's hospitals are engaged in designing the 6,000 roles. They are coming out of those services and we are trying to make sure that the work is carried out at a convenient time in order not to impact services. The potential to impact services will only increase when we move to the really hard work, namely, standardising how we deliver services across the system. This requires resourcing, which we have included in the building of this project.

Scoliosis services are a long-standing issue in children's health. I heard about it before I came into my post. We have managed to secure funding to address it. Our challenge is that while we have the consultants in post, nurses for the ward areas and anaesthetists, we have seen a huge turnaround in our theatre nurses. Some of them moved out of Dublin when posts were offered in the rest of the country, but we had as much as a 25% turnaround in nurses in our theatres, which has resulted in rolling theatre closures and the inability to open the new theatre. Our plan is international recruitment because there is not a resource available within Ireland to address this. Our directors of nursing are going out next week and we have lined them up with a plan to have recruitment open by the second quarter of next year. In the meantime, we have an opportunity to consider what services in the old theatre could open up into the new theatre so that the staff and patients would at least be in new theatres. The new theatre should not be left sitting there as it is fully commissioned. We will be outsourcing some of our services between now and the year end with the funding that has been provided for waiting lists to address this. Probably more importantly, we have engaged with the three advocacy groups and they have committed to come on board with us to co-design the services. We want the same as what they want. We do not wish to be seen on opposite sides. Our consultant staff are meeting with us to identify consultants, nurses and people with process and lean experience to work with the advocacy groups to design how to work around this challenging issue. It will take us about a year to get this into a better spot from its present position.