Mr. Liam Woods:

We are doing research on that to look at the trends. The commentary that we have shows there is a significant increase in out-of-hours work which is up 11% in the current year in the GP space. That has a higher propensity to give rise to hospital referrals. I would emphasise that only about half of our total attendances at accident and emergency departments first see a GP. Many people are self-referring, are walk-in and are not going the GP route. There are multiple factors there. It could be pressure in the GP environment but also a higher level in the community of people who are self-presenting to hospital. Those are the kinds of drivers for the increase.

Our current capacity is a concern for us and it is a key focus towards the end of this year to try to address some of the longer waiters. Our current capacity in terms of delivering scheduled care is challenged. The committee would have heard some of the hospital groups say they are trying to create dedicated elective space, to protect some space from emergency take, to allow for the rational doing of work on a surgical basis such as day surgery units, for example, on stand-alone sites, and that is happening at the moment.

There was a question on multiple co-morbidities. There is a plan for frail elderly management which is to deal with that issue. There is investment in this, with a number of other programmes in chronic condition management, of about €9 million to do some pilots this year and next year. The plan itself has been documented by Dr. Siobhan Kennelly who is a geriatrician in Connolly Hospital. That would involve moving resources and has involved nurses and geriatricians moving into the community, attending at nursing homes, particularly private nursing homes where there may be limited or no service available, and looking to see to what extent they can reduce presentation at accident and emergency departments resulting from infection or fairly simple health care needs. That plan has started at the moment and work is undertaken in some hospitals. St James's Hospital did some very specific work in addressing the needs of frail elderly last year, and very successfully. There is other work under way specifically in areas such as COPD and cardiology where there are relatively significant numbers attending emergency departments that are potentially avoidable and could be treated in the community, with some support. There is investment going into those areas, but as the discussion here has flagged, it will need to be much greater in the future.