Dr. Emily O'Conor:

I will start. If I forget anything, members should feel free to remind me as I go along.

In response to Deputy O'Connell, I have no data on how or if private hospitals alleviated pressures over the Christmas period. I do not know whether the HSE has the data. We have a two-tier health service. Private hospitals work hard for the cohort of patients who can pay and provide a service to that population. I believe, having worked in the public sector, is that private hospitals cherry-pick non-complex cases that are profitable because of their business model. I do not see private hospitals taking on the complex cases of our frail and elderly population that the public sector takes on every day and every night. We do not run a business. There is absolutely no profit in the vast majority of what I spend my time doing every day. I would never be a profitable investment given what I do with the complex cases of elderly patients. We need to consider this aspect as we move forward.

The Deputy asked whether the winter initiative was successful. The delayed discharge initiative was a success but we need to keep going. If the funding for transitional care beds is stopped then the number of delayed discharges will build up again. The initiative was a win. We do not know yet whether it is a permanent win or only a temporary win while the transitional bed funding was available. The Deputy asked me to identify other wins. Although I am not part of the task force I know that at its meeting after the trolley crisis peaked that out of the 55 beds, that had been promised to be opened before the winter, that 17 beds had opened. Perhaps more beds had opened that I do not know about.

The Deputy asked whether we could cope with a massive disaster. I have huge concerns about that. In terms of the emergency departments in University Hospital Galway, Cork University Hospital, University Hospital Limerick, the hospital in Drogheda and my department which copes very well, if there was a massive disaster that generated a sudden influx of hundreds of patients into the system then we would struggle to deliver care. We are already over 100% capacity but we would do our best to cope. We have highly trained people so we would all step up. We would do our best to make the system work but I have grave doubts about how we would cope with a disaster.

The Deputy asked about moving outside of the 9 a.m. to 5 p.m. model, as did a couple of other members. As a society we used to accept that doctors and nurses were just available between 9 a.m. to 5 p.m. Even when I was growing up, one did not wake up the doctor, unless one was half dead. People delivered their babies at home with no help. One accepted that granny died in the corner during the night. One accepted when one's baby died. One accepted that children died. We have moved on as a society. We have much greater expectations from the health service. We are unwilling to wait with our child who has a tummy pain until a doctor wakes up in the morning. We are not going to let granny die in the corner from a chest infection because she is 75 years old and getting on. We want things to be different. Wondering why we used to have many empty beds is because we, as a society, have moved on and have greater expectations. Patients get sick outside of the hours between 9 a.m. and 5 p.m. so we should move towards providing 24-hour care but that comes down to what we can afford as a society.

In response to the comments made by Deputy Kelleher, medical and nursing care is very hands-on and very expensive. We, as a society, must decide how much we can afford. In the interim we are looking at consultant delivered care or consultant shopfloor care operating between the hours of 8 a.m. and 8 p.m. We are actively moving towards that model in emergency medicine. I am not here as an industrial relations representative for emergency medicine so I will not discuss contracts, remuneration, etc. Most consultants working in emergency medicine have moved to working between 8 a.m. and 8 p.m. most days of the week but not all. This was done before contracts were decided or remuneration was agreed simply because we saw a need to do so. There have been variable approaches to working these hours outside of emergency departments.

The hospital system will respond outside of the hours between 9 a.m. to 5 p.m. for critical care. That means if I telephone another service in my hospital and say I think my patient will die before tomorrow morning, of course the system will open up for him or her and on-call services will come in. I cannot open up the system simply because I believe a person could go home on the same night if I got a certain treatment for him or her. The system is so thinly spread that I cannot make such demands at 10 p.m. Most of the services that work until late at night are unavailable the next day due to a lack of resources. Therefore, I must choose carefully which cases I get the radiologist out of bed for at night. My hospital's radiographer travels from her home when I need a CT scan to be done at night. Every time I get her out of bed she cannot work the next morning. We must pick and choose when logistics are at stake. We do not have to choose when a person is critically unwell, has suffered a major trauma, need acute resuscitation or where I think the person will die before the morning. The service does open up in such cases.

How many beds are required? Do we need 2,000 new beds in our system? I want politicians to tell me how we will fund the provision of 2,000 new beds. We need to be ambitious. I do not think the numbers we have heard so far are adequate.

Deputy O'Connell asked whether the decisions on the prioritisation of clinical need are made by management rather than clinicians? Hospital managers have no choice but to make decisions on whether they are going to bring in elective or acute care. I will always believe that a patient in an emergency department is in more immediate need of an ICU bed than, for example, a major esophagectomy case that is on a waiting list for cancer treatment who also needs an ICU bed. If it is my patient who is in the emergency department then the surgeon and I will not agree on which patient has greater priority. Therefore, hospital managers must make difficult decisions and bring balance to the situation. The problem is there are not enough ICU beds. The people I feel sorry for in our system are the nursing staff who have moved on to bed management roles. They must telephone people to tell them their operation has been cancelled. They must negotiate with management about whether to bring in electives or whatever. They must also clear emergency department trolleys, which is a horrible job.