Dr. Emily O'Conor:

Managers are expected to come in on budget. I cannot say more than that. Thankfully, in the emergency department I do not even look at who has health cover or not. I could not tell, looking around at patients on trolleys in my department, who has got cover. Thankfully, it is something I do not have to deal with. My hospital managers do have to come in on budget and make a certain amount of income, but I cannot give the Deputy any insight into how that is done.

We need to start commissioning modular bills for places that do not have enough acute hospital beds. We need to open every single bed, along with nurses and care assistants, that we have already built in our hospitals. I am not in IR, but from a medical staffing viewpoint, we need to sort out our contracts, conditions and remuneration for consultants or else they will not come home or stay. I would love that to be sorted.

Deputy Kelleher has raised some good societal decisions. We have gone from what Deputy Durkan was describing, which was not needing acute hospital beds, to everybody needing an acute hospital bed. We have huge expectations for what will happen in end-of-life situations. As a society, we have to deal with what we want for ourselves at our end of life. When I am 90, if I get sepsis from a chest infection in a nursing home, I will not want to go to an acute hospital for treatment, even if it means I am going to die. That is happening all the time for patients at the moment, however. It is really difficult. We are coming from a society where Catholicism was prominent and it was God's will. One did not discuss interfering with God's will at the end of life, but I think we have got to start having that discussion. Our age group needs to start doing that so that we do not leave this burden to our children.

At the moment it is hard for nursing homes to hold on to patients. All nursing home deaths are reportable to the coroner. HIQA has strong statutory reporting responsibilities for nursing homes, so the paperwork must be correct. There is really good practice out there. We have an example in my hospital with what is called a nursing home liaison geriatrician who spends half the time in the hospital and the other half seeing patients in nursing homes. It is a fantastic model. I can send someone to a nursing home and say: "It might be a risky discharge. Could you see them in 48 hours in the nursing home?" They will say: "Yes. We'll call in and make sure everything is okay." If we could expand that model it would really help.