Mr. Liam Woods:

I thank the Chairman and members for the invitation to attend. We welcome the opportunity to appear before the committee and engage with members.

Our urgent and emergency care service operates across the health and social care system. It comprises a wide range of services, including the National Ambulance Service, emergency departments, injury units, GP out-of-hours services, primary care, acute mental health services and community intervention teams, to name but a few of the emergency and urgent care services that make up this system. Throughout 2016, our urgent and emergency care system saw a substantial rise in activity, including 310,000 emergency ambulance calls, representing a 4% increase over the previous year, 1.155 million emergency department attendances, representing a rise of 4.9% over 2015, and 286,000 emergency department admissions, representing a 5.3% increase over 2015.

I will now set out some of the key causes of the current pressures on our urgent and emergency care system and the actions being taken by the HSE in light of these pressures. During the first week of 2017, an unacceptable level of overcrowding was evident in emergency departments. Emergency department overcrowding and long patient waiting times for emergency care are of critical concern within the health service in terms of providing patients with timely access to necessary care.

In December 2016 and January 2017, there were a number of factors that led to increased pressure on the numbers of patients delayed for admission. These include increased demand for emergency care, a 6% increase in attendances in December 2016 over 2015, a 7.2% increase in admissions in December 2016 over 2015, a 7% increase in respect of GP out-of-hours services in December 2016 over 2015, and an 18% increase in ambulance calls in December 2016 over December 2015.

With regard to bed capacity, as of 24 January 2017 there have been 150 acute beds and 190 community beds closed within our public health system due to essential refurbishment, infection prevention and control, and staffing deficits. There has been an increase in influenza and respiratory-related illness. This commenced in mid-December, earlier than last year, with influenza virus strain H3N2. This primarily affects those aged 65 and older. In the period in question, we recorded the highest ever number of respiratory admissions in our hospitals.

It is well recognised that the causes and effects of emergency department overcrowding are multifaceted, complex and health service-wide. The causes span a range of complex issues across the health service, including: increased demand for acute hospital care; underdevelopment of alternative avenues of access to health services in primary and social care; limited acute bed capacity; and challenges in meeting the increasing demands of our ageing population for social care services to facilitate timely discharge of patients from acute hospital settings. As a result, the response to emergency department overcrowding cannot be limited to focusing on emergency department's alone but must be health system-wide. Improving processes and achieving efficiencies in hospitals in order to alleviate emergency department overcrowding continues to be a priority. Additionally, to address the causes and challenges of emergency department overcrowding and sustain the solution a more strategic approach is needed, from both policy and operational perspectives, in the medium and longer term.

Our population is ageing and it is expected that the number of people aged over 65 years will increase by nearly 110,000 in the next five years. The number aged 65 years and over increased by 30.2% between 2006 and 2015. This trend will continue, with projections from the Central Statistics Office showing a 37% increase in the 65 years and over age group between 2015 and 2026. This is great news and is due in no small way to significant improvements in treatment and care provided by the health services.

A large proportion of this age group is living with two or more chronic conditions which make many of our older citizens more vulnerable and frail. Emergency departments have seen evidence of this over the holiday period with people aged over 75 years constituting 14% of total emergency department attendances for December 2016. In turn, December 2016 saw a corresponding 12% increase in the number of people aged over 75 years being admitted to hospital through our emergency department's when compared to December 2015.

The aim of the winter initiative plan 2016-17 is to provide a focus on specific measures required to help minimise the surge in activity experienced at this time of year across hospital and community services. One of the key objectives is to reduce the numbers of people waiting to be discharged from hospitals and require specific supports and pathways to do so. Targeted reduction of delayed discharges freed up the equivalent of an additional 200 beds for the acute system. This was achieved through increased provision of fair deal and home care capacity.

The plan contains a number of key measures in terms of hospital avoidance, timely access and discharge. It is being implemented through a specific and detailed planning process required in all hospitals and community health care organisations. The detailed actions in the plan are set out in appendix 1. Most of these actions are already implemented, bringing tangible benefits to the system and patients. Under the plan, €40 million was invested to alleviate winter pressures.

While considerable planning was undertaken through the winter initiative, the system's ability to expand to meet spikes in demand is limited by a number of factors that vary from hospital to hospital. These include: not having enough beds in the system to deal with a surge; difficulties in recruiting nursing staff, which, in turn, pose a challenge in opening some of our surge capacity beds; and a shortage of certain services in some parts of the community such as diagnostics or access to home care. The early onset of influenza, coupled with a significant rise in respiratory illnesses during the holiday period, put further pressure on an already stretched system, particularly in the context of people aged over 75 years.

In light of ongoing pressures on emergency departments, on 5 January 2017, the Health Service Executive announced a series of additional measures as part of the existing winter initiative plan. These measures focused on augmenting the supports for primary and community care, targeting a small growth in acute capacity and further strengthening existing actions, such as our information campaigns on influenza vaccines. These additional actions are also set out in appendix 1.

The HSE has a steering group in place, comprising all the key operational divisions, which reviews performance of the winter initiative to ensure an integrated approach across our hospitals and community services. The HSE's special delivery unit oversees progress across all our services on a daily basis. This is in addition to the normal line management of our hospitals and community health care organisations delivered through the HSE's accountability framework. In addition, an oversight group has been put in place by the Department of Health to oversee progress with the winter initiative plan and agree any revised actions as challenges arise.

A dedicated focus will be needed to progress the development of the acute model of care; structured demand and capacity planning; effective information systems enabling analysis of emergency care demand and utilisation and facilitating appropriate performance oversight; staffing capacity; bed capacity; and continued process improvement in hospitals. The recently announced acute bed review will be one important piece of the long-term solution. In addition, to address the causes of emergency department overcrowding in the longer term, the enhancement of primary and social care services, the development of integrated patient centred care for the management of chronic conditions, investment in hospital infrastructure and models for the delivery of acute services all need to form part of a strategic health policy initiative.

Within a more responsive health system, many more people could and should be treated within the community, for example, through an enhanced primary care service. Additional investment in the community would mean that many scans and tests could be done without people having to attend acute hospitals, more home supports could allow people to move out of hospital sooner and community intervention teams could treat people in their own homes rather than in a hospital environment. However, this would involve a decisive shift away from the most expensive form of treating and caring for people, namely, the acute hospital system.

The scenes of overcrowding we witnessed at the start of January were distressing for both patients and staff, and for this we apologise. However, unless we shift our model of health care from its current hospital-centric focus and towards the community, with the associated investment required, we will continue to be challenged in delivering the service we would wish for our patients. The appendices set out the specific actions in the winter plan and feature a number of graphs on trends. In particular, the final page features a graph depicting the trend delayed discharges. The substantial reduction in delayed discharges shown has been one of the successes of the plan. This has had a significant beneficial effect in the east of the country where the number of delayed discharges tends to be high. It is less so elsewhere where access to home care on an accelerated basis is more important. My colleagues and I will endeavour to answer any questions members may have.