Mr. Tony O'Brien:

On the issue of nursing homes, in my opening statement, I was referring to situations where nursing homes were now following the guidelines so that patients with flu were being retained there. Consequently it was not appropriate to discharge into them. They were being supported both by public health teams and community intervention teams. This is part of the emerging and developing integrated care programme for older persons. We are seeing a reversal of the previous pattern where patients were automatically sent into hospitals. We have to get further down that road, but it means that the nursing home, even if it has two or three empty beds, is otherwise effectively regarded as a flu ward into which we cannot discharge patients directly. Overall, that is a better place to be.

I will ask Mr. Connaghan to comment on the performance issues relating to trolleys when I am finished because that is an area within his brief.

I do not agree with the committee's perception of the correspondence or the budget process as it relates to the service plan for 2018. We have had the pleasure of discussing a number of service plans across this floor, and the spectre of the famous medical card probity issue of 2014 was raised. We are nowhere near that territory. The committee must know that if I had concerns of that nature I would express them, as I expressed them previously. Within this service plan a number of risks to its successful delivery are spelled out. The service plan in its full form was approved by the Minister, having consulted Government, with those risks taken into account. Every service plan and every budget has some element of risk associated with it, and it is appropriate for a public body proposing a service plan for ministerial approval to be transparent with that Minister about what those risks are. The 2004 legislation, combined with freedom of information legislation, makes our service planning process extraordinarily transparent, especially when added to the performance reporting process, which I would contend is more transparent in the HSE than in any other public body in the State. That does not mean that from time to time we do not have some crunchy conversations where we share our different perspectives. We are not living in North Korea; we can have good discussions. We all accept the fundamental reality that, ultimately, the budget for the HSE is decided and announced on budget day. Our task then is to construct a budget in the shape of a service plan which we can propose to the Minister and the Minister can subsequently approve. We then publish that and make every effort that we possibly can to deliver that service plan in the way that we framed it. That, essentially, is what this service plan is about.

The correspondence is the ordinary correspondence that goes on between Ministers and their officials. I would not agree with the proposition that the Department of Health is not a strong advocate for the health system. I believe it is. I have worked within it and alongside it. I have had the opportunity to work with every Minister of Health going back to Deputy Micheál Martin, and every one has been a strong advocate for the health system in their day. The difference between the past, when we were in the most difficult of economic circumstances, is that we now see targeted investments around specific improvements that were not possible in the past. Matched against that, we seek - as outlined in the value improvement programme which Mr. Connaghan might say a word about - to use better the relative small proportion of the total resource we have, and stretch those resources to get the best possible range of services we can. The overriding priorities are patient safety and access. That has been clear in all of the correspondence from the Department and back to the Department. The Minister has been very clear about it. We will make our best efforts on all parts of the service plan, but nothing will take away from those priorities the greatest possible quantum of service to improve access in a way that supports the highest level of patient safety that we could possibly achieve with the resources we have.

On the variable performance regarding trolleys, as the Minister has said it is probably too simplistic to take the trolley count in a given hospital and reach a conclusion about the overall performance of that hospital. It has to be adjusted for the size of the population it serves, for the resources it has and for the quality of the infrastructure it has in its emergency department versus the balance of the hospital. I can give two examples of that. Kilkenny and Limerick, hospitals which have had particularly challenging trolley counts this winter, are locations which have recently had the benefit of new acute care buildings with modern, first class, contemporary accommodation, versus ward accommodation which in general is of the "nightingale" variety. Consequently the clinical decision is more likely to be to hold the patient in an individual room - which often has an en suite, climate control and environmental control - rather than transfer the patient to the ward, even though that will add to the trolley count in that particular hospital. There are a variety of factors, and I will ask Mr. Connaghan to expand on that.