Kate O'Connell (Dublin Bay South, Fine Gael) | Oireachtas source

What about my patience? When my colleague, Deputy Donnelly, was asking Mr. Bolger why the situation was different here when he was comparing the spend per head with other countries, eventually Mr. Bolger said it was not just about beds but was about staff and reform. Will he elaborate on what reforms he was referring to?

Again in response to Deputy Donnelly's questions, Mr. Gloster mentioned life expectancy in Ireland being higher. While I do not want to misquote him and I know Deputy Donnelly has left, is Mr. Gloster saying that Deputy Donnelly was not comparing apples with apples, in that it is simple to take a top-line figure for a spend per head, but when there is universal access for children under six to GP services and a roll-out of vaccination programmes, there will obviously be a spend, so it is not as simple as just comparing the oversimplified figures that the Deputy supplied? Will Mr. Gloster elaborate on that? Maybe I misinterpreted what he said.

In response to my colleague, Deputy O'Reilly, Mr. Bolger said the Department does not get into comparing prices and that it does not take on all the tenders that come through. Thank God that someone is keeping an eye on the chequebook. He also said that he believes there are controls in place to get value for money. Again, thank God for that. When representatives from the HSE come in, it is always someone else who made a decision somewhere else. I go back to Mr. Woods and Deputy O'Reilly who was talking about whole-time equivalents and student nurses. Mr. Woods is the national director of acute hospital services operations in the HSE, yet he needs to talk to somebody in HR about who decided that a fourth-year nurse was one whole-time equivalent and not half. The vast majority of the times that we ask questions of people in the HSE, it is someone else's job. It happened recently with the CervicalCheck issue. People continually say that it is someone over here or someone over there. I am worn out with it always being someone else's question to answer.

The real questions I wanted to be answered were asked before I came in and obscure responses were given. Can somebody, perhaps Ms Cowen, outline why things have improved with the retention of graduates? Has it been looked at? Are there plans to focus in on the reasons that we are retaining more graduates and to increase the retention of graduates?

Deputy Durkan mentioned primary care centres. I am a firm believer in Sláintecare and in moving treatment into the community from the acute hospital setting. In Smithfield, Dublin, there is a good primary care minor injuries clinic that contributes to accident and emergency department avoidance. Many people are treated there, and there are good nurse practitioners working there, plastering up people with injuries and referring them to the Mater Hospital. It may not be true but I have heard this service in Smithfield is becoming very popular. I used to refer many people there myself when I was working in the community. I found it to be a brilliant service but people did not know about it at the time.

There is a cultural issue where people think they have to go to an acute hospital. It is just in us to think the best place to go is Crumlin with a sick child or the Mater with a broken arm. What steps is the HSE taking to try to address that cultural issue, so that people go to the primary care centre as opposed to the acute hospital? I also hear that patients who should go to St. James's, Tallaght or Blanchardstown are going to Smithfield and in turn ending up referred to the Mater, which receives many patients who would ordinarily be dealt with by the other hospitals.

There is now a capacity issue when it comes to the referral of patients because so many people are being taken in from Smithfield. How will this be addressed?

There are challenges in the area of step-down facilities. I have heard that when consultants sign off a patient as being fit to return home, they sometimes are reluctant to go to a step-down area. Have any of the witnesses a solution for this? Anecdotally, there is no reference to an exit plan when patients are admitted and it is not discussed until it is time to exit. This is often the case with older people. If a patient from Dublin 1 is discharged and then is sent to Mount Carmel Community Hospital, which is near where I live, for their step-down he or she might say he or she could not go all the way over there. Has the HSE put anything in place to try to address this in order that when a patient is admitted, he or she is told that after he or she has been fixed up, he or she will be sent to a particular step-down facility and that is how it works? I am not talking about forcing people to go anywhere but about bringing patients and their families along with the medical professionals on this journey.

I visited Carlow-Kilkenny hospital a couple of years ago, where they had GP referral to fast-track people through the emergency department. The Mater Hospital has something similar for older people, where a GP can refer them and it bypasses the emergency department. It works very well. Older people and their families are much happier with it and it is far preferable not to have older people with chronic conditions waiting in emergency departments, which is not suitable. What plans does the HSE have to replicate the system used in Carlow-Kilkenny and that in the Mater?

Recently I heard that 477,000 hospital appointments were missed. I understood that outpatient hospital appointment lists already factor in such no-shows. Will the witnesses elaborate on this? It is not the case that doctors are waiting in emergency departments twiddling their thumbs waiting on this 477,000 people. It is built into the figures that a certain percentage will not turn up.

Finally, Mr. Woods said that a roll-out of texts was the way forward. Surely that could be done over a weekend. We are back to IT. Even the most basic, small community pharmacy now has a text service for their patients. I cannot understand how it is that things are done very safely in the community with appropriate data protection and so on but when it comes to the HSE, we almost need two years to do everything and a team of people to implement something that I would have a young one do for me over the weekend. It is constantly the case that everything seems to take longer. No one seems to know who is responsible. It is like the deck chairs on the Titanic. I would like the witnesses to address those points. I apologise that I cannot stay to hear the answers. If the witnesses cannot answer them today, I would like them in writing soon.