Oireachtas Joint and Select Committees
Thursday, 17 December 2015
Joint Oireachtas Committee on Health and Children
Acute Hospital Services: Discussion
Apologies have been received from Deputies Ciara Conway, Billy Kelleher and Caoimhghín Ó Caoláin.
Before we begin the main discussion, on my own behalf and that of the joint committee, I pay tribute to and congratulate Mr. Geoffrey Shannon on his appointment as a judge. As members know, he is the Special Rapporteur on Child Protection, as well as chairman of the Adoption Authority of Ireland. He has been an eminent spokesperson for and advocate on behalf of children. I formally congratulate and thank him for the work he has done and his courtesy and co-operation with us. He will be a huge loss to the committee, but we wish him well in his new career. I propose that we write to him to congratulate him. Is that agreed? Agreed.
This is the first of a number of meetings we will have, if we are back in the new year, that is, on the reconfiguration of acute hospital services. This morning it is the turn of acute hospital services in Cork and Kerry. One of the key aspects of the reform of the health service is the streamlining of services at group level. I welcome Mr. Michael O'Flynn, former chairman of the non-executive advisory board that produced a comprehensive report on the reconfiguration of acute hospital services in Cork and Kerry. He is joined by Professor John Higgins, a former director of acute hospital services in Cork and Kerry, who has also been very prominent and is one of the major drivers of health service reform in the region. We are also joined by Mr. Gerry O'Dwyer, chief executive officer of the South/South West Hospitals Group. All of our guests are welcome and I thank them for being here.
I wish to advise members and witnesses that by virtue of section 17(2)(l) of the Defamation Act 2009, witnesses are protected by absolute privilege in respect of their evidence to the committee. However, if they are directed by it to cease giving evidence on a particular matter and they continue to so do, they are entitled thereafter only to qualified privilege in respect of their evidence. They are directed that only evidence connected with the subject matter of these proceedings is to be given and are asked to respect the parliamentary practice to the effect that, where possible, they should not comment on, criticise or make charges against any person or an entity by name or in such a way as to make him, her or it identifiable. Members are reminded of the long-standing ruling of the Chair to the effect that they should not comment on, criticise or make charges against a person outside the Houses or an official, either by name or in such a way as to make him or her identifiable. I invite Mr. O'Flynn to make his opening remarks.
Mr. Michael O'Flynn:
I thank the committee for giving us this opportunity to share our experiences as members of a non-executive advisory board that supported and challenged from the outside a major health service reform project. As the Chairman has mentioned, l am joined by Professor John Higgins, who is the former director of reconfiguration for Cork and Kerry; and Mr. Gerry O’Dwyer, who is the CEO of the south and south-west hospital group. The project we are discussing today was based on a document, "Reconfiguration of Acute Hospital Services, Cork and Kerry: A roadmap to develop an integrated university hospital network". Much of this statement is covered in more detail in my chairman’s report to the Minister, Deputy Varadkar, which was published by the HSE in December 2014. Everyone in Ireland is aware of the ongoing issues in our hospital emergency departments and the significant waiting lists for accessing some services. These issues remain major national challenges. Unfortunately, I do not bring any immediate solutions. However, I want to highlight a reform process that will bring long-term advantage to hospitals and communities in our region as they tackle health care challenges, while ensuring there are adequate primary care centres with appropriate diagnostics for hospital avoidance. I want to make a few simple but fundamental points, before bringing in my colleagues to assist me in answering the questions that members may have.
The reconfiguration of services in counties Cork and Kerry was a significant health reform project. It brought about real change in the way health services are delivered in both counties. We sometimes lose faith in the capacity of the health service to achieve reform, but it can do so when it goes about reform in the right way. I would like to mention some headline outcomes from our experience. Over 800 staff transferred their places of employment without any major industrial relations issues arising. One hospital changed from being an acute hospital with an emergency department that was open 24 hours a day, seven days a week, to being a dedicated elective hospital with no emergency department. The number of emergency departments and hospitals performing emergency surgery in Cork was reduced from five to two. This was supported by the introduction of advanced paramedics and intermediate care vehicles throughout Cork and Kerry. Local injury units and medical assessment units were established at the other sites to support the two 24-7 emergency departments in Cork city. The local injury units have achieved a 65-minute average time from patient attendance to discharge.
The transfer of the stand-alone St. Mary’s Orthopaedic Hospital to a dedicated elective hospital at South Infirmary Victoria University Hospital resulted in the same quantum of service being provided with a reduced number of staff. The remaining staff were redeployed to open 50 extra long-stay beds in community nursing units and to enhance support services at Cork University Hospital. The new model of care at South Infirmary Victoria University Hospital enabled the achievement of the best figures in the country for length of stay for hip and knee replacements and a 48% reduction in the number of patients waiting to be seen in the first year after service reconfiguration. Reconfiguring services at Bantry and Mallow by ceasing emergency and inpatient surgery and developing strong day surgical services, with visiting outreach consultants from Cork city hospitals, has provided safer and more sustainable services that comply with the recommendations of the small hospitals framework and the relevant HIQA reports.
The provision of cardiology services was consolidated from multiple sites to a new purpose-built unit at Cork University Hospital. The provision of pain medicine, plastic and maxillofacial surgery was consolidated from two sites to a purpose-built unit at South Infirmary Victoria University Hospital. The adoption of lean principles for the pain service led to a 49% reduction in the number of patients on the waiting list in the first 12 months following this transfer. The wait time was reduced from three years to nine months. The consolidation of all gynaecology cancer surgery at Cork University Maternity Hospital involved the reciprocal transfer of benign surgery to the South Infirmary Victoria University Hospital. Significant savings in the amount of time spent on call out of hours by non-consultant hospital doctors have been achieved through the amalgamation of services on one site or the introduction of cross-city on-call arrangements. Information technology improvements have been achieved through the roll-out of the integrated patient management and national integrated medical imaging systems and the development and roll-out of electronic referrals from GPs to outpatient clinics. The reconfiguration team provided the executive support and the pilot sites for this national project.
I would like to place it on the public record that my experience with this grouping is that this large-scale reform project achieved significant results over a five-year period with phenomenal commitment from front-line staff, clinicians and managers. However, this could not have been achieved without formal structures for managing the change and bringing people along with the process. I will mention the key elements of this. The dedicated reconfiguration team, which was well resourced, had the singular task of reconfiguring the hospital system. A reconfiguration forum, which was chaired by the director of reconfiguration, met every two weeks and acted as a steering group. This forum, which comprised clinical directors, senior hospital and health service managers, a GP representative and representatives from the UCC college of medicine and health, kept going through thick and thin. It heard presentations, discussed issues, took initiatives such as commissioning lean projects and got medical students to upload data from theatre log books so theatre usage could be analysed. Over 40 clinical subgroups were formed to discuss and feed in the views of specific clinical services. This brought to the table a depth of understanding and a realism that informed all the detailed reconfiguration moves and ultimately resulted in the successful implementation of much of the report.
I had the privilege of chairing the non-executive advisory board, which brought together some of the most senior clinical, financial, legal and educational corporate executives in Ireland. For a period of five years, they gave their time and commitment freely to ensure the project did not fail. They supported and challenged the director of reconfiguration and his team and the HSE south directors. They mediated with the HSE corporate team and with the political system when necessary. Most of all, they gave the director of reconfiguration confidence that he was supported from outside the system by people who knew what was involved in managing and changing large organisations. I will give three specific examples. In March 2010, after six months in existence, questions arose over the respective roles of the director of reconfiguration and HSE south's regional director of operations. Members of the non-executive advisory board engaged actively with the CEO of the HSE and others in the HSE corporate management team to get all parties to agree a document on reporting roles and a series of actions to enhance communications. This was a critical moment in the project. I believe the actions of the board were vitally important in resolving the issues at stake.
In September 2010, the board was asked to advise on the launch of the reconfiguration roadmap, which had almost been completed. It offered a number of strategies to support a successful launch of the roadmap. For example, on 3 November 2010 it brought all reconfiguration clinical subcommittee chairs together to sign off on the draft report. I believe this was a major factor in ensuring universal clinical and institutional buy-in to the final report, which was successfully launched later that month. In particular, it allowed some last-minute issues to be raised and addressed that otherwise could have derailed the consensus. The board was anxious to assist and support the implementation of the roadmap. To this end, it established three subgroups, which met from 2010 to 2012, in the areas of governance and external partnerships; finance and strategic planning; and change management and communications. Membership included senior managers from HSE south and members of the reconfiguration team. Each was chaired by a member of the non-executive advisory board. It is clear to me, as the chair of the non-executive advisory board, that competency-based boards with business, finance, health care, legal and education skills will provide effective oversight and objective support to our health system and challenge that system. All external members of this board gave of their time pro bono. Many of their skills are transferable. People in the corporate world understand the power and pressures that are at play. Most of all, they know that all users of the health service want it to work for ourselves and our loved ones when the time comes.
The implementation of the reconfiguration roadmap is a work in progress. As we approached the end of the immediate implementation phase, we were greatly encouraged when the then Minister for Health, Deputy Reilly, published the report on the establishment of hospital groups in May 2013. This report provided for six hospital groupings, each with its own board and principal academic partner. I was delighted when one of our advisory board members, Professor Geraldine McCarthy, was appointed chairperson of our group board in the south and south west. I am happy to pass the baton to her to finish what we have started. The establishment of hospital groups in line with government policy follows HIQA recommendations that boards should be competency-based rather than representative. From our experience, I would wholly support that conclusion. I encourage the current Minister to appoint the board and enable its work to commence. What is the work we are handing over to the new board? There are four large projects which are well under way to being completed and we may be assured that they will.
These projects comprise the transfer of ophthalmology from Cork University Hospital, CUH, to South Infirmary Victoria University Hospital, SIVUH; the consolidation of paediatric services at CUH; the development of a regional gastroenterology service at Mercy University Hospital, MUH, and development of a regional laboratory service.
There is one which is complex and difficult and probably the issue which the board is most disappointed about not having seen delivered, namely, the reconfiguration of general surgery and a single on-call surgical rota for Cork city. One project was largely overtaken by events. However, it has become a great deal more likely now that the academic health care model has been accepted as a valid form of relationship between hospitals and universities. It will see the development of a memorandum of understanding between the HSE and UCC leading to an academic health care centre arrangement linking health and higher education in a single governance model.
The last project involves finding the location of a site for a new elective hospital for Cork which would, in time, replace the city centre sites of SIVUH, MUH, and the dental hospital and to allow the expansion of all diagnostic services as appropriate. What is needed is a second hospital site in Cork city which would be developed in a modular way over 15 years as an elective hospital with the latest facilities for day surgery, diagnostics and ambulatory care, as well as with a number of elective beds for inpatient surgery, which would replace the three existing hospitals in Cork, namely, SIVUH, MUH and the dental hospital, resulting in synergies in the services.
CUH and this new hospital would be a single hospital on two sites, one specialising in acute admissions and the other specialising in elective and day surgery but both managed as a single entity by the South-South West Hospital Group. Services would be truly complementary. The site needs to be within easy travel distance of CUH, linked by good public transport. The advantages are real and substantial. The new hospital should be designed and built in a modular fashion over time, using financial resources allocated to key reconfiguration projects to commence its development as those resources become available. Capital moneys would not be wasted on piecemeal developments on the existing sites but could be spent in a cost-effective and incremental way. Services at CUH and the new hospital would be complementary rather than competitive, both being managed by the South/South West Hospital Group. UCC, the primary academic partner of the South-South West Hospital Group, would be partner to the planning from the outset, thus creating a teaching hospital in the fullest sense and a flagship for the proposed academic health centre linking UCC to the South-South West Hospital Group. UCC has already indicated it wants to build a new dental school and hospital. This needs to be on the site of the new hospital. UCC really needs to know the location now. Accordingly, the urgency of this situation cannot be stressed enough.
The effect on staff morale and performance would be transformative, making the task of attracting and retaining high-quality clinical staff much easier across the hospital group as a whole. CUH would be enabled to develop as a truly effective level 4 emergency hospital for the city and a provider of last resort care for the region. Outpatient and ambulatory services at the new hospital would serve the city as a whole, planned de novowith full account taken of patient flows, logistics, parking, diagnostics, clinical therapies, clinical teaching, day patients, pre-op assessment, etc. The transformation of acute service delivery on such a scale will have a major and increasing impact on hospital performance reducing average length of stay statistics and waiting lists.
This is a vision that is practical, necessary and urgent. There are no major impediments to delay its realisation. Both SIVUH and MUH are committed to it. The establishment of the hospital group provides the decisive management and governance initiative to facilitate and oversee the development. It does not even require major capital outlay in the initial stages. We are arguing for a staged commitment over ten to 15 years, beginning with site choice and acquisition, followed by concept planning, consultation with local authority planners on transport and logistics, as well as with other hospitals in the group. We are seeking support for a decision in principle to locate and purchase a site for a modern elective hospital in or around Cork city, with ready access to main transport corridors, and to commence planning for the phased transfer of services under the auspices of the South-South West Hospital Group. The new elective hospital would be planned so that it can be built in a modular way as resources become available. We also must future-proof it for the next generation by picking a site which is sustainable.
The past several years have been difficult for the whole country. I have had some well-publicised issues in business. However, while all that was going on, my involvement in this project gave me hope for the future of our health system and for our country. With this in mind Chairman, I commend the efforts of all those I have worked with over the past five years. I ask you and your committee for continued interest and support as we look to secure the future of our reforms with a second hospital site in Cork.
I welcome Mr. Michael O'Flynn, Professor John Higgins, and Mr. Gerry O'Dwyer and extend my best wishes to them for the festive season. I thank them for their work on this issue.
The report was detailed in its content. Was it based on the Horwath and Teamwork review of acute services in HSE South? The delivery of acute hospital services in the south and the hospital groupings do not exactly mirror each other because we have an expansion of that hospital grouping to include Waterford and south Tipperary. This means it is a larger geographical and population area. Are there any issues that have to be addressed in the overall reconfiguration of acute hospital services? Will that change any of the strategies or long-term planning and vision in the general region or is it just an administrative and management issue? Does further research have to be done on this? South Clonmel has had 1,200 to 1,300 births every year, for example. There is a move to bring ophthalmology and other services from Waterford to Cork. Will services be sustainable? All of these will place further additional pressure on the tertiary hospital in Cork if we do not have a strategic plan to develop a second tertiary academic hospital there.
We often discuss acute hospital services in isolation. I accept this report has not done that. For too long, however, we have been obsessed with the acute hospital being the provider of all services. When we are looking at developing strategies across the health service, we need to take account of GP services, community services, primary care centres, urgent care centres and acute hospitals. In the overall report, does Mr. O’Flynn see a need for us to look holistically at the further development of policies and initiatives which provide health care across our communities? Should it be a case that we are not looking at primary care centres based on one set of criteria which are not complimentary to the broader acute hospital service itself? Many people attending our acute hospital services, particularly our emergency departments, should not be there in the first place. That has been statistically proven time and time again. If we had a stronger primary care network with more diagnostic availability for GPs and more decentralised, then we have more capacity for elective care.
On the issue of academic research and innovation linking UCC and the teaching hospitals, Mr O'Flynn stated a memorandum of understanding would be required. Is there something similar in place already?
The reconfiguration of services often happens not because of strategic long-term planning but for the need to contain budgets. It is dressed up as reconfiguration.
This has happened time and again across the State: a tightening budget, capital plans shelved and current expenditure rolled in so services are reconfigured. The theory behind reconfiguration is to centralise in centres of excellence and farm out the least complex surgery and treatments to primary care and the peripheral hospitals but traditionally that does not happen. Instead, there is centralisation but less complex treatments are not transferred. Is there any acknowledgement in this report of the need when reconfiguring to take a twin-track approach rather than centralisation? This is not a political point but an observation that is widely acknowledged.
When people see reconfiguration and concentration of services the elective issue is not the major concern but emergency services cause huge concern. People will travel a distance for elective care, surgery and diagnostics. Did the witnesses consider the ambulance and emergency services for the whole region when proposing the reconfiguration?
Every politician will be promising to have one of these services in his or her townland between now and February. When the witnesses talk about a modular hospital and space, I assume they mean physical space in terms of acres or square metres for sites, and by public transport they mean trains, buses and proper motorway structures. Have they also considered the additional, eastern part of this new hospital group in terms of proposing a hospital site? It does not have to be in the east of the city but there will be extra capacity required in the long term because the hospital groupings will take in an additional 200,000 people. Has that been taken into account or is there scope to amend this to allow for that to happen?
I thank the witnesses for their efforts. Public service, professional and voluntary is often not appreciated but should be acknowledged.
I welcome the witnesses and thank them for their comprehensive report. It is detailed in content and not only does it tell us what they do but asks questions and provides some answers too, which is very useful.
What surgeries are they referring to when they say some have not gone well? What are they doing to address that? The one that comes to my mind is orthopaedics, the length of time some people have to wait to have knee and hip replacements. I know many who take out private loans because they are in so much pain and have to wait so long. The witnesses spoke of waiting lists coming down to nine months but I know of people who are waiting four years. What are the witnesses doing to tackle that?
I apologise for that. I agree with Deputy Kelleher about the need for more primary care centres. Our accident and emergency departments are constantly full. I see a reference to a nine-hour turnaround in them. There are local injury and medical assessment units which have a 65 minute turnaround. This shows that we need more primary care centres.
People are always concerned about ambulance services and I see a mention of intermediary care vehicles in Cork and Kerry. Are they meeting their target times or what percentage are meeting them in the city as against the rural areas? Has the service worked out well? How can it be improved?
I welcome the witnesses and thank Mr. O’Flynn for his presentation. They have done huge work, to a large extent successfully. The proposal for an elective modular hospital in Cork city provides a key for the future.
Although the reconfiguration is for services in Cork and Kerry it seems to be more Cork and city-based. What has the effect of this reconfiguration been on the Kerry services, particularly those at Kerry General Hospital? What effect, if any, will the addition of half of the old south east region to the South-South West hospital group, including Waterford University Hospital and South Tipperary General Hospital, have on the future services in Waterford and Clonmel?
I do not know Mr. O'Flynn, apart from what I have seen publicly about him. I am very glad to see this work. At least it is not all negative. I am not going to talk about Cork and Kerry.
We are building a children’s hospital in Dublin and it has been mired in controversy about where it will be located but mostly about the position of the car park. That stuns me because if I had a child, or when I have a grandchild in the next few months, I would be more interested in knowing the best place for that child to go if he or she is sick. Have the witnesses identified a site? This is very important because the nonsense that has gone on over the children’s hospital is frightening. Maybe I am missing out on something but the transfer of the National Maternity Hospital from Holles Street to St. Vincent's Hospital seems to have gone seamlessly and I do not hear talk about car parking. I would like the witnesses to deal with the site issue. It has to be a hospital of excellence.
Modular schools are prefabricated buildings but when the witnesses talk about a modular hospital building I take it they are talking about, for example, putting in the maternity department first and adding to it. I wish them luck and hope they will tie down the best site for the children’s hospital. They had better include the politicians in their deliberations or it will be going on for years
I thank all the witnesses for the work they have done in this regard. It has not been an easy job because all sorts of power games go on all the time in the medical profession and within the entire hospital structure. Consequently, it is a great achievement to have effected the change that has come about. The position in Cork always intrigued me in that there were a number of different hospitals in which everybody did a bit of everything. The present position, with the grouping together of particular services into one hospital or another, has worked out reasonably well. Much work has been done and it was necessary to jump a lot of hurdles to achieve this goal. I thank the witnesses for the work they have done in this regard and it has been a huge achievement. There is further work to be done, such as with the maternity units, for instance. Cork had three maternity units but now is down to a single newly built unit and that has worked out effectively. Another example that always intrigued me was paediatric services and how such services were offered in all three units whereas people now are working towards having paediatric services offered in one unit.
At present, Cork has two voluntary hospitals, namely, the South Infirmary-Victoria Hospital and the Mercy University Hospital. In the proposals outlined by Mr. O'Flynn, what will be the role of the voluntary groups in this restructuring? In particular I am considering this from the point of view of funds that could be made available in that the sites of both the aforementioned hospitals are in the middle of the city.
My apologies. I refer to the role of the voluntary hospitals and, in particular, the value of their sites. If the voluntary hospitals no longer will be part of the structure, what will be their attitude about the structures they own and the funding that could be realised from those sites?
The second issue I wish to raise concerns the roll-out of the modular building. My understanding is if one does this, one still must put in all the services, such as broadband, sewerage systems, water supplies and car parking, at an early stage if one wishes to build a large unit for the long term. Will this not entail spending a lot of money initially to put in the services? How is it intended to deal with that?
My third issue reverts to the point Deputy Mitchell O'Connor raised and is about access. I visited the Mater hospital recently for the launch of a new project and was struck by the fact that more than 4,000 staff members work there. My point is about people getting to the site, the issue of parking and the lack of public transport when trying to get there. Consequently, when a site is being identified, one must ensure there is access to public transport. How will that point be dealt with? It is not merely public transport from the point of view of patients or visitors but also from the perspective of staff members. For instance, I recently spoke to someone who works in Cork University Hospital and who now is inside the hospital by 7 a.m. to secure a parking space, even though work does not start until 8 a.m. This person tends to come in at 7 a.m. to park and have breakfast inside the hospital rather than having it at home. This is a big issue for staff members, and in the absence of a proper public transport service to the hospital, how will it be dealt with if staff members believe they must drive to the site to get there? In identifying the site, the manner in which this issue is dealt with will be important. Obviously, another important issue concerns the access of the university and its involvement in any unit.
The big issue for all members and for the two voluntary hospitals, namely, the South Infirmary-Victoria Hospital and the Mercy University Hospital, is about funding for services these hospitals wish to continue to provide. In respect of South Infirmary-Victoria Hospital in particular, I refer to ear, nose and throat, ENT, dermatology and oncology services. How does one accommodate the fact that funding must be provided to them for the next ten to 15 years in order that they can continue to provide an up-to-date service while at the same time developing this other modular structure that has been proposed? I refer in particular to dermatology and note the dermatology service in the South Infirmary-Victoria Hospital is handling double the numbers being dealt with by St. Vincent's Hospital, Dublin. Despite this, I have heard of one secretary who has a desk under the stairs and people are sitting on the stairs while waiting for clinics because there is not enough room in the waiting rooms. Should people put up with this for the next ten to 15 years or should an attempt be made to improve services while at the same time putting forward this proposal? It is a case of how both are done at the same time and it is one thing about which I am concerned in dealing with this issue.
I welcome back Professor Higgins, Mr. O'Flynn and Mr. O'Dwyer. Deputy Mitchell O'Connor was concerned about the process being entangled in bureaucracy, as happened with the national children's hospital. However, Mr. O'Flynn has gone about his work in a dynamic and collaborative way and I believe he has brought most people on board with him. I congratulate him in this regard because he has done a fine piece of work. I note that within the ten to 15-year timeframe the board is considering with regard to the development of this hospital, many other infrastructural works will take place on the north side of Cork city. For example, the north ring road probably will come on board, something probably will happen at Monard and perhaps, on foot of the housing availability study, down at Ballyvolane, all of which are within a couple of kilometres of each another. In Mr. O'Flynn's submission, he stated the board is seeking support for a decision in principle to locate and purchase a site. Does the word "purchase" preclude the possibility of the campus at St. Stephen's Hospital, which I consider to be perfectly located and already in the ownership of the Health Service Executive, being the site or a site? There also is land at Stoneview, Blarney, on which there originally were plans for a hospital back in 2004. Have these sites been considered?
I thank the witnesses for their volunteering, for giving of their time and for their commitment to the project in recent years because it is a testament to the quality that currently is on the board. I wish to add a tiny note to the effect it is sad that Mr. O'Flynn was obliged to say - I know why he said it - he was pleased the boards now are based on competency as opposed to the way it used to be done regionally. It is just bonkers to think we would have done it the way we did, but that was then and this is now, so I say "well done" to the witnesses.
While I am merely being nosy, I have two questions for the witnesses. Two points Mr. O'Flynn made concerned the reduction of emergency departments from five to two and that in the reconfiguration of services, it was vital to have good transport between locations. What engagement did the board have with either sets of bodies, that is, from the National Ambulance Service, the national emergency delivery services, or from transport authorities or transport providers? Did it have serious engagement with them and did it change its plans? Will the witnesses describe this process to me?
Mr. Michael O'Flynn:
I assure the Chairman they will be coming in on many of the issues. I thank members for their comments, kind remarks and observations. The questions are varied and many and I took note of many of the comments that have been made. I will deal with a few issues regarding the question of the site and then I will turn to Professor John Higgins. I perceive the responses as being divided into those pertaining to reconfiguration and others that are touching on the system, which is not why we are before the joint committee. I will leave it to my colleague, Mr. Gerry O'Dwyer, as to how much he does or does not wish to comment on some of these issues at this meeting. As people are aware, my approach always has been to be open and frank about anything asked of me. If we can be helpful, that is why we are at this meeting.
As for the board, when Professor John Higgins invited me on day one to chair this grouping, everybody we asked agreed to serve. Many of them were not from Cork or might have had Cork connections, but it demonstrates the interest people have in being involved and in helping.
This should not be ignored by the public system.
I will address the issues about the site quickly. As Deputy Mitchell O'Connor and Senator Gilroy referenced, we cannot have happen what happened with the children's hospital. Partly because I had a large interest in the children's hospital, having been on the board of the Children's Medical & Research Foundation in Crumlin for the past 15 or more years, I have a great deal of experience in this respect. I ended up in my position because I was seen to have only been involved with a Dublin hospital, albeit a national one, and I was invited to participate. I feel strongly and passionately about health, but everyone should be prepared to help. As to my involvement in Crumlin, I had a major interest in where the new hospital's site would be.
This cannot be political. No political grouping should believe it must be. The 20, 30 or 40-year vision for the region is so critical that there must be a site selection process. Let us be frank in that we have no public transport in Cork other than buses. We do not have trains or any other system. We must be practical and realise that, other than bus connections and good roads, the site selection will not be significantly influenced by public transport considerations. That said, we have not excluded or included any location. Having seen what happened in the case of the Mater, though, the selection of which I was against at the time because it was unsuitable, let the current site be what it will be. Since the process is under way, it would not be appropriate to comment, but we cannot afford delays that will hold up urgent projects.
Professor Higgins will go into this matter in more detail, but there is a need and it would be a crying shame if we did not progress with the site selection in the Cork area, devise criteria and arrive at a system to find the right site in the right location. It must be accessible to Cork University Hospital, CUH, for them to work hand in hand. Since Cork gets gridlocked like everywhere else, we must be practical about this. We cannot afford it to be otherwise. We have been spending money in recent years. I held this discussion with the prior Minister for Health when our engagement was at that point. We cannot justifiably spend money on brownfield sites and difficult buildings at existing hospitals.
One must plan ahead. The word we use is "Modular". I have seen good examples of it in Europe, particularly in Finland. A building can be created that is extensible. It is not modular in the sense of prefab modules. A point was raised about site costs. One can create car parks and buildings to be extended, so one should not create something that is not easily extended. A modular structure allows for extensions to be made in a way that has no impact on operations. It is designed so that, over a period of 15 or 20 years, extensions can be added continually without anyone realising it is a building site. I contend that some of the CUH site is overdeveloped. There is no point in saying otherwise. We must get away from that situation. I feel strongly in this regard.
We must consider a large site, albeit one that does not initially intimidate based on costs. Hospitals should be accommodated in areas where developments should not be accommodated. This would give them a special position. We would not want the land bought to be sold for a hospital. We must ensure we get the criteria right, the site selection process right and people involved who understand that business and can lead it. We should not end up in the planning crux that affected the Mater site and was predicted by a number of people.
Mr. Michael O'Flynn:
We need leadership from the political system. It is not difficult to find a suitable site in Cork. We do it all the time in the business with which I happen to be involved. Political leadership must say this should happen now. The requirement is immediate and we cannot afford to put money into buildings that are not cost effective or reflective of the future.
Mr. Michael O'Flynn:
We encountered this issue in Crumlin because we had to keep investing until we had a new hospital. One cannot stop investing in the structure. For example, the dental hospital is a current requirement, but include that as a catalyst project on the new site instead of trying to extend or build it piecemeal somewhere else. One cannot stop investing, but one must equally have an implementable plan. I cannot stress enough how desperate we are for that leadership decision to be made for the Cork-Kerry-Waterford region. I understand that more than Munster is served by CUH. My colleagues would know more about that.
A point was raised about surgery. It is a major disappointment for us. It was not that there was no effort.
Mr. Michael O'Flynn:
We held many meetings and much of this was new territory for me. The relationship between the executive and the advisory board was challenging at times, but co-operative and constructive. I will leave it to Professor Higgins and others to comment. I favour advisory board systems. They are not used enough in Ireland. We all could do with external help in our fields. Perhaps we did not have enough of that.
I am dealing with the site and I am happy to deal with specific questions on it, but I will hand over to Professor Higgins regarding the many points raised about reconfiguration. Mr. O'Dwyer will discuss reconfiguration as well, but also some of the system issues.
Professor John Higgins:
I thank the committee for inviting us. The reconfiguration of the hospital system is unfinished business. We are focused on our area. I formally thank Mr. O'Flynn and the entire advisory board, the members of which were volunteers. They were acting as citizens of Ireland, which is what we expect and hope of people with great expertise. They helped us considerably. I also thank the staff of the hospitals in our region and the management within the HSE who worked closely with us.
Turning to the questions, I will start with Deputy Kelleher's. He mentioned Howarth and Teamwork and asked whether that report was our platform. We inherited it. On my first day, I dealt with a report that was going to be released within eight weeks under the Freedom of Information Act. The Howarth-Teamwork report provided some of the direction, but it confirmed for me something I had long believed, that is, when we want to change our health care system, there is already significant expertise in Ireland and we do not need to get someone from Birmingham, Leeds or elsewhere to tell us how the hospitals in Cork and Kerry should be reorganised.
There were large gaps in that report in terms of detail. One related to a point raised about Kerry. There were no changes in Kerry because Kerry is a long way from anywhere else in terms of hospitals. Howarth and Teamwork seemed to have missed the location of Tralee. While the philosophy in the report was good and Howarth and Teamwork outlined fundamental changes that needed to be made, our first task was to put some distance between a report that was going to be published and what we were going to do in Cork and Kerry.
The larger hospital group will require us to re-examine some of the specifics of the services that might be in the second elective hospital, but it will not change the recommendation. The core issue is that we have two hospitals that are no longer fit for purpose. As Mr. O'Flynn mentioned, we need to look for a site for a new dental hospital and school. We are within weeks of saying that we will definitely go ahead with that. Since it needs to be built on the site of the elective hospital, we cannot spend money to build it in the wrong place. There is a bit of urgency about this.
The larger hospital group will force us to re-examine some of the individual services and the nuancing of where they are located.
In fact, almost all the services at University Hospital Waterford and South Tipperary General Hospital are critical to the region they serve. In a city such as Cork, reconfiguration is much more important because it is a big urban area and there are not the distances and the access problems due to having a long distance to travel by car. Therefore, we have to achieve the efficiencies in the big urban areas. We have a requirement to produce a strategic plan, as a hospital group, and that is going to look at the whole region and will underscore the need for the elective hospital in Cork. Having said that, there will be a capital priority list. The building of this hospital, as opposed to the purchase and identification of the site, might not be the number one capital requirement, whereas the capital requirements in Waterford and Tipperary might be top of our immediate list.
Deputy Kelleher mentioned primary care in the context of configuration. We involved general practitioners in all of our working groups. They were central to all we did at the highest level of the steering group and the sub-groups that were working on project planning. We engaged with them in all the changes we made. I completely agree that we need to look at the services that could be provided in big primary care centres. However, there is a step before that, which is to say that, within our hospital system, we need to move away from thinking of a hospital as a place where people go in an ambulance but rather a place they go to for advanced diagnostics, outpatient work, elective work and ambulatory work. The problem is that the population has not trusted the system as it has changed, perhaps based on an experience that has not been as good as it should have been. We need to move to a space where we look at the development of hospitals in an entirely different frame and, in particular, where we underscore that the future of hospital care will be based much more on advanced diagnostics, ambulatory outpatient care, elective care and plannable care, and where the acute element will be more concentrated.
In terms of how we link the hospitals with primary care, the national clinical programme is one of the best things that has happened in the past five years. It is something Ireland is doing better than almost anywhere else and it provides the clinical framework for looking after patients across the two systems. This needs to be emphasised as it is beginning to have a direct impact on how patients are looked after.
With regard to teaching, training, research and innovation, we have existing memorandums of understanding but the whole point of the hospital groups report is to move that on to a higher level. The world's best hospitals have embedded within them a shared mission for delivery of patient care with teaching, training, research and innovation. If that is how the best hospitals in the world do it, then that is how we want to do it - and how we should be doing it - in Ireland. That was a key element in the establishment of the hospital groups report. How do we do that when we have so many demands? Deputy Kelleher mentioned that reconfiguration has sometimes simply been a dressed-up version of cutting costs. While I agree, I do not think we took that approach as we had a small but very important ring-fenced budget that was critical as budgets fell across the entire system. When we launched the hospital groups report, I recall talking to the Deputies from the Opposition parties. It was Deputy Kelleher who emphasised that for the groups to work, no matter how much pressure we were under, we needed to find a small amount for a ring-fenced budget. We had that luxury and, while it was not a lot of money, it was critical in allowing us to make some changes while people were struggling. While we were trying to reconfigure, one of the phrases we used was that the urgent always replaces the important. One has to put some resources into what is important. Any ring-fenced budget is invaluable in terms of bringing about change.
With regard to the data on the use of our services, as mentioned by Deputy Kelleher and others, we had health intelligence embedded in our process which was coming from the public health service in the south. That was critical in that we could count every single patient and procedure. When we were not happy with the accuracy of the data around the number of operations we were doing in our 33 operating suites, we employed 50 medical students over a weekend to note down from the hand-written operating theatre logs exactly how many cases we dealt with in order that we could look at how these changes would impact. There is a lot of detail in that but if we are going to change the service, we have to roll up our sleeves and be willing to spend an endless amount of time on the detail. The big picture is easy and attractive but it is the detail that means there are no strikes and that patients do not fall through gaps.
Deputy McLellan mentioned surgery. We were talking about general surgery, for example, surgery on gall bladders and bowels. Orthopaedic surgery was reconfigured. In fact, the biggest thing we would have done was to close the stand-alone orthopaedic hospital and move that service to the South Infirmary Victoria University Hospital.
With regard to the intermediary care vehicles, ICVs, the key element in their utilisation is that those vehicles are bigger than the average ambulance and, while they would not be used for emergencies, it is possible to put two or three patients in them. Ours is a particularly big region which stretches from Wexford across to west Kerry, so we need vehicles such as these that can take two, three or four patients, if they are reasonably well, rather than using an emergency ambulance that should be available when a person has a heart attack. The ICVs were a long time coming. I have pictures of them in Bantry, where I go myself, and they are doing a very good job.
Deputy Healy referred to the Kerry hospital. We did focus on it at the very start but regardless of their report, we are of the view that while we accept their expertise and know they are very good international reviews, Teamwork-Howarth were actually wrong in regard to Kerry. We cannot close the maternity services or the emergency department in Kerry hospital because the facility is too distant from other options. It was great learning for us to accept that, within Ireland, we know our own system. If we are willing to accept change, we can provide the expertise, although, unfortunately, we had not been open to change in the past.
Our chairman referred to the children's hospital. I am not going to enter that debate. Senator Colm Burke highlighted the paediatric unit, which is one of the most important changes we got agreement on. We had not been able to get agreement on one single paediatric unit in Cork when we needed one, and we got that.
The two voluntary hospitals will have to be accommodated in a new group. The Minister said again this week that the Government is hoping to bring in legislation for the hospital groups by 2017, and I know he said that in two other important speeches in the last few months. It is very important that legislation comes through to make the groups a reality. Any legislation will have to deal with the legacy issues the Senator highlighted.
With regard to the modular build and the early spend, I would again refer to the UCC Dental School and Hospital, which is a university entity. We are within weeks of being able to make an announcement about the funding and the university has been working on putting the financial arrangements in place to be able to do that. We have to know where to build it, so we have to be ready. This will be a big thing for Cork and we need to know the site. That is where we are seeking help from all Deputies and Senators from Cork.
On the ongoing funding of dermatology, the second hospital will focus on ambulatory care and diagnostics because dermatology is a specialty that falls into that category, particularly in view of the fact that there are very few inpatients.
Some 250,000 patients a year attend the three hospitals in Cork. For different reasons, they find doing so next to impossible. Elderly people in particular dread having to go to any of our hospitals. There is either no parking or not enough and they find it very intimidating. This new hospital must be easy for them to access. If a shopping centre is being built, it is made easy for people to enter. The new hospital should be a different concept - it must be easy. It must have good transport links with the city but it must also have access for people in cars. We all go places in cars and we expect to be able to do so. Elderly people who are being dropped off need to be driven right to the front door in order to walk in. This seems impossible in our system whereas it happens all the time in American hospitals.
They have got that worked out. The new hospital must address this. Dermatology is also a key objective. Those 250,000 people should be the first people to use the new hospital. Let us get the outpatient facilities onto that space and make access easy for patients.
In regard to St. Stephen's Hospital, I understand that the HSE capital projects have looked at all of the current sites and have done a fairly detailed assessment of them. One concern regarding this hospital is that in order for this to work, the same staff must be able to manage an operating list in CUH in the morning, finish by one and then go to the clinic. They will need to jump on a bus on a circular bus route that is continually going around. The process must be dead easy to enable the staff to be in the clinic on time ready to go. This means the clinic must be very close if the system is to work.
Deputy Doherty raised the issue of the reduction of emergency departments from five to two and asked what engagement there was on that. We engaged with the population and with the ambulance service in an unprecedented way. We met all the community organisations and the Irish Countrywomen's Association. I spoke to them several times in west Cork. We explained the importance of the change in the ambulance service and we explained to the ambulance service why what it did impacted on our ability to change things in the hospital. The ambulance service and its staff gave the Powerpoint talk in many venues, including secondary schools and local organisations, and explained why it was important to change how the services were being provided in the small hospitals, why it was important for them not to stop in many hospitals and to go to the right one. They were terrific. Once they got going, they were impressive, engaging and quite inspiring.
I will finish on that, but I am happy to take any follow-up questions. I suggest the ambulance men should be used in presentations. They were better than us at it when they got going. The staff in the Irish ambulance service are very well trained and we should rely on them. If the reconfiguration process had an unspoken agenda, it was to energise, enthuse and motivate the hundreds of staff who engaged in the process.
Mr. Gerry O'Dwyer:
On behalf of the executive, I compliment and thank the Chairman and the members for the work they did. I do not want to go back over issues raised by Professor Higgins, which have been answered comprehensively.
One of the issues is the focus for health in the future. The focus should be on ensuring that people are treated as close to home as possible. The focus of the HSE has consistently been to work with general practitioners and build up primary care centres. It aims also to work closely with the ambulance service to ensure we have a comprehensive service. Part of the roll-out of reconfiguration in west Cork was the advent in the area of a speedy response car. The effect of this has been that on a number of occasions an advance paramedic arrived, treated a patient and discharged the patient at the site or advised the patient to go elsewhere or called for back-up to remove the patient to hospital. This speedy response service has been provided while we have rolled out the reconfiguration in the south-west area.
The reconfiguration report feeds into a strategy which we must present to the Ministers in Q1 and Q2 next year. This will incorporate the three hospitals in the south east, Kilcreene Orthopaedic Hospital, University Hospital Waterford and South Tipperary General Hospital. Work has commenced on the strategy and there will be widespread consultation on it. Our chairman, Professor McCarthy, is adamant on that. This consultation will happen over the next 12 to 16 weeks, because we have a tight time frame on this.
On services, we are still in the process of completing the transfer of ophthalmology from CUH to the South Infirmary. Some construction is required to finish this, but it is in process. The paediatrics service is important to all of us. This needs to be centralised in Cork rather than leave it shared among the three hospitals that currently deliver it. Work is under way on that, phase one of the building project is under way and bids have been entered for phases 2, 2a and 3. Submissions are being made to the capital programme in that regard. The issue of site selection has been covered. A process must be gone through in that regard and it will be adhered to.
The role of the smaller hospitals, such as Mallow and Bantry, has been enhanced. We have a much safer sustainable service now, with good outreach from the centre. The figures show this. For example, approximately 15,000 people attended the local injuries unit set up in the St. Mary's Orthopaedic Hospital, run by the Mercy University Hospital, in 2014 and turn around time was noteworthy. In my view, the reconfiguration process is working and has worked. There is more work to be done and a decision must then be made in terms of where we go from here. We must incorporate the south-east component and there will be full and frank discussions with all parties on the strategy which we must present to the Minister in Q1 and Q2 of 2016.
Professor John Higgins:
To be fair, we had the benefit of learning from the north east and the mid west, where the situation was quite fractious. On the first weekend we were in post, we had marches in Bantry and tractors half way from Bantry to Dáil Éireann. Therefore, we had to change the discussion. There is a template now. To go back to the point made about the urban areas, we have only one big urban area left as most of the country has seen significant reconfiguration. The big area left is Dublin and that is work for the new groups. Our advice would be to spend as much time as possible on engagement and to get expertise, like we did, from within Ireland but from outside of the system, who can provide business, financial, educational and clinical input that is independent and objective and to use that to ensure what is being done is right and will bring about change. We implemented significant change, which is better than to have a report that is not implemented.
In the final part of his presentation, Mr. O'Flynn mentioned leadership within the health service area. Is that leadership in tandem with political leadership? I had to smile when he spoke about the orbital route and networking. Is there buy-in at local level from local authorities also? It is great to have the plans on paper. The work he does and has done testifies to his commitment to the development of the services, but how do we take it from the page to the next level? That is what we have to try to do.
Mr. Michael O'Flynn:
The future is more important than the past in terms of the work that has been done. If there is no future for the work we have put in, we will not see it as a success. The former Minister gave us the go ahead to do initial assessment work, but we need momentum and energy to ensure a decision is made to go live with this. I am not saying initial work is not going on, but there is not enough energy or momentum behind this to deal with the critical future of health in the Cork region. That is my position and what I believe is necessary. Our group has finished its work and produced its report. I see this as very much the last event for it.
I will call Deputy Kelleher shortly. The witnesses spoke about the site selection process. However, if the group has been stood down, as it were, what people are involved in the site selection process? Is it the Health Service Executive? I presume Professor Higgins's role in the reconfiguration is finished as well.
Professor John Higgins:
My role in this area is finished. I am still on the leadership team and head of the College of Medicine and Health. I hardly need tell the committee that capital projects, above all else, are ultimately about the elected representatives making the decision. We are not asking to build a hospital. We are asking for a 20- to 25-year view to be taken, which we do not do well or often enough in Ireland, and to decide on a site. That is a political decision in which the HSE makes a choice on the site, hopefully with input from real expertise, the Government, the private sector and so forth. It is not that difficult because it is not as though there are 50 options. However, we must make the decision to look for the site. We are not building the hospital.
Mr. Michael O'Flynn:
Having spoken to the current and the former Ministers, I am aware that there are always concerns about costs, but I believe we cannot afford not to make a decision. The site will not be the most expensive part of the equation, but with proper phasing and by incrementally planning it in a modular type of system, we can do it as we go, but with a master plan in a way that works for the future. I am concerned that people are saying we cannot afford to make the big decision. That is not a very economical thing to do. I am not saying the HSE is not doing its work, but as I finish in this role I must point out that it requires momentum or energy. I do not see that, but I hope the political interest the Senators and Deputies are showing will generate it. It is needed.
Obviously, the site would have to be in the Cork city area. It must be near the hospital for collaborative work and ease of movement of staff, patients and so forth. I am sure a site can be found. What we must do is make a decision to find a site in the first place.
On a broader issue, we talk about the hospital groups, the collaborative work that universities do with industry and bringing that into the sphere. How far has that been developed with UCC, for example? There are many pharmaceutical industries in the Cork area, while in Galway there are many medical device industries, so there is huge experience available in industry. On top of that, and as we move to centres of excellence and a stronger academic and teaching input, with regard to the attraction and retention of consultants, do the witnesses see the current hospital group structure as the way to go to ensure we can attract the best because of the stronger emphasis on academic research and innovation, along with the potential for international collaboration? In addition, there are the sub-specialties. If we have a hospital grouping system, who decides at a national level about sub-specialties, which obviously cannot be in every hospital group? Who will decide that sphere of health care? Was that taken into account when considering the new hospital, elective surgeries and so forth?
Perhaps Mr. O'Dwyer will clarify something. Can I take it from what he said that strategic planning for the region either has started or is about to start? He said he would have to report to the Minister in the first or second quarter. He also said there would be consultation in that regard. The HSE and the Department of Health have not had a good track record on consultation. Are there proposals in place for a consultation and what stakeholders will be consulted? I certainly hope it will not be like the consultations in the past, where the decisions were made and, effectively, people were only consulted after the horse had bolted. Perhaps he would give us clarification on that process.
Mr. Gerry O'Dwyer:
We have been asked very publicly by the Minister to present a strategic plan; all of the groups have been asked. The responsibility for that lies with our leadership team and the chair until the board is in place to do that. There will be consultation with public representatives and with all of the groups. The Deputy will see from the track record of Professor Higgins, as director of reconfiguration, and of Michael O'Flynn that they consulted people widely and came to a number of conclusions. It is our intention to follow that format in so far as we can. There will be widespread consultation. One cannot have a plan without consulting with people, securing the necessary buy-in and ensuring that there are no unnecessary battles or challenges. If one could eradicate those simply by consulting, why would one not do so? We will be consulting widely before the plan is submitted.
Mr. Gerry O'Dwyer:
It will take off seriously in the new year. We have had some consultations with the nine hospitals and there will be more, because there are some internal mechanisms we must get right. At a point after that we will consult with all concerned. We have agreed on that and we will do it. We will present to the local HSE south forum on it and we will present to all of the Deputies, Senators and councillors, as appropriate, as we move forward. At all times we have offered to meet any groups of Deputies or Senators who wish to be briefed on any issues. That invitation has been in place all along and it has been utilised by a number of the Deputies in the area.
Professor John Higgins:
On research and innovation, I could not agree more with Deputy Kelleher. A key element of the hospital groups was to embed that in the system. In terms of the value of manufactured goods and exports, health care is responsible for almost two-thirds in value terms of what we produce as a country. We must be a place where not just manufacturing but research and innovation in health care are a central element of what we do. The health care system up to now has not accepted that as a responsibility. If the Deputy reads the report on the hospital groups, he will see a key change in policy where that is now accepted as part of the mission. It is very important. Cork has probably the biggest concentration of pharmaceuticals in the world bar none. As evidence of that, the demonstrator site for the national health innovation hub, which is a joint interdepartmental initiative, was based in Cork. It was part of the work we were doing. I am fairly sure that the national hub to be announced shortly will be headquartered in our region because of the fact that we joined the dots between clinical service, training, research, innovation and job creation.
I have a final comment about retention. We have had a long tradition of our specialists going to the world's best hospitals, becoming the best people there and then coming home to spend their working lives in Ireland. There is a grave danger of that long tradition coming to an end. What will keep them here? There is certainly an issue with salary, which has been mentioned and discussed previously, but there is also an issue with the culture within the Irish hospital system, which must be changed. A key element in that change, not the universal element, is that we have a system that is open to innovation, is ambitious and fosters enthusiasm and excellence. That is a different culture from the one we have at present. The young trainees are in hospitals overseas where that is part of the mix, and we must get them back here again. A key element in making the hospital groups a success is the link to the academic partner.
Mr. Gerry O'Dwyer:
I concur with Professor Higgins. It is really important from a different point of view. If we want to retain and attract the best people to our hospital group, which we intend to do, we must work in partnership with the universities and the institutes of technology. We have a strong relationship with the Waterford IT, Tralee IT and UCC, our major academic partner. The hospital system has to reform. This is the best opportunity for our hospital groups to have the best outcomes for our patients. At the end of the day, this is all about patient care. It is about ensuring patients are treated in the most appropriate location for them. It is about a seamless transfer from primary care to a local hospital and to what other service they need within our group. We need to have the best people working in our group. We need to have the freedom to operate in a different way than heretofore. That is the reason I see the new board and the groups working very differently from the system we have inherited in recent years. This is a new beginning.
The report is the platform by which we can move a number of issues forward, incorporating what needs to be done in the south east. The beneficiary at the end of the day will be the patient. The patient is at the centre of everything we in the hospital group do and is important as we move forward. We must instill that confidence. Five or seven years from now, I would hope to hear patients say they want to go there because the staff are the best and because the patients have been treated with respect, dignity and with understanding. That for me and for our group is very important. We need to change. If we get something wrong, we need to say we got it wrong and explain to people the reason we got it wrong and ensure it does not happen again. That is the reason what our group is trying to achieve is important. This is a major opportunity.
I am passionate about what we do. I am at the end of my career and I see this as a significant opportunity to provide a better service in the interest of our patients. I could be a patient.
Mr. Michael O'Flynn:
To revert to the Chairman's comment on the site for the proposed national children's hospital, as Deputies and Senators have pointed out, we have seen where things can go wrong with a structure that one would imagine could not have taken the time and given rise to such a number of issues. We should not just leave it and hope it will work. We should create a structure to ensure it works. We cannot afford a delay and we cannot afford not to get it right. I would not want to have it misunderstood. We need to ensure it has public approval. It needs political input and leadership to make it happen.
I thank all the witness for their presentations and, more important, for the significant amount of work in recent years. I hope it will not be a question of being stood down but rather that today will be a platform from which we can move the project forward.
I thank members for their participating. I thank Professor Higgins, Mr. O'Flynn and Mr. O'Dwyer. I hope Mr. O'Dwyer is not at the end of his career just yet. I thank them for their courtesy to us. I thank the staff of the HSE in the Cork region for the work they do.
I wish our three witnesses and their families every happiness and joy over Christmas.
Mr. Michael O'Flynn:
On behalf of the non-executive advisory board, I thank everybody who has been involved with us and I thank Deputies and Senators for their interest in going through the report and understanding what we have been trying to do for the past number of years. The Chairman's closing remarks as well as the interest of members are encouraging. This is so important to us all.