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.