Oireachtas Joint and Select Committees
Wednesday, 14 September 2016
Select Committee on the Future of Healthcare
Future of Health Care (Resumed): Dr. Stephen Kinsella
I remind members, witnesses and people in the Public Gallery to ensure their mobile phones are switched off. This is important because they cause serious interference with the broadcasting and sound recording systems. Apologies have been received from Deputy Michael Harty.
This meeting comprises two public sessions during which the committee will hear evidence on different aspects of the health reform agenda. In the first session, we will hear evidence from Dr. Stephen Kinsella, an economist from the University of Limerick, on workforce planning models in the health service. In the second session, we will hear evidence from Mr. Richard Corbridge, chief information officer with the Health Service Executive, on the role ICT can play in delivering an integrated health service.
Before we begin, I acknowledge the work of the wide range of stakeholders who contributed to the committee's public call for submissions, which process closed recently. The response was very strong. That is very welcome.
The committee received in the region of 140 responses, which were hugely informative and will assist us all in our ongoing work.
With that, I welcome Dr. Stephen Kinsella to the committee. I draw the attention of the witness to the fact 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 the committee to cease giving evidence on a particular matter and they continue to so do, they are entitled thereafter only to a 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 they are asked to respect the parliamentary practice to the effect that, where possible, they should not criticise or make charges against any person, persons or entity by name or in such a way as to make him, her or it identifiable.
Members are reminded of the long-standing parliamentary practice to the effect that they should not comment on, criticise or make charges against a person outside the House or an official either by name or in such a way as to make him or her identifiable.
I invite Dr. Kinsella to make his opening statement.
Dr. Stephen Kinsella:
My submission is on a body of work Dr. Rachel Kiersey and I carried out for the Health Research Board. It is a review of five different workforce planning models and consisted of an evidence-based review and a series of interviews with the people who make the models in these countries. A workforce model is a series of forecasts based on a baseline data set of the number of doctors, nurses, physios, etc. in the system and what one thinks the demand for the services they provide will be over a given period. It might be the number of doctors or physiotherapists in Limerick University Hospital in 2025, and it might cover the integrated care pathway patients can expect to go through to get the highest level of care and the requirements for same.
It is also about how these services change over time. An example that kept coming up involved dialysis nurses across four of five countries. When technological change takes place, certain service specialties tend to be used to a lesser extent. Technology means there is less demand for nurses specialised in dialysis because people can dialyse themselves at home to an increasing extent. How can the system know that it should reduce the number of training places for dialysis nurses? How does one know whether one is producing enough or too many doctors? It is about the connection between the demands of the system in five, ten or 15 years, the supply and also the mitigating factors. For example, we know that migration is a major issue across all health professionals, including nurses and doctors. Most of these models involve very simple modelling. It is just forecasts being formed. What is really difficult is getting the data on a fine-grain level and obtaining a very qualitative understanding of what is going on.
I will take the committee through what we found. I ask members go to the results section of the paper. We found that the onset of health workforce planning emerged independently in each country we studied. We studied Australia, New Zealand, Scotland, Wales and the Netherlands. Each time it happened, it was in response to some pressure. Either it was demographic pressure, financial constraints or issues surrounding future supply. In several countries, for example, it was the lack of available nurses that caused people to ask how many nurses were being trained and how many were being bought in from abroad. There are very few integrated national care models. Many take modules and only look at doctors, nurses or allied health care professionals, respectively. Very often, they start with doctors, for various reasons. It is very interesting that once one has moved beyond doctors and their sub-specialties, one sees that there are is a great deal of thinking and planning to be done. Data are always the first problem. Typically, we do not know what the data are on a given day. If one stopped the health system today and asked the chief information officer of the HSE how many people were working that day in the health system, it is most likely he or she would not know the answer. If one asked him or her how many doctors or phlebotomists the service would require in Temple Street in 2020, he or she would not be able to provide an answer. That gives a sense that the planning system is short-term in nature. While there is a workforce planning model in place right now, everybody agrees that it could change.
Each workforce planning model that we studied was country specific. That is to say it was generated with respect to the institutional structures that underlay each individual country's needs. Australia is completely different from New Zealand institutionally and similarly Wales and Scotland, notwithstanding similarities in terms of the National Health Service, NHS, have quite different financial and legal structures. However, they all begin in the same way. One creates a baseline analysis of how many doctors, nurses, etc., one has in a particular year and then forecasts based on demographic supply. We know our population is ageing and that we have both a very young and a very old population and that will increase over time. We are aware that demands on the service will change. We are also aware that there are regional differences in the numbers that are accessible. Once there is sight of the regional data and the patient flow data, it is possible to analyse the evolution of our system, which is very important.
When I started lecturing years ago, people said, "Get the summary in first, in case people are not sufficiently caffeinated." Here is the conclusion. This is not just a quantitative process. That is, it is not just the case that some nerd in a room comes up with a forecast, a line goes up and that is fine. This is a qualitative process, which is to say that it is a way for the Department of Health and the Health Service Executive to initiate a dialogue across all the sub-specialties. As an aside, I note that I will be setting out some thoughts on governance structures in a while. This qualitative process starts with saying, "Here is our forecast. Is it right?" It is about asking the individual services and specialties whether it is correct. Every time, of course, they will come back and say it is not and that more of specialty X is required or less of specialty Y. However, what is really valuable is being able to have that dialogue. This was a real surprise to me as a technocratic, quantitative person. In all of the expert interviews we did, this qualitative process and the idea of generating fora surfaced. It means one could get the deans of medicine of all the major colleges and universities, a representative of the Department of Justice and Equality, who will talk about migration issues, and representatives of the Department of Health and the HSE around a table with the Departments of Finance and Public Expenditure and Reform. If the medium-term forecast to 2021 is that health spending will increase by 7%, we can drill down and ask the different specialties how much of each resource they need and where, if we had the money, resources should go. We can then ask the colleges if they are training the necessary personnel. Before the Fottrell report and the massive increase in the number of doctors we produced, we were not producing enough doctors. Now, it seems like we are producing too many. The system needs a check and a balance. There needs to be feedback into the system to slow things down.
In many of the cases we studied, clear and legislated connections to policy levers were very important.
For example, if an individual service did not do its forecasting plan, it does not get funded. It is legislated in Wales that the medium-term strategy for workforce planning is allied with the financial plan, so if one does not do these forecasts one does not have one's service level agreement signed off. If one does not have the forecast carried out, that is it. Similar actions are being taken in New Zealand. In Australia, where it is most developed, people can tell one down to the hour what each pharmacist, doctor, nurse and every other sub-specialty is doing. They have activity data by the hour so they are able to compute productivity levels not just by hospital, but also by individual service. I am not suggesting that we go that route just yet. Perhaps we could find out where all the doctors were, although I am being slightly facetious because we have quite good data on that.
However, if we had a robust data gathering exercise, the modelling is not very difficult. What is difficult is getting these fora established and having them repeat. In Scotland, for example, when it was rolled out there were 150 individual contact sessions between the workforce planning unit and the relevant sections. We are not just talking about the workforce planning unit talking to the HR manager of a hospital but to all of the people who run the services, who might say they need three administrative personnel rather than seven, that they do not need ten nurses but two nurses and six more doctors and so forth. One might think that system could be gamed. I am a university lecturer and if somebody asked me how many more university lecturers are required in economics, my answer would be "all of them". One would imagine that people who hold budgets would say that. In fact, it is not true. Most of the time if one is asked for a fairly credible forecast, typically one gives it. People are not that incredible, especially if they are held to it - "Last year you said your expectation was that you would need eight physiotherapists, but you did not need eight because you have coped perfectly well with four. I know this because I have latent demand data and I know that there was not much of a waiting list and it was cleared quite quickly." On the other hand, the service might not be sufficiently resourced with support staff. This is a pretty big issue in certain areas. The support staff is not there, so one has highly qualified medics, nurses and other allied health care professionals running around finding labels. Much of this is about balancing and understanding the team composition.
This qualitative aspect is really important. One of the matters I wish to impress upon the committee today is the need to think about what the structure of those engagements would be. What would that structure be like if one had to have the deans of all the colleges of medicine, all of the various representative bodies in the Higher Education Authority, HEA, justice and so forth there, as well as a sense that the funding will follow whatever strategic priority is set? The strategic priority is typically on a five to seven year basis, not one to two years, which means the funding must be set roughly in those parameters. As I will outline later, the Irish context does not put the lie to that medium-term planning approach, but historically it has been quite difficult to do it.
We found that the engagement with the whole workforce planning process across all the countries we studied, and particularly a discourse around the modelling itself, is really influential. It changes the wider health workforce policy, because it simply promotes a conversation. This allows stakeholders concerned with health workforces to become actively involved, even me. I am talking about doctors and nurses. Very few people ask how many phlebotomists we need. It turns out that this type of work gives what one might call the medical scientists a voice at the table, that they did not previously have because everybody is concerned that the public discourse is around doctors and nurses. In fact, one needs a large number of allied health care professionals to make the system run and creating these engagements gives them a large voice at the table which they would not have had previously. They get input into policies which they previously did not have and that is very good. These types of conversations give one a sense of being able to sense and identify trends in a system, and these trends in a system turn out to be very important. One will not get this data sitting in a room with a spreadsheet. One only gets the data by talking to the people who run the service; that is the only place to get this data.
That is the reason the governance structure I recommend is so important. If one locates a workforce planning unit completely within the Department of Health, the links it has with service users may be limited. If one locates it entirely within the HSE, it will not have the strategic element which the Department of Health provides. My recommendation is to have the workforce planning unit, division or department span both and have links into other areas, simply because the health system is so big.
As part of the context for our review, we looked at the evolution of the Irish health system to date. I have a panel of figures for the members of the committee which is included in the series of graphs I have provided. I am delighted it is done in colour because mine printed out in black and white and is completely illegible, so I was a little worried we would be looking at the wrong things. These figures are indexed figures from the Department of Health, the Department of Public Expenditure and Reform and from the HSE's annual reports. I am seeking to give the committee a sense of what has happened to the evolution of the Irish health system since the mid-1990s. The members are looking at these numbers indexed; that is, one can imagine them as a type of horse race. We are not looking at the nominal numbers. We are only looking at them relative to a given index year, and for all but one 2008 is the index year. Everything is relative to the height of the crisis, which I believe is a valid way of seeing it.
If one looks at the first figure, it shows all the Vote if one adds in the voted expenditure for health and the HSE. That includes capital, non-pay, pay and pensions. If we look at the rest of the public sector, we can compare the evolution of both directly. One can see that from the early 1990s up to 2008 for much of the time health grew at a lower rate than the rest of the system. It caught up around 2003 and 2004 in terms of its funding levels, which it then matched exactly until the crisis hit in 2008. The emergency budget in 2009 pulled the wheels off the bus somewhat. One can see the jagged drop in health and HSE funding, which then jumped up again. One can see that the evolution of the health system relative to the rest of the public sector has been quite different. The spending on health, despite all of the negative press it has received, has been relatively high if one compares it with, for example, education which is rather different as a subject. Over the time there are two contrasting stories. One is of relative underfunding followed by a levelling out of funding, especially relative to the rest of the public service.
Look at health worker numbers in the second panel. Of course, they both fall relative to 2008 but health recovers faster but later. The rest of the public service begins recruiting. The public sector moratorium is removed in 2013 but it does not actually begin until 2014 for the health sector. In terms of the deficit of people, there is an approximate 10% deficit of people by the end of the crisis in the rest of the public service and it is a 12% or 13% deficit in the health service. If one looks at voted expenditure on pensions, we spent approximately €2 billion in 2016 on pensions.
An interesting point is that the health service accounts for approximately one third of all public sector staff - approximately 103,000 people are employed in the health service - but just a quarter of all public sector pension expenditure. It is clear from these statistics that health was relatively insulated from the decrease in capital expenditure over the period of the crisis. Again, that is to be expected. The next statistic to which I would like to refer explains the large increase. The voted expenditure on non-pay items is 25% higher in 2016 than it was in 2008. Non-pay expenditure in the health service is higher today than it was at the height of the crisis. We can get into the various reasons for that in response to members' questions. The level of voted expenditure on pay is relatively similar, as one might expect given that they are all public sector workers.
When we break down the staff levels, based on the HSE's annual report, we can see that 25% of those who work in the health service work in management, in administration or as support staff; 14% of health service staff work in health and social care; 34% of staff work in nursing; 9% of staff work in medical and dental roles and 18% of staff work in patient support. I would not attach massive amounts of explanatory power to these numbers, for several reasons. Support staff in this sense can be categorised in various ways. ICT personnel and pharmacists could be classified as support staff. It is not the case that all support staff are people who write letters. If one looks at what many of those who are counted as nursing staff do on a day-to-day basis, one will find that they are managing the system. There are other aspects of this in the patient support and medical and dental categories. This is a very imperfect measure, in terms of the breakdown of the levels, but it gives a sense of how the HSE sees itself and perhaps of how it has evolved.
We know for a fact that we will need to spend more on health in the coming years. Demographic pressures alone mean that current expenditure in the health service will have to be increased. This will have to happen independent of policy change or anything else. We know that demographic pressures will push this up. I would like to refer to an estimate of the dependency ratio that assumes there will be middling amounts of migration and fertility. It uses a pretty standard migration and fertility measure known as the M2-F2 assumption. It is estimated that the dependency ratio will increase by between 12% and 15%, which means that more older people will have to be cared for through their taxes by fewer younger people.
We have studied five different national models in the system. We have spoken to experts on these systems in several countries. I will break down the main findings from these models. There is no one single model that I would recommend for the Irish system, simply because we are so institutionally different from some of the other models. The simplest thing to do would be to take the Scottish model, find a logo and slap it onto the Irish system. I think that would be a mistake. The NHS system is very different from the Irish system, especially at the service delivery level. It is far less diffuse than our system, which has a very different public-private mix. While I would be reticent to recommend an individual model, I will go through the strengths and limitations of the various models.
The authorities in Scotland have spent a substantial amount of time engaging with the people they are going to be working with. They have been doing this for approximately ten years. One of the limitations of this approach is that Scotland organises its medical and other nursing training differently, relative to other areas. The Scottish authorities feel there is an over-reliance on quantitative data. I was completely shocked when this came to the surface in the expert interviews. I had a notion that this was a very technocratic exercise. Those who went out to talk to everybody said it was actually a matter of structured engagement where they got to look people in the eye and ask whether everything was going okay. As part of this engagement, the interviewees are asked whether they have enough people and whether they need more. This helps trust to build up over time. I think there is great value in thinking about that and about what kind of structure enables that.
As I said earlier, Wales has a legislative foundation for workforce planning. It is based around five-year planning cycles. There have been some strong quantitative studies in Australia. They are less focused on the qualitative elements. A far more collaborative approach is taken in New Zealand, where data quality is a huge challenge. A great deal of the data in New Zealand comes from surveys. Anyone who has ever decided not to fill out a survey on one's phone will appreciate that a representative sample is lost when surveys are used. This turns out to be a big issue.
The medical manpower model used in the Netherlands is objectively the simplest one. It is based on GP planning. If we want to adopt the simplest possible system, we should choose the Dutch system. The authorities in that country are able to pursue such an approach because they use the universal health insurance model. That may be a bad phrase to use around here - I am not sure. While this is very useful, it is important to note that an important aspect was lacking in the Netherlands model because there was no way to mix the different teams. It produced a headline number of doctors, nurses, phlebotomists and so forth. Under that model, one could not tell whether two doctors were needed for every three nurses and so forth. There was no skill mix.
Three things are needed if workforce planning is to be done properly. First, a well-resourced unit dedicated to information collection and analysis needs to be established. Second, this unit needs to be split between the Department of Health and the HSE - the strategic and operational sides of the health service - and needs to have links to the Departments of Justice and Equality, Education and Skills, Public Expenditure and Reform and Finance. Obviously, much of this is about financial control as much as anything else. Third, there needs to be a commitment to the generation of a minimum data set, rather than a maximum data set, to make this thing work. There is an international standard for what that is. There are data quality indicators that enable us to say that our estimates of nursing provision in Tipperary are as good as our estimates of nursing provision in Dublin, for example.
The qualitative side of this workforce planning process cannot be neglected. The establishment of forums and the dissemination of information about workforce planning should be a crucial task for the workforce planning unit that is set up. This should be done before any formal model is put in place. I will set out a rough governance structure to give the committee a sense of what this would look like. Of course we have a large private sector in our system. This includes GPs. Tusla, the voluntary bodies, the various section 30 groups and the various hospital groups are also involved. It is quite a diffuse system. It is quite difficult to get one's head around just how complex the Irish health system is. The workforce planning unit will take data from all the various bodies, work between the Department of Health and the HSE and contact external stakeholders like the ESRI and the OECD. I think something like this can deliver a workforce planning model in two to three years, which would be a pretty good return on the taxpayers' investment. I suggest we would get a significant level of engagement from the various health care professionals along the way. They would start telling us in a structured way what it is like to run these services and what they think needs to change. I do not think we would end up merely with people asking for more and more. I think most of the people who work in the health service are committed to making it better. Obviously, they are personally incentivised to make it better. I think we should create a system like this, to the extent that we can do so, in order to help our growing and ageing population.
I thank Dr. Kinsella for his helpful presentation, which I appreciate very much. I would like to ask a couple of questions before I invite members to do likewise. I would be interested to know how Dr. Kinsella deals with the various variables within the health workforce. I refer to things like the model of care. I presume all of this depends on where the services are delivered and the extent to which there is a primary and community-based focus within the health service.
Do decisions need to be taken with regard to skill mix, which has been mentioned by Dr. Kinsella, prior to the construction of a model to ensure that model is effective? A similar question could be asked about work practices. The issues of skill mix and work practices are inter-related. For example, will chronic care programmes be predominantly delivered through nurses? How many nurses does one GP equal? What is the equivalent number? Do such decisions need to be made beforehand?
How does one deal with variables in work practices, in terms of whether people are working seven over seven or nine to five or whatever, or the question of the mix between nurses and nurses' aides? Do they need to be decided before one builds an effective model?
Dr. Stephen Kinsella:
All these questions came up time and again. This is called strategic health workforce planning. The strategic element is based on the notion that the policy-makers set a direction for the health system, that it moves to a primary care-based model with large hospitals and subsidiary hospitals. This has been the model we have been saying for many years that we are moving to. If that is the case, then hiring more people into hospitals is not in accordance with that strategy. The model of care is determined in an interplay between what the clinicians say they need and what the policy-makers know from their constituents and from what the experts are telling them is best placed. That is very important as well. The model of care comes from a dialogue between here and the people who run the service on the ground.
Where services are delivered is crucial. For example, if there is an area of the country that is poorly served by an individual service, workforce planning can spot that quickly. It is an efficient way of doing that, because there is a forum for saying, for example, that patients may have to drive for two and a half hours to get treatment. We can then ask whether there is a way to put a system in a satellite spot to help these patients. This is why I was talking about patient flow data, which is vital. One has to know, for example, what proportion of the people of Sligo are visiting Dublin on a weekly basis, and so forth. There is some data on that but it is quite old. I think it was done mostly for cancer care services.
The question of where services are delivered goes back to the primary care model versus the tertiary care model. This model is set at the strategic level and is then backfilled by the quantitative model. To take into account the skill-mix requires a very large amount of data. One has to have each individual service tell one what it needs. Running a cardiac care unit is very different to running an opthalmic surgery. What the service-provider needs is different and they need to surface this, somehow, to the service-provider. That is quite difficult unless we have these data-gathering fora. In Scotland, for example, we found there were very good templates. They were very simple, one-page templates, asking service-providers where they are located, where they think they will be in two years, what they need to run their service at maximum efficiency, how many people they saw last year, and how many people they think they will see this year. In Scotland, they map these simple team composition structures onto the map of clinical care they know they need.
We all have a clinical care pathway we think is the best, but if we did a workforce plan for each clinical care pathway and each one took three years, it would take 90 years to do the whole thing. My suggestion would be to start in a simpler way, then work up to a skill mix. Even in Australia, where they have the most advanced methods, where they know what people are doing by the hour, they find it difficult to do this. My suggestion would be to start with a service delivery model and then maybe incorporate skill mix later on.
I thank Dr. Kinsella for attending. He made us aware of the paper at a very opportune time for this committee, given what we are studying. I have a few questions and observations. It is a great study and the timing is very important for us. We have a defined period to do this work, but as regards governance structure, Dr. Kinsella has a great deal of analysis of what is going on across different jurisdictions. I agree there is no one model that can fit - there never is - but as regards planting a model here, what would the structure be? Can we define it? Could Dr. Kinsella come back to us at a later date with something that we will not stick him with but that, from his analysis, will work best? There is a requirement for far more continuous input and analysis into it than just sticking it between the Department of Health and the HSE. The Department of Public Expenditure and Reform would have to play a significant role, from my knowledge.
In respect of Dr. Kinsella's analysis and correlating it to Ireland, my background is IT, where there is a saying, "dumb data in, dumb data out". How good is the raw data here in Ireland? Are there sectoral differences? Are there differences across different areas? That would be an issue. I am very much taken by Dr. Kinsella's story in respect of technology change and how it is not prepared for. The story in regard to dialysis is a very good example. Is that something that is present across the board in respect of other countries and how does it relate to Ireland? Technology in health care is changing dramatically all the time. Are we prepared for it?
On forecasting in Wales, Dr. Kinsella said they were held to account. How were they held to account? In a situation where that happened in Ireland, where someone did not do their work, there would be a political outcry, saying that people are not getting services, and then everyone would buckle. How is the Welsh approach different to than here?
In respect of the qualitative-quantitative issue, there is a huge volume of quantitative data out there that needs analysis. I presume the qualitative analysis is necessary on top of it to execute continuous workforce planning. What are the best examples across those Dr. Kinsella has studied for getting that information? This is a continuous process. It is an iterative process. Workforce planning never stops; it is continuous. Could Dr. Kinsella discuss the provision of that qualitative data and the engagement process, with models of engagement that worked across jurisdictions? I am not sure the information will get out there.
Dr. Kinsella spoke earlier about how he believes that the majority of people do forecast and if they are held to account they are very honest about it. In one of our submissions, which I was reading last week, the CEO of one of the hospital groups proposed, as one of her main solutions, to take a great deal of money off the group and put it into community care. That would solve most of her issues. I found that to be incredibly honest.
Could Dr. Kinsella speak about gathering that information and the models that worked? I thank Dr. Kinsella. It is a very good study.
I, too, thank Dr. Kinsella. I echo what Deputy Kelly said about the study - it is very interesting and very timely. Dr. Kinsella referred to planning cycles. Clearly we have been locked into something of an election cycle with regard to our health planning for a very long time. Would he have a suggestion as to what the ideal cycle is in terms of workforce planning? Clearly 50 years is too much and one year is too little.
I would be interested to know whether any of the 25% increase in non-pay expenditure from 2008 that Dr. Kinsella referred to was spent on purchasing man hours or whether it is all capital expenditure. My sense is that some of that is agency staff and some of that actually refers to what I would call privatisation by stealth, although I am sure other people have different terms for it.
With regard to the IT systems we have at the moment, I am aware that the nursing and midwifery planning and development units, NMPDUs, were disbanded because the people working in them were needed back on the front lines - they were put back on their tools. We have a great deal of workforce planning that we need to make up and in this regard we have a huge deficit.
In terms of the number of qualified people, if we were to snap our fingers in the morning and say that we will put in place a workforce planning team to do this, how close would we be to being able to get that personnel together? What would be required in terms of IT? As was said earlier, one only gets out what one puts in when it comes to data. I would not be convinced that we have the IT infrastructure that would be able to support it but I would be interested to hear whether Dr. Kinsella has any views on what it would take for us to be able to do that.
I will revisit a few points that have already been made. First and foremost, policy must set the template for the direction the health services will take. In that context, I assume that if we are to produce a workforce planning model in the years ahead, we need a definitive view as to where we are going with our health services. That would mean that we would have to assess whether primary care would become the bulwark of the delivery of health care in our communities. On top of that, we also have an issue that is not compatible with other countries that we looked at, such as Australia, New Zealand, the Netherlands, Scotland and Wales. This issue is a national health system. We have a national health system but half our population has private health insurance. How can we assess the delivery of health care in the private sector vis-à-vis efficiencies there versus the public sector because if we are to amalgamate or move to a stage where it should all be done through public health, clearly, we must assess it very stringently to see whether different efficiency levels, etc., exist? Did Dr. Kinsella look at that part of health care delivery in this country in terms of his views on assessing performance, etc.?
This leads to how one assesses efficiencies in a workforce planning model and how one extrapolates from quantitative and quantitative data in terms of efficiencies for future workforce planning. It goes back to Dr. Kinsella's original point about dialysis nurses not only in that context, which is just changing technologies, but in terms of assessing efficiencies such as how many people are required to carry out a certain task and whether there can be changes because of technological advances, IT, changing work practices and inherent ability to get more efficiencies out of individuals and the system.
When we speak about skill sets, I have always noticed that when one meets groups of people to address the problems in our health service, while they come with the best of intentions, they also come as captives of their own profession. Dr. Kinsella said earlier that management, the Department of Health, the HSE and others, by and large, forecast honestly. I suppose they do forecast honestly but not all forecasts are correct so it is very hard to assess whether it was a forecast with the best of intentions or whether it was just a forecast with other intentions. How does one assess where health policy analysts vis-à-visthose who deliver health policy such as the Government, the Department of Health and possibly even the HSE may be steered because of political considerations? In respect of laying off staff and cuts in numbers, we were always told that it was able to deliver but it was quite evident that when one drilled down through it, it was not able to do that. Where can we independently ensure that workforce planning models are independent of the decision making of policy makers even though the model on the policy is being assessed? This is critically important. Could Dr. Kinsella address how we assess private health insurance vis-à-visrolling it into a public health model?
Dr. Stephen Kinsella:
I will do my best. Defining the structure in governance terms is very important. The correct structure evolves. These things must evolve. Data quality is variable everywhere. One of the ways one assesses data quality is by using this minimum data set requirement. There is an international standard. If only 9% of the nurses fill out a survey about what they do on a daily basis, perhaps the information in the survey is not that great. It is that kind of idea. There is a minimum data standard that is pretty good.
Sectoral issues abound. It turns out that we have pretty good data about the medical sub-specialities that are working. Examples would be cardio-thoracic surgeons. We know exactly how many of those we have in the system because one could probably count them on two hands. There is capacity in the system to do that.
Are we prepared for technical change? I would say that the answer is "No" right now. Quite simply, we only perceive technological change as an increase in the cost of delivering medicine. There is a lot of data on health inflation, which runs far in advance of the inflation rates for other goods. Some of that is as a result of drug pricing, etc., but some of it is simply as a result of the newest technical "whizz bang" thing that will deliver better care but cost a lot more.
How do we hold the forecasters to account? The answer is that it is legislatively backed so nobody can back out of it because it is enshrined in law that this is something that needs to be done as part of the budgeting cycle. If one does not do this, the political system is, for want of a better word, insulated from this. One can simply point to the legislation and say, "look, it is not us, it's those bad people who legislated for this in the past", who may also be us. The hue and cry about this may be less than one might think because there is a fair amount of data to back it up. When one has external experts saying that this is the best standard of care given in light of where one is - I am sounding awfully political because I know that another debate about this is taking place - and this is what it should be, people tend to go with that, generally speaking.
What is the best example of engagement? The regional fora in the Scottish example were really excellent. They had two people whose only job was to go around gathering this data. They were two principal officer-level people driving Scotland just hearing what people had to say so these two people amassed an enormous amount of soft knowledge and had amazing emotional intelligence. When I spoke to them, they really knew when somebody was on the level and when they were not so there was credibility there.
The ideal planning length is somewhere between three and five years. Seven years is too long. One forgets what it was. I would imagine that, for us, three years is probably where we want to be because we still have a single-year budgeting cycle. However, we have a system with over 100,000 people working in it and it is very difficult to turn that in under five years.
In respect of the 25% increase in terms of support staff management and administration, there could well be agency people in there. I do not know. They do not drill down into the data. I can check with the HSE and come back to Deputy O'Reilly.
Dr. Stephen Kinsella:
I do not know but I can check and get back to the Deputy.
There is an IT workforce deficit but there is a very large spend in the Department of Health on IT. In respect of the eHealth strategy and data analytics, there is a deputy secretary just for data analytics and research who is a very good and competent person. My hope is that one can ally this with those data gathering initiatives. What is the capacity if we turned it on? There are people who have produced workforce planning models in SOLAS.
Professor Eilis McGovern and her team in the HSE have done considerable work as well. A group in the Department of Health has done this work to a high standard for midwives and nurses. In terms of boots on the ground, the capacity to deliver the service exists, at least in skeleton form. We would need to buttress it by adding in more people. Another group that would be very useful is the Irish Government Economic and Evaluation Service, IGEES. Some of our best University of Limerick graduates are with that group now. These are really smart people and very numerate but, most important, they give us a direct connection back to the Department of Public Expenditure and Reform because that is where they were originally located.
Deputy Kelleher asked several questions, including one on the private versus public health system. This is the main reason I do not recommend either the Scottish or Welsh models. It is also why the governance structure should be managed between the Department of Health and the HSE. The Department can compel access to some of the data from the private systems whereas the HSE cannot.
Data issues abound. Assessing performance has to be done on qualitative and quantitative basis. If we set a target, then people will move to fulfil the target. If we do not have the qualitative elements along with other data, then all we get is people trying to hit targets. Some of the best performance models set the targets but do not tell anyone what they are. It is really interesting. They set they target and then tell those involved simply to try to do the best they can. They found that everyone exceeded the target. Behavioural economics suggests that if we give people a target, they work to it. There is a great example involving Boston firefighters. They brought in a rule to the effect that no one could be absent for more than 15 days per year. Then, the absenteeism rate exploded because people realised they could take 15 extra days. Staff who had not taken a day off in 20 years then took 15 sick days. Then, when they removed the cap the figure stayed at 15 days. We should be careful of the targets we set.
Can we assess efficiencies in workforce planning? We can, but it is typically done through the price system. People try to figure out how expensive it is to recruit 100 new consultants or 25 new phlebotomists and so forth. Typically, it is done through the price system. The Australians have a very good system but I would caution against introducing a similar system immediately. It comes back to work practices. If we were to ask every consultant and nurse what they do on an hourly basis, I do not think they would be able to give an answer. Producing the system to give us that answer would be enormously destructive in terms of the trust we want to build up with everyone. I would do that only as a last step, if at all.
Forecasting quality is absolutely vital. It turns out that we can figure out whether forecasts were of high quality. We relate the forecasted levels to the levels that actually materialised. Let us suppose we have six different anaesthetist groups and we are forecasting their levels. Then let us suppose three are bang on. We can measure that by the amount of latent demand. If we have three people with a fairly average waiting list and then two others over-claim and have no waiting list while three other people are waiting around not doing much or doing mostly private work instead, then we may have overshot here and undershot there. It is a rough balancing act over time and we can see that, especially with the qualitative element.
Is there a tension between these developments? There is, absolutely. There is a question of leaving it with the Department of Health and the HSE and then perhaps putting it with a body like the ESRI. There is a tension. In Australia they created an entirely new institute of workforce planning and had what was almost an ESRI body for workforce planning. Then after some years they ended up nationalising the organisation and bringing it in to the health service again. There are many different models to make it work. I am uncertain whether such a body should be independent of policy. I think we would want it to be fairly connected to the policy-making system. Otherwise, it ends up evolving into a fairly technocratic dry exercise where someone produces numerous charts and people say it is grand but there is no action. It needs to be close to the systems of power, including the committee.
I thank Dr. Kinsella for his presentation. I have some brief questions. Where are we in Ireland with regard to the data-gathering process? Are we at zero or are we somewhere along the line? Is the information Dr. Kinsella has presented to us part of his role? Has he been seconded from the University of Limerick to gather this information?
Have we any information regarding the relationship between the timescale of someone coming into an accident and emergency department and getting blood checked, X rays, ECGs, MRIs or whatever might be needed and effective treatment of that person? It seems to me that the gathering of data on that level is critical, and if we have a quick turnaround in getting what we need to diagnose a patient, then we will have a quick diagnosis and everyone benefits. Are there data on that?
I thank Dr. Kinsella for the talk and for the many interesting things to ponder. I have three questions. They relate to the issues of demographics, the question of current staffing levels and the increasing use of agency staff within the health service and hospitals in particular.
It would seem to me that one of the tasks posed here is to look at the big picture and the broad brush stroke before getting down to the detail. I am calling on Dr. Kinsella to comment. It would also seem to me - again, I am inviting comment on this - that there are two issues which point in the direction of significantly increased staffing levels in the context of putting forward a plan. The first is the issue of demographics. The map on the dependency ratio with the M2 F2 graph is quite dramatic. Dr. Kinsella referred to an increase of 12% to 15% over a period of ten years or so. One statistic relates to the numbers of our population over the age of 65 years. Currently, the figure is below 600,000 and about 585,000. That is set to rise within ten years to 850,000 or perhaps beyond to 860,000 or 870,000. There will likely be an increase of approximately 50% in that one group within society. There is another statistic on the prevalence of chronic disease. It is not entirely linked to the demographics, but it is not unrelated either. The figure is expected to rise by 4% or 5% per annum. That figure was produced by the Irish Nurses and Midwives Organisation. It strikes me as a very strong statistic.
I am also wondering how we factor in other things. For example, there are things that people may not be presenting for now but for which they will be presenting in five or ten years' time. Let us consider mental health and the question of depression. The culture is changing and it is becoming less of a stigma for a person to say that he is feeling bad and needs help, but there remain many people in society who would not present with depression or anxiety. They would rather try to power through and batter on. There is a better and more open attitude among the younger generation. I imagine that as the demographics shift, there may be an increase in mental health issues. I suspect there will be, but there may also be an increase in the number of people willing to present and say as much.
Considering those factors together, it strikes me, particularly on the issue of demographics, that it points to an increased need for health services and recruitment of professionals within the service.
The second issue is current staffing levels. The graph is interesting. It shows worker numbers in the health service to be down perhaps by about 7% on where they were in 2008. The graph is a somewhat optimistic one because it points upwards. However, I think it would show a plateau if it included the numbers for 2016, because there is this X and Y policy now, as enunciated by Tony O'Brien of the HSE, that one can only hire Y if X leaves. Therefore, while there was an increase in staffing numbers of more than 4,500 the year before last, I think last year there was a plateauing of the situation. For example, we are down more than 3,000 nurses on the 2009 figures, and there are quality of care issues such as the linking of bed closures to staff shortages and so on. Again, I am inviting comment, but to me these issues point also to the need for significant recruitment.
My final question concerns the issue of agency staff. Anecdotally, I am getting back from health service workers reports of a very significant increase in the number of staff being brought in from agencies. This applies perhaps particularly to nursing. I saw one figure which indicated that there is a budget this year of €226 million for agency staff and that half of the budget had been exhausted by the end of April. In other words, a third of the way into the year, half of the budget had been used. It also strikes me that if one is planning in a sound way, surely there is a very strong argument to base staffing fundamentally on the recruitment of full-time permanent posts rather than using agency staff, which seems to me the epitome of short-termism. One is considering not just quantity, but quality as well. Obviously, if someone is employed in a hospital, he or she works there and it is good for morale - there is an issue with demoralisation in the health service - and it will improve the quality of the work. Would Dr. Kinsella therefore agree that an over-reliance on agency staff is an indication of short-termism and that a more planned approach would base itself far more on the recruitment of permanent staff?
I thank Dr. Kinsella for his presentation. My first question concerns the way our system is structured in Ireland. We have the regional health organisations and, on a separate wing, mental health and social care. Is that kind of division between acute care and social and metal care reflected in any of the other models Dr. Kinsella considered? It seems to me, from my position on this committee, that if mental health has its own wing, that immediately stigmatises it. Is that division present in any other country?
Dr. Kinsella mentioned something about pensions in the health service accounting for 25%, I think, of overall pensions. Maybe we do not know the reason for this, but is it to do with salary levels or the fact that nurses within the HSE are forced to retire at 65 even if they do not want to? Is it because we force people into retirement early?
To follow on from Deputy Brassil's point about where we are now and whether we have done anything yet to fix things, does the same go for IT? Are we 50% of the way through the IT developments or are we just starting off?
We talk about workforce planning over a two-to-three-year period. That is great and must be done, and there is obviously time that one needs to spend planning things, but while that is being done, could a section of the health service be taken and sorted out in tandem with that so that we are not just coming up with another plan or report - so that we could actually achieve something? For example, everyone seems to agree that the national cancer strategy was a major achievement and everyone says it seems to work very well. My experience of it has been very positive. The national maternity strategy is ready to go. Maternity hospitals are separate from general medical hospitals. Could one theoretically carry out that strategy in tandem with a kind of overlook of the whole health service? Instead of this "Let's fix the health service" approach, could we set about planning for it over a number of years while fixing little sections of it as we go along?
Finally, doctors, pharmacists, physiotherapists and occupational therapists from Ireland have moved to other countries and there is a fair amount of skills transfer. As a nurse, one can go to Australia or whatever. Do we have any data on, or are there any optimum ratios of staff that we could take from other countries? Would it be possible to say that on average, internationally, for every ten consultants one needs 30 nurses, three pharmacists, two phlebotomists and five care assistants, or whatever? Is there some point at which we could start that we could use as a standard for what we might work towards?
Dr. Stephen Kinsella:
To answer Deputy Brassil's point about where we are in Ireland, in our readiness for workforce planning, my understanding is that the HSE has devised a scoring system on its readiness to produce these data. I myself have not seen the scores. I imagine that, on a score of one to ten, we are somewhere around five, in that we know how many doctors we have. We know because we have a payroll and we know how much we pay them. One can use such a system, but I sense that once one moves away from the two or three main categories, the quality of the data degrades pretty quickly. Deputy Brassil asked if I had been seconded to gather the data. No, I have not; I was asked to write this report for the Health Research Board. I am still teaching classes in UL. I am teaching one at three o'clock. I am tipping along and very happy there. I am very interested in this stuff. It is great.
Regarding timescale and treatment, patient flow data are absolutely vital. They come from a unique identifier system. One needs to have such a system and get over the data protection and privacy issues that surround it in order to gather that kind of patient data. If I bring my ten-year-old son into Nenagh Hospital tomorrow for a broken arm - touch wood - he will be seen and treated, but if I bring him in the next day to University Hospital Limerick, they will not know he has been in Nenagh Hospital unless I tell them. It is therefore a database issue, a big data issue and a very important issue in terms of quality and reliability of care. It is related to some of the efficiency issues about which Deputy Kelleher spoke. I gave a talk at University Hospital Limerick, the grand rounds lecture, at which I asked the doctors present, if I gave them the money to hire the people lost between 2008 and today, what they would do with it. I asked whether they would hire more nurses or more people like them. They said they would put all of the money, every single penny, into ICT systems. These are young doctors who are all vying for registrar positions and so on. To me, that was a really important issue. Deputy Brassil asked whether there are any data on that kind of treatment flow. The answer is yes, but they are case studies. Case studies are typically examples of excellent care, which is great, but one also needs the middling stuff and the bad stuff.
In response to Deputy Barry, that 50% increase is on a low-fertility assumption. The dependency ratio I think he was seeing was using the M1F3 measure, whereby the population explodes, which is reflected in the chart. I think I have seen the chart circulated recently. It is based on an assumption of very low fertility.
I have not seen the INMO stat, but I will check it out, and I thank the Deputy for telling me about it.
Regarding the mental health issue, I am glad to see that it is becoming more publicly acceptable to do this. People in my family have suffered from it, so that it is coming out more is great to see. Medicine and medical care comprise a derived-demand system. The more that people use it, the more it gets used. It is like a road, in that if one builds a new road, it will be full of cars. Do not get me wrong, as it is good that people present with these issues, but it entails a necessary increase in cost to the system. The best example of this is autism services. We are finally getting around to producing really good autism services in some parts of the country, which is producing a natural increase in Exchequer spend. Once autism is diagnosed, it obviously does not go away. The State has rightly made a commitment to the person and his or her family for the next 40, 50, 60 or 70 years. When these diagnoses are made, they do not tend to be associated with one-time spikes in expenditure, but with long-term increases. Nonetheless, it is the hallmark of a good and decent society that we do these things, so the State should do them. However, in a world of constrained resources, by definition this means that the money in question is not being spent on early childhood education, higher education, etc.
In general, there will be an increased need for staffing across almost all grades, but my sense is that this is not true at the fine grain or service level. I will give an example. If we decided that we wanted to route more services into the community care space, we would fund that area and not other areas, but we would route people to that area in order to decrease demand there. To do this, one needs a plan. One cannot just stop something and hope that it gets built up by the private sector or the like. That tends not to work. The private sector tends to take options that maximise its profits, as it should. There is an issue with that. I do not want to give a two-handed answer but, while worker levels would increase, they would not increase by the same amount everywhere. I only have anecdotal data on this.
No workforce planning model that I have seen plans for agency staff. Models plan for full-time or part-time staff on a full-time equivalent, FTE, basis. We are discussing worker equivalence, not agency staff. Agency staff are seen as a sticky plaster to solve the problem. My strong preference is for permanent and pensionable people in positions where they can do their best work. One does not get a professional system if one does not hire people for professional reasons and pay them appropriately. In fact, one overpays for agency staff.
May I ask Deputy O'Connell for clarification on the divisions issue? Does she mean funding or the actual locations of the systems, for example, mental health services in one place and coronary care somewhere else?
Dr. Stephen Kinsella:
Yes, it happens elsewhere. It happens in certain countries like the Netherlands, but other countries integrate them. Typically, it depends on how the system evolved. Essentially, our health system evolved from the Catholic church and a series of 19th century Victorian systems that were effectively designed as workhouses. Our hospitals are in certain places because of a decision that someone made in the 19th or, in some cases, 18th century. We have stuck with many of these systems because they have been there. Some of the governance arrangements are 19th century ones, which is bizarre. We are stuck with a large number of systems because that is how they were in the past. Our approach to mental health, for example, has been to ignore it for generations. This is why one is separate from the other in physical, funding and governance terms. I hope that our approach will change, but it depends on one's starting point. New Zealand does not do it in the same way and instead uses an integrated model of care. New Zealand is an interesting model of health care delivery. Not all of its staff are permanent and pensionable, but it is efficient and good value for money and everything is integrated in terms of funding and delivery. I do not want to give the Deputy an "it depends" answer, but it is where we came from.
Dr. Stephen Kinsella:
With our current population density, one would keep everything separate. With a population of 7 million to 8 million on the island in 30 years' time, which is what this committee should start planning for, Dublin will have 2 million or 2.5 million people, which is probably the population density per square mile of Los Angeles. Places like Limerick will have 300,000 or 400,000 people. It is a different proposition. There will be areas of the country where almost no one lives. Interestingly, it will be back to the same level that obtained before the Famine, when 8 million people lived on the island. In such a situation, one would plan to integrate services as the population grew and aged.
I will offer an example. The Deputy asked whether there was a section of the health service that we could do something about now. The answer is "Yes", and it is the national children's hospital. It is a big piece of capital infrastructure, but it is not there currently. We could plan for the workforce that will be involved. For example, we could place Child and Adolescent Mental Health Services, CAMHS, in there. As the system evolves, one builds things in. We could fix that. There is some talk of moving to the trust model for our large hospitals. As one moved to a trust, one could build in that workforce planning along with the legislative and financial backing.
Regarding ratios of staff in various countries, I have seen many studies. My sense is that this work would have to be done at the service level, which would mean contacting all of the major professional organisations and asking them what they believed best practice would look like if, for example, they delivered ophthalmic surgery. One must listen to the service users and service providers. If one does not, one ends up with a load of nerds producing spreadsheets. That sounds good to people like me, a nerd who produces spreadsheets, but does it help those who are on the ground delivering services? This was the feedback from all of our expert interviews. While we could generate a baseline, we would need to ask the experts first.
I thank Dr. Kinsella for his excellent presentation. Workforce planning entails a number of activities, but the main thrust is to have the right amount of people in the right place at the right time. The common refrain is that the HSE is top-heavy with management, in that there are too many chiefs and not enough Indians. Has this been borne out by Dr. Kinsella's studies?
Is there sufficient talent management within the HSE? Are high achievers being rewarded within the system or is promotion due to seniority still an issue? How do we address this or has Dr. Kinsella examples of how it was tackled in his other models?
I will be brief because many questions have been asked. I thank Dr. Kinsella. I wish to ask him about his studies. Our health service has moved from the Victorian type to matrons to the church, etc. Generally, everyone attended public hospitals, for example, accident and emergency departments.
Given that the national cancer strategy has worked well, should we start with that to find the information required for the national children's strategy, the national mental health strategy, the national disability strategy, the national cystic fibrosis strategy and so on and feed it into services that are provided through our public health services or otherwise?
Is this taking on board that we are looking at a single-tier health care service based on need rather than ability to pay? Reference was made to the population reaching eight million in so many years and those services coming together. The way the health service has developed in Ireland means there has never been direct information pulled, for example, from the national cancer treatment plan: what are the issues, what does one need, how does it get put through the system, how many patients are there, whether there will be more patients in the system over time, etc. Consider people who have cystic fibrosis or scoliosis and where their national treatment plan is going. It is done in Galway and at the children's hospital in Temple Street, among other places, but the issue is how to pull all that information together and how it can link in to make a more efficient service so health care can be provided based on need rather than ability to pay. It is about getting people into the public health service rather than letting them go private because they feel the public service is not there.
Dr. Kinsella mentioned that the health care sector included section 30 bodies, the voluntary sector and Tusla. What are Doctor Kinsella's feelings on that side of things? All of those bodies have their own individual management committees and it is probably difficult to get information from them. Perhaps the witness could indicate whether that is a big stumbling block in the area of workforce planning and if there is any way around that or any suggestions in that area?
I am going to try to read Dr. Kinsella's mind a wee bit. When he spoke about workforce planning in Wales and Scotland, Dr. Kinsella indicated that he liked it. However, he felt that it might not fit with the health service in Ireland and its mix between public and private. The question must be asked: is it the case that we make plans to suit the system or that we adjust the system to the plans? When one looks at the population issue with a broad brush stroke - for example, in 30 years' time there will be 2.5 million people in Dublin and eight million in the State, which equates to a population the size of Los Angeles - if we are going to plan this properly, do we need to move more in the direction of England and Wales with regard to a national health service and a centralisation of health services? Can the current system be properly planned for, given the types of changes we face?
I want to pick up on the question asked by Deputy O'Connell about ratios in terms of staff. Will Dr. Kinsella indicate whether there are objective best-practice ratios, issued by the World Health Organization or the OECD, with groups of countries comparable to Ireland, at least with regard to the number of cardiologists or speech therapists, for example? Should that be our starting point, if those objective ratios are set and adjusting for profile of population and so on?
Dr. Kinsella made reference to elements of good practice in respect of workforce planning for nurses, midwives and other categories of worker, but is he saying, fundamentally, that there is no overall workforce planning of consequence going on in Ireland? Are there no agencies or bodies taking responsibility in the round for health workforce planning? This is what I took from his comments.
Another question to which we would want to apply our minds very soon is the allocation of resources and what we know to be very wide variations in staff ratios on a geographic basis. Has Dr. Kinsella looked at that issue and, if he has, what are his findings on those variations?
Dr. Stephen Kinsella:
On the question of whether we are top-heavy with management within the HSE, my role was not to look at the HSE but to look at everybody else and come back. I am hesitant to criticise the HSE because everyone does. My sense is that if 25% of staff are doing management, administration and support it feels like a lot, but one has to look at where they began and where we are now. I am not trying to evade the Chairman's question but I would be much more interested in the question of what it would look like in ten years' time - would there still be a 25% ratio or would it be reduced to 15% by using better technology to do some of the work and what does that mean for those administrative staff? When one considers the ratio of management to administrative staff within the HSE versus comparator countries, the percentages do not look wildly out of kilter. However, those data have to be taken with a pinch of salt because there may be nurses who perform lots of administrative work and there may be support staff who do much of the front-line work, so we are not 100% sure.
With regard to talent management and rewards within the system, the public sector is, unfortunately, not replete with massive amounts of rewards within the system. I cannot imagine what a bonus culture would look like in universities, for example. I would love one, if the politicians want to do one - that would be great. I believe that our public sector and public structures are still within a very early-20th-century mode in which one gets a job for life, stays there and moves up in terms of seniority. I do not see any evidence that it is different in other parts of the system. My own experience is mostly within the higher education system, but I do not see any evidence that it is different.
Deputy Barry asked about work planned around the national strategies, such as the maternity and cancer strategies. That can be done, but if we do that we will not get around to the major ones for quite some time. I believe there are some 30 different clinical care pathways. If we worked on one plan at a time and each one took three years, that would be 90 years. Even this long-term committee does not quite hold to that. I believe that we need to do one overarching plan and maybe work on specific modules at the same time. It is important to have a workforce planning unit - that is, a group of 10 or 15 people whose sole purpose is to gather all the data. It should not be done separately by Solas, the HSE and the Department of Health. The group would gather the data and would fit it into the e-health strategy and all the rest of the system. In being enabled to do so, the group would build up a competence so it can determine, for example, a module on midwives. We saw this in Scotland, where a workforce planning module was prepared specifically for midwives. This has happened in other places also, where having people on the ground with the data means that further investigations can happen in a particular dimension, as policy makers require. For example, we know that diabetes levels are going to increase massively, so we may need more diabetes nurses - who knows? It will be a case of planning for that. We know it is going to get worse: the clinicians are telling us that we will have a problem into the future. Autism care requirements may increase. Care for people with different developmental disorders and those with mental health care requirements will increase. We will need to do a workforce plan for that. It would all be done in one place and it would not be aligned to a particular strategy whose work, when the strategy runs it course, might never feed back into anything else. That would be one of my ideas - one resource putting all the data together.
With regard to the section 30 queries by Deputy Daly, that is why one needs to have a governance structure at the level of the HSE.
Even the Department of Health finds it difficult to get data from some section 37 and 38 organisations. The Government will need to change the law in order to have them comply as efficiently as possible, as if they were fully public hospitals. Again, it is interesting; it comes back to our history in that voluntary care has typically been provided in the absence of the State providing it and so what one has is a half-way house whereby one has charities doing the State's work that are poorly regulated. People are set up to do a job, whose vocation in life is to help homeless people or people whose children are dying of cancer, for example, and one is saying to them that they must also fill out a risk register and the skill-sets are just not there.
I do not have the answer but a good question for me to pose to the committee is whether we have too many charities. That is a question this committee could answer. What are the consequences if the answer is "Yes"? If the answer is "Yes" then this committee must recommend that some of those charities get amalgamated, go away or become regulated out of existence. That is a big question. Do we have too many hospitals? That is another big question. Do we have too few? This is why we elect Deputies. They must answer those questions. I wish members good luck in answering them.
In terms of the information, the law must change. Some of the organisations are just private companies, effectively, with a board of management and the CEO is subsumed into the board and the board might decide it is not giving the information. The HSE has made lots of changes in order to get the information on a timely basis and it is starting to get to the nub of some of the issues, but I strongly suggest that with thousands of charities we have not seen the end of this.
A good question is whether we adjust the system we have or strategise for the system that we want. I strongly urge the second option. I would argue that one should set the strategy for the system one wants and one should build funding on a multi-annual basis in order to get there. The best example of that is the city of Copenhagen. It was decided to plan the city using the finger model and to develop in a certain direction along one finger for five years and then go back and develop another finger and then another one. The intention was to connect up the fingers using public transport. Anyone who has been there will know it is a very nice city. They did not plan for the city they had, they planned for the city they would have and then money was put in as it became available. When the money was not available no building took place, but over a 30-year period they produced a beautiful city. One could do the same with the health system. One would do it by simply sticking to a plan. That is why it is called strategic health workforce planning. It is strategic because the Government sets the strategy. It is interesting to see where the strategy is set but my hope is that it would be at Cabinet level and committee level.
In reply to the question of whether ratios should be our best starting point, the answer is "Yes" but what one will find is that the ratios are different by country depending on their institutional structure, so one must control for that and it is quite difficult to achieve. I have seen many of studies that tried to do this. Eventually, what they end up doing is focusing on doctors, nurses and physiotherapist and then they give up because it is very difficult to get comparable data. Reference was made earlier, for example, to nurses and nurses aides but they do not have those comparable distinctions in other countries which means one cannot compare them directly and it becomes a little difficult. That said, we could do that as our starting point. To my knowledge it has not been done but I am open to correction. It could be done as part of the work of the committee. I imagine the HSE would be the first ones to do it.
In terms of allocation of resources and staff ratios, one should follow the other. The question is what is the appropriate staff ratio. There must be dialogue with the people who do the service. If one does not, one will impose a system where there are too many doctors and not enough nurses or one will forget something. I believe in listening to the people who do the work. That is probably the best way to do it, and that is informed by best practice.
I thank Dr. Kinsella, it has been a really worthwhile session. He has been very generous with his time. I speak for everybody in saying that we very much appreciate the fact that he picked up on all of the questions asked and provided very direct answers, which is not always the case at committees. We know he is under time pressure as he must be in Limerick for 3 p.m. We appreciate Dr. Kinsella's attendance.
I suggest that we take a ten minute break. People might like to get coffee or whatever else. Witnesses from the HSE dealing with ICT are outside and are ready to come in. Members should be back here in ten minutes.