Mr. Liam Woods:

I will take Deputy Kelleher's questions first and I may ask colleagues to take one or two. He made an observation on senior decision-makers and asked where we are with having them available between 8 p.m. and 8 a.m. An 8 p.m. to 8 a.m. service for diagnostics is substantively in place. It came into place as part of the negotiations on the Lansdowne Road agreement. In terms of senior clinical decision-makers, there are a couple of issues. The Deputy asked what the driving factors were. The availability and total number of senior decision-makers are challenges for us, as I am sure the Deputy is aware, when one reviews the OECD data. That varies by site. I was in Cork University Hospital not so far back and I saw the senior decision-makers come down at about 10.30 p.m. from theatre to support the emergency department. We have a strong commitment from our clinical groupings and directors within hospital groups and on hospital sites. They are constantly working to ensure that clinical decision-making is available to provide for effective flow. Clearly, that is our significant concern. We have challenges in that which are primarily about capacity. Some facilities may have one to two emergency department physicians and that does not provide for round-the-clock service. I have not personally experienced anything in contractual terms around that. The Deputy referenced contract. The main challenge we face is that there are many and competing demands on the delivery of services with a fixed number of clinicians on site.

The Deputy is absolutely right to say the support of older persons in the community is key. It is the kind of work that has gone on in Gurranabraher, St. Mary's and in the St. Francis unit reaching into communities to support more people at home and expanding the already in place outpatient antibiotic treatment process to ensure people from nursing homes do not need to come into an acute environment, which is critical. We do some of that but could do more. I ask Dr. Henry to make one or two comments on that as a geriatrician himself.