Mr. John Connaghan:

I will make some comments as someone who has recently joined the Irish health system from a different jurisdiction who has the benefit of being able to compare and contrast in some respects. In common with most modern health economies, the Irish system has witnessed significant changes in bed use over the past ten years, characterised by a significant drop in length of stay for medical beds. In recent years, that process improvement has begun to stand still. In fact, we have flatlined over the past couple of years. That points to a system where some of the process improvements we could make have begun to bottom out.

That is an important point in comparing the relative efficiency regarding the use of our resources, as Deputy Durkan pointed out.

The increasing elderly population is also an important factor. Over the course of 2017, we have seen an increase in admissions of people over 75 of approximately 5.7%.That drives a longer length of stay. Patients tend to be sicker and elderly patients tend to have increased comorbidity of a number of conditions, which means that the stay in hospital is more complex. That makes discharge more difficult. This is another material factor in considering where we stand regarding trolley waits.

One of the issues that strikes me about the Irish health care system is that our ability to discharge effectively and efficiently in the evenings and at weekends is hampered by our ability to have diagnostics readily available. That is a simple fact in terms of the number of consultants and support staff that are available to man operate facilities on a 24-7 basis. We need to consider what we can to do alleviate this as part of any consideration of expansion. We cannot simply expand bed capacity without considering what needs to wrap around that to make the expansion more effective.

There are things we can still do in terms of pursuing process efficiencies. This links in to value improvement. There are a number of elements we need to consider that are perhaps not entirely in balance, such as the number of acute assessment beds we have, the number of beds in the system, and where we are in terms of community resources. When we consider the differences in performance between Limerick and Beaumont, for example, which have been mentioned already, we can do some very simple maths. What is the population we need to serve? What is the expected rate of admissions and discharges and how does that lead to our bed base? We can readily see that some parts of the system are more stressed than others. We need to consider where we would ideally like to have beds in the longer term versus what is opportunistic and what we can invest in the short term.

We also have what I would call failure demand in the system, which is another reason that drives matters regarding people on trolleys. Failure demand is where we cancel electives for a considerable period, which is what we do in extremisduring the first part of January, and where they then reappear in the system as emergencies. We need to avoid driving failure demand. The long-term plan in Sláintecare to separate elective and emergency care is perhaps something we really need to pursue quite quickly. It would also allow us to enhance what we are doing in terms of efficiency and effectiveness regarding elective care.

I will pause there and can say a word or two about the value improvement programme if the Vice Chairman wishes.