Dr. Diarmuid O'Shea:

The questions clearly illustrate the depth of understanding this committee has about the challenges we have ahead and how we are going about addressing them.

In general, clear direction in terms of models of care, guidance and pathways are important elements in delivering change. Using the older person programme as an example, people have a good understanding of what needs to be done and the demographic changes occurring. There is a need for support both politically and financially for the implementation of the models of care we have in the older person programme. It is no accident that the first step in the ten-step framework in the programme is establishing local governance groups. I have had the privilege of travelling around the country with Dr. Siobhán Kennelly, our co-lead, looking at all of the integrated care sites, hospital sites, the community sites, the integrated care programme and frailty education programme. I see the enthusiasm, drive and desire of people at the coalface to deliver this integrated care. The governance group gives a unity between the CHO and the hospitals to pull that together.

If we use the knowledge and experience gained from the pilot integrated care sites, of which there are 12, and the frailty education programme sites, this will empower people with knowledge and understanding to effect change from the ground up.

We need leadership and direction from the HSE and the colleges in respect of the clinical programmes and unifying people. From a public health message point of view and from a multidisciplinary and professional perspective, education is one of the key enablers in all of this. It is important, it is not threatening and everybody is willing to sit around a table and talk about those things. It has a wonderful way of breaking down barriers between different groups. Having pilot sites and other sites across the country develops new ways of working within teams and groups. That helps improve flow throughout the system, which is one of the challenges for us all.

We hear regularly about trolley numbers. They always a concern and a worry. When I go down into the emergency department on a post-call round, it is devastating to find that a person has been there for longer than he or she should be. However, it is not actually an emergency department issue. It is an issue around getting good control of community services, good access to community care and good programmes around the country. Deputies have mentioned some such programmes in terms of good input to outreach programmes and co-operation and co-ordination with general practitioners.

Older people are big users of health care. If someone over 80 or 85 attends hospital, he or she has a 50% chance of requiring admission. It is not that they do not need the admission; they do need it. What we need is co-ordinated pathways of care that get older people through their acute illness quickly and get them out of hospital, back home or back to the nursing home quickly. Professor Collins mentioned the success of the stroke unit. We know about the success of the cancer care programme and how well people do in coronary care units. The same is true of older people in specialist wards. They are more likely to go home and to do so more quickly. They are less likely to need to go into a nursing home. We have a lot of initiatives in this regard; there are a couple in Kilkenny and some happening in County Cork, in Deputy Murphy O'Mahony's area, where we are demonstrating that taking a targeted approach to patients leads them to spend less time in hospital. If exposed to interdisciplinary service and the allied health professional team early in the course of an illness, a person is less likely to functionally decline and more likely to go home more quickly.

Senator Colm Burke asked about the need for change and the drivers relating to that. It is a question of having clear plans and models of care from the HSE and from the programme. After that it is the ground-swell of people working together to provide that care. That leads on to the Senator's second point, which is the staffing question. There is a lot of work being done around workforce planning. We talk about the importance of new ways of working. Through both the HSE and the national doctoral training programme in the Royal College of Physicians, in 2014 there was a clear look at workforce planning. However, the workforce has changed and so has that sort of medical workforce planning. Work practice has even changed in the past two or three years for me as a consultant. My clinical job today is different from what it was three or four years ago.

We recently saw the Department of Health create 120 new advanced nurse practitioner roles. They are not new in the sense that we have had advanced nurse practitioners in stroke care for a number of years. While we have had an advanced nurse practitioner dimension, these posts are clinical advanced nurse practitioners. In the first tranche, 43 of them were appointed in older persons care. They are going to become an incredibly important group over the next number of years as they evolve, providing co-ordinated care and crossing the boundaries between hospital and community.

Our challenge in staffing is comparable to capacity. I certainly welcome the Sláintecare report, which we will talk about later in response to some of the other questions. It clearly identified issues around capacity, funding and more integrated work practices. All of the models we are talking about very much fit with that. Going back to the 1980s and 1990s, bed capacity was taken out at that time. According to OECD figures, for 2015 we had 3.3 beds per 1,000 of the population. The figure is approximately 4.5 beds in other countries. We are not just investing for the now but are playing catch-up from underinvestment in the past. When money goes into the services now, we do not see the added value from all of it because it is playing catch-up. That is a problem for us. I welcome much of the Sláintecare report. I welcome the focus on the fact that, while capacity expansion is needed, there is also a consequent need to employ additional health care professionals to provide for those beds. I welcome that it clearly states that there will need to be a €2.8 billion increase in funding by the end of the ten-year programme.

Although there are big challenges for us, I am proud when I look at the group of people who are working together, directed from the HSE's clinical strategy and programmes division, and when I see how the different clinical programmes are evolving. Of most critical importance, however, are those on the front line and how they are providing care. We only need to think back to last week and the efforts that health care workers made to keep things on the road both from a transport point of view, getting people in and out of work, and people being at work and staying there, to understand how committed people are to the work we are doing, in spite of the challenges.

Senator Colm Burke asked a specific question about two consultants, virtual clinics and staffing. Professor McDonald might be better positioned to respond to that.