Mr. George MacGinnis:

I will give an introduction to the nursing problem. We talk in the report about the immediate injection of the capacity needed to get occupancy levels down to an acceptable norm. We make the point that, although we have quantified it in bed terms, in practical terms the measures that need to be used are very similar to those with which members will be familiar from the winter pressure planning process. A combination of things are needed to improve patient flow. In other industries that would be called productivity. There is a need to look at blockages in the system. That is why it was particularly important to look at capacity outside, as well as inside, hospitals. I know from my experience of working in the system here that this is a key driver of extended lengths of stay, particularly among older people. There are also internal measures that can be taken. When we worked with the national clinical programmes in Tallaght, we could see that there was significant potential for improvements in patient flow within the main wards in the hospital, even in the emergency department and the acute medical units on the acute floor. Patients were being admitted who would not necessarily have needed to be admitted if the right tests and the right things had been done on time. It is possible for people to be given morning-after appointments in order that they do not have to wait overnight in the emergency department in circumstances in which they are not going to be seen. Comprehensive geriatric assessments can be made in order that patients who need to be admitted can be moved on quickly and effectively from the acute medical assessment unit. There are many productivity improvements that could be made.

Questions were asked about the staffing of hospitals and workforce reforms. We did not make a comprehensive workforce assessment. The review has significant workforce implications for capacity within hospitals and other areas. As Mr. Daly has alluded to, workforce reform should be on the cards when the scale of things is examined, but it is not something we have looked at specifically. It is really a matter for the professions to get together and agree what the suitable roles are. I have mentioned the work we are doing with the national clinical programmes in Tallaght. One of the simple measures on which we worked with them involved doctors being able to delegate to nurses the authority to discharge patients at the weekend. We worked with them on a paper form to authorise nurses to get on with discharging patients whose test results had come back with certain acceptable results without having to wait for the next ward round. The presence of advanced nurse practitioners is another example of the measures being introduced. Such personnel can engage in all sorts of duty, including prescribing. Consideration could also be given to workforce reform for care assistants in other areas. The scale we have set out means that there is no silver bullet. The comprehensive package of reforms we are discussing is akin to some of the reforms that were on the cards previously, as clearly outlined in the Oireachtas Sláintecare report last year. We expect it to come through.

I want to make sure I have answered the question about the changing role of nurses. I think I wrapped it up in my response to the two other questions. In summary, this is a big reform package. It is not just about providing capacity anywhere. As Mr. Daly said, if capacity is the only thing that is introduced, it will be used in the same old way - it will block up in same old way and we will get the same old results.