Mr. George MacGinnis:

Deputy Kelly asked about reform options, community health organisations and hospital groups. We have modelled capacity to say what is required at CHO level and at hospital group level. When one does a strategic capacity assessment, some of the specifics are going to get in the way and current performance is related to specifics to some extent. The international direction of travel is towards population health management, which requires accountable care in the US, for example, and generally requires that, in planning delivery of services, one has a comprehensive view of the hospital, community and social care services which the population will receive so that one can make outcome-based decisions to put resources into different places, so that one gets the effect one wants. A misalignment of populations has been clear in England recently. Most of the rest of the UK has population health boundaries but England went away from this and, in the past two years, it has been struggling to realign the governance of the system so that hospitals, primary care and mental health organisations start talking about common populations. We believe the same challenge will emerge in Ireland.

When we worked with the national clinical programmes in Tallaght, one of the issues we saw was the number of different organisations involved in discharges from the hospital, the number of different procedures for discharging and the number of discharge co-ordinators with whom the hospital had to work. The more fragmented and complex the picture is, the more difficult it is for the system to achieve the level of patient care and the patient experience to which we aspire. We have modelled capacity needs and there are implications, particularly in the third scenario, for how hospital groups work together and with their catchment areas, community health organisations etc.

We are not specifically modelling a scenario to reshape the CHOs so that they are all lined up as there are complex issues in doing that. However, in getting systems to work together, there is a legal structure. We need to ask if people are able to work together and can flex budgets. Hearts and minds will be a factor and we need to ask if people will accept it if things go in different directions. Certain specialties are delivered in some places and not in others and we have to ask if people will accept such changes in authority in the groups involved. We agree with the Sláintecare report that an alignment is, in principle, a good thing and other systems are, indeed, heading back in that direction.

We were asked about challenges we may not have foreseen in the area of future capacity. We have to model what is sensible to model. We have looked at challenges in what we call "non-demographic growth", which is a technical phrase for things that happen that do not involve people getting bigger and older. For example, we looked at the trend in day cases and we found that it was a trend that would probably stop, rather than carry on.

There were factors associated with bed blocking, among other issues, which meant that hospitals were performing day cases as an alternative to some of the other surgeries they would probably have preferred to be doing at that time. We have changed some of those trends. We can pick up some of the non-demographic growth. One would anticipate that, over time, medical technology will change, but I do not believe that it will change in a completely transformational way in the next ten to 15 years time. There will be more personalised medicine on a relatively small scale which might have some implications for capacity at a very detailed level. There may be a number of gene and cell therapy clean rooms, some wards, and things like that. However, at this stage I do not believe, in terms of the level of detail we have provided and the parameters we have provided, that it is sensible to add in any other factor to do that. That is a sensible basis for planning.