Mr. George MacGinnis:

All we are saying is that the average length of stay in hospitals appears to be higher in Ireland than we would have seen in some other systems for similar procedures. That means that the number of beds used for the same sorts of issues is higher than in other systems. I was trying to understand why that is. It is not because people in Ireland are physiologically different from people in other countries. It is to do with the way the system works. I will answer Deputy O'Connell's question while addressing Senator Colm Burke's and give some examples. Some of this is about the integration of the system and the issues of engagement between hospitals and GPs and between GPs and practice nurses and so on. We have looked at other systems. I have worked in other systems, and not just the system of the country from which my accent comes.

In terms of returning people to the community out of hospital, in the US there was a behaviour at a system level to reduce the average length of stay continually, which resulted in people getting out of hospital too quickly. Penalty tariffs were introduced. In effect, the insurers would no longer pay for a readmission that happened after 30 days. This had a significant impact in the US. In England a similar tariff was introduced. It has not had the same dramatic effect as it had in the US for other reasons, but there was a behavioural driver linked to resource which indicated that if work was given to be done in the community, resources were needed to do that work. It is not a question of whether people are discharged early. In the example the Senator gave of someone needing a call, that is extra work for someone's workload. What is that person's caseload? Can he or she do that? Is the resource following the patient? This is what we mean when we talk about population health. We mean that when rational decisions are made which say that care is better delivered in community settings, it is not just a matter of getting everyone out of hospital. The community providers have to be resourced. We have to recognise that. Another really good example from the UK was discharge summaries. The community teams there were unable to do their job because they were not being informed by the hospitals in time. Again, a system was introduced to get people out. I think similar initiatives are being worked on in Ireland which will enable hospitals to get discharge summaries out to GPs as effectively.

This sort of integrated care involves quite difficult clinical governance issues. I did some work in Scotland where the system has quite a different structure from that of England. I was working in a surprisingly remote area. I will not name it, but it had the equivalent of a model 3 hospital and several model 2 equivalent hospitals. GPs had admitting rights to the model 2 hospitals. It was found that people from remote rural communities were being sent to the model 3 hospital, often for diagnostic tests, and were being admitted to older wards and being held on to. Why was this happening? It was because the consultants in the hospitals did not think that the GPs would have the time or the facilities to look after the patients at risk properly. They started to work on a different model of clinical governance whereby people could be stepped down into the model 2 equivalent hospitals while still under the consultant and in which there was an information system that allowed the consultant to keep an eye on the patient. It was particularly used for cases of sepsis. The sepsis teams were still able to give that service to the model 2 hospitals and the model 2 hospitals were a safe and effective place for patients to be. Evidence was coming out that people who were returned to that type of model 2 hospital, which had community rooms and so on, actually returned home faster than if they had been recuperating in a ward in the model 3 fully acute hospital. The hospitals worked on that model. That is an example of how it is not just about providing the capacity or giving some good policy. There is a lot of clinical governance and detailed work involved and the way that resources move around the system needs to work for this to work effectively in Ireland.