Mr. Tim Daly:

On the cost-benefit analysis side, I cannot speak for what the HSE has used, but I can offer a view on the common factors we generally see health systems considering when they are involved in service change. Such changes can range from very centralised surgery services down to more localised services such as the ones we have been involved in which have included the use of telecare or telehealth locally to help shift out care and different ways in which paramedics and ambulances can contribute to the system. I would highlight six factors which generally come up. The first is about quality. Underneath that there are the clinical outcomes, the patient experience and patient safety. What impact will a given change, be it a service change or a policy, procedural or regulatory change, have? The second factor is access. In the questions the committee has raised, we have spoken about what a change means for remote communities. Some services need to be very local, others need clinical volumes to get good outcomes. Another factor is the workforce. We have discussed that. Part of that workforce factor is the education and training requirements. The junior doctors, trainee nurses and allied health professionals need to see the right amount of patients in order to train. The productivity of a training establishment will be different and a system needs to reflect that.

The fifth factor relates to the financial side and the net present value. However, that is, as the committee can see, one of six factors. The final factor is deliverability. We have spoken about the next steps and feasibility. Whether it is a massive building programme or a big requirement to train up and create a workforce, how it will be delivered must be considered. That is just at a national level but it is equally applicable at a local level if a GP-led health centre or a more local hospital is being set up. It must be considered whether it can be practically delivered in terms of infrastructure, IT, estate, timing and such things. Those are the six factors that repeatedly come up. Then there will always be, depending on the level at which it is being done, particular local issues. There may be a particular issue around health inequalities in a particular area which needs to be addressed. This would mean that provision in that area would be designed slightly differently. That would be our general view of the cost-benefit analysis but, as I have said, we cannot speak to exactly what the HSE would use.