Dr. Tony Holohan:

I will reply to some of the questions. In response to Deputy Murphy O'Mahony's first question on why we are excluding the private, we see what we are describing here as ultimately a full set of licences that will apply to public and private. The step we are proposing along the way, as part of the proposed patient safety Bill recently approved by Government, is to pull out the patient safety parts of what was the health information and patient safety legislation which was considered by this committee. The committee made substantive observations about the non-patient safety parts of that legislation and recommended it be broken into separate components. That is happening now and the patient safety legislation is moving forward under its own steam and will move faster as a consequence.

One part of that will be to extend HIQA's existing powers. That is fully recognising the point made earlier by the chief executive officer, that we know those powers are not adequate. It is a stepping stone to take us some way towards being able to address issues that currently arise but we are not at all saying we are satisfied that it is enough. Licensing ultimately will be the full set. It will take time to get to a point where that legislation is enacted, where the regulations are in place, where the system is prepared in the way that Ms Dunnion described, for that to be fully operational. Our proposal is that we extend of HIQA's existing powers, even though we know that is not the full ideal. One example, which the committee may recall because it considered it, is the case of the defective breast implants some years ago. A group of women dealt with completely in the private hospital system found themselves unable to seek any form of engagement or redress. This brought home the extent to which the public is vulnerable in that situation and the limited powers we have other than to simply appeal, as we did, to reasonable people, who turned out not to be reasonable, and to the providers of those services asking them to respond to, and fulfil their duty of care to, those women they had brought into their services. People were harmed and exposed as a consequence. The extension of HIQA's existing powers, although not ideal, will allow us to address some of those kinds of issues. Cosmetic surgery comes up from time to time as an issue when people seek services outside the public system without protection.

The Deputy also asked a broad question about patient safety. Without giving a full treatise, it is important to point out that everything we do in patient safety is not just a question of regulation. There are other systems of regulation. The professions in most of the major healthcare providers, such as the Medical Council or the Nursing and Midwifery Board, are either currently regulated or new professions being brought into the Health and Social Care Professionals Council, CORU, and we are continually extending the powers and modernising those frameworks. A great deal of work has been done on audit and clinical guidelines. We have established that the national level of capacity for the Minister to approve national clinical guidelines on major issues and many of the recommendations coming out of important reports such as the Halappanavar report, the material we prepared on the Midland Regional Hospital Portlaoise and further recommendations arising from previous HIQA reports, have led to major national clinical guidelines being developed with the aim, or in the interest, of creating a common standard. One example is the idea of an early warning score to allow patients be monitored in a hospital environment so that those who are deteriorating can be picked up. The international evidence is very clear that this can have an important impact on in-hospital mortality. We now have that national standard in this country. Through these means we are giving ourselves a stronger mandate to be able to support and assure the implementation of those standards because, even though we have mandated that standard, I could not sit here, hand on heart, and say this is being fully implemented and in the best way possible in every clinical situation in which it should be. Giving ourselves the means of being able to see and assess that is part of what this legislation aims to do.

We have increased the range of reporting and referred to the patient experience survey. There is a range of other matters such as reporting of serious reportable events, which now forms part of the monthly public relations reports of the HSE. We will in time make all of that mandatory as part of our mandatory disclosure. There is already an administrative system providing those reports in public and we have mentioned our national healthcare quality reporting system. These all involve increasing the level of reporting and transparency. It is not easy for the healthcare system to put itself in a situation where it puts more and more of this kind of information out into the public domain because, of course, it creates questions. It is a necessary part we believe of engaging with the good and the not so good in the delivery of healthcare and not putting our heads in the sand. The first step in improving patient safety, as in most other aspects of life, is acknowledgement and acceptance of the scale of the problem we have in the first instance. Every country that has been trying to do this has had this experience. Much has been said, and we have had an opportunity to talk to this committee on many occasions, about open disclosure and we can talk more about that. We have a national open disclosure policy and we are supporting that with legislation to create the safe space and mandatory reporting of serious reportable events.

That has been done because, as I have stated, the only thing in which we are interested from a health system point of view is full, proper and well structured open disclosure in respect of every clinical incident. Patients simply must know, and that has been our policy position all along.

Patient involvement is another key element. We have increasingly involved patients in the development of policy, the oversight of its implementation and a range of other measures. Without boring the committee with all the details, I will cite some examples. There was direct patient involvement in the development of the cancer and maternity strategies. The patient experience survey is an example of that. Two patients were directly involved in the committee overseeing work done in the recent past following an escalation from HIQA in regard to the national management by the HSE of serious infection by carbapenemase producing enterobacteriaceae, CPE, which are a type of superbug. It is not always easier to have patients in the room when those decisions are being made but it is better and it works. I offer those examples as a flavour of our efforts in this area. We do not say that all our eggs are in the basket of regulation or the basket of licensing but it is an important additional strengthening of our implementation and oversight.

On the question of whether all activities will be licensed, the idea is that, without ruling anything out in the future, what everybody would understand to be hospital-type activities will be licensed. Activities that do not take place within hospitals but are the kind of things that one would expect hospitals to undertake will be the subject of requirements for licensing. That is why I mention things such as general anaesthesia. If a person gets a general anaesthetic in a non-hospital environment, the fact that they are having a general anaesthetic generates------