Seán Crowe (Dublin South West, Sinn Fein)
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Apologies have been received from Deputy Gino Kenny who will be substituted by Deputy Richard Boyd Barrett. Apologies have also been received from Senator Frances Black. We will deal with one housekeeping matter before I introduce the witnesses. Draft copies of the minutes of the private meeting on 2 March 2022 and the public meetings of 1 and 2 March 2022 have been circulated to members. Are the minutes agreed? Agreed.

Today, the committee will meet with representatives from SIPTU, Fórsa, the Irish Medical Organisation, IMO, and the Irish Nurses and Midwives Organisation, INMO, regarding the ongoing and persistent overcrowding crisis in hospitals. I welcome from SIPTU, Mr. John McCamley, sector organiser, Mr. Ted Kenny, sector organiser, Mr. Greg Lyons, ambulance sector president, who is appearing virtually, and Mr. Peter Ray, chairperson of the Irish Ambulance Representative Council, IARC; from the INMO, Ms Phil Ní Sheaghdha, general secretary, who is hopefully on the line, and Ms Karen McGowan, president; from Fórsa, Ms Catherine Keogh, assistant general secretary, and Ms Chris Cully, assistant general secretary; and from the IMO, Dr. Mick Molloy, IMO consultant committee and consultant in emergency medicine, and Ms Vanessa Hetherington, assistant director, policy and international affairs. They are all very welcome to this meeting.

All witnesses are again reminded of the long-standing parliamentary practice that they should not criticise or make charges against any person or entity by name or in such a way as to make him, her or it identifiable or otherwise engage in speech that might be regarded as damaging to the good name of the person or entity. Therefore, if their statements are potentially defamatory in relation to an identifiable person or entity, they will be directed to discontinue their remarks. It is imperative that they comply with any such direction.

I call Ms Hetherington to make her opening remarks.

Ms Vanessa Hetherington:

The IMO thanks the committee for the invitation to discuss the ongoing and persistent overcrowding crisis in hospitals.

Hospital overcrowding, however, is not a new phenomenon and nor are the solutions. Quite simply, the persistent overcrowding crisis in our hospitals, like our record hospital waiting lists, are the direct results of an equally persistent failure, by successive Governments, to invest in bed capacity, infrastructure and medical workforce to meet the needs of a growing and ageing population, a fact which the IMO has reiterated consistently to our politicians. When the Taoiseach was Minister for Health more than 20 years ago the bed capacity need was identified at 5,000 more inpatient beds than we currently have. Since that time there has been little positive growth in capacity yet our population has grown by more than a million and we are now at a point of frightening waiting lists, inability to deliver timely care and too few doctors in the system.

Ireland has a growing and ageing population. During the past ten years the population of those over the age of 65 has grown by 35% and is set to grow by a further 35% in the next decade. While the majority of older people are living longer and healthier lives, an ageing population combined with increased rates of chronic disease and complexity of illness all place additional demands on the system. OECD data show that in 2019 Ireland had 2.9 beds per 1,000 population compared with an OECD average of 4.4, and we were ranked among those countries that had highest occupancy rates at 90%, a figure well above internationally recognised safe occupancy rates of 85% for inpatient care. The HSE is also suffering from a major medical workforce crisis. One fifth of consultant posts are vacant or filled on a temporary locum basis while we require up to 2,000 additional consultants in the next five years to meet the needs of our growing population. We continue to rely on non-consultant hospital doctors, NCHDs, in both training and non-training posts to fill service requirements, and for whom illegal and unsafe working hours are the norm. Last month we saw an unprecedented number of patients boarding on hospital trolleys in our emergency departments, EDs, and wards while our waiting lists for outpatient appointments, diagnostics and elective care are quickly approaching the 1 million mark. The emergency medicine programme set out a target that 95% of patients should be either admitted or discharged within six hours of arriving at an ED. However, the target is currently achieved for only about 60% of all patients and for 30% of those requiring admission to a bed.

The consequences of overcrowding at these levels are dangerous for both patients and those trying to deliver care in an under-resourced environment. Numerous Irish and international studies show that ED overcrowding is associated with increased mortality - within 30 days - and poorer outcomes for patients, whether admitted to or discharged from an overcrowded ED. Studies have also shown that ED overcrowding is associated with delays to receiving pain relief, medication errors as well as greater hospital lengths of stay and the consequent risk of hospital acquired infection. Delays in diagnostics, outpatient appointments and elective care can lead to poorer outcomes with patients presenting at a much more advanced stage of illness. Overcrowding also impacts on staff with doctors across the health service experiencing high levels of stress and burnout.

Covid-19 exposed the fragility of our health services but it did not cause it. The absence of any surge capacity within our health system meant that non-urgent care was cancelled while staff absences, combined with requirements for infection control, reduced capacity even further. It is important to note the policy of cancelling elective care was in place before Covid-19, as the HSE’s full capacity protocol has been in operation in many hospitals on a 24-7 basis. After the initial wave of Covid-19, the IMO met the Oireachtas Covid-19 committee on a number of occasions and proposed to Government a range of measures to address the deficits in our health services but despite two years of the pandemic little action has yet been taken. Urgent and simultaneous investment is needed in a range measures to ensure a robust and resilient heath system into the future. These measures are as follows. We need urgent investment in acute bed capacity and infrastructure, including immediate investment in temporary modular builds. We need to develop, finance and implement a multi-annual capital investment programme in acute bed capacity to include a minimum of 5,000 additional public acute beds. We need investment in stand-alone public hospitals for elective care and to increase critical care capacity to 550 critical care beds. The minimum requirements of 2,600 beds in the Health Service Capacity Review 2018 were never and will never be enough and were based on a significant expansion of capacity in general practice, community care and long-term care for the elderly, all of which has yet to happen. We must appropriately resource diagnostic, radiology and laboratory departments to allow timely access to investigations for both hospital doctors and GPs in the community. We need to invest in secure systems of electronic health records across health systems and community health centres. Systems must be able to communicate and allow embedding of national summary patient records as per the 2019 GP agreement.

Immediate action must be taken to recruit and retain doctors to work in the health service, including targeted measures to address our unprecedented number of consultant vacancies. These include the immediate reversal of the two-tier pay system for consultants and the negotiation of a new fit-for-purpose contract to attract consultants to a career in the HSE. Successive reports and studies have demonstrated that the two-tier consultant pay issue is a major barrier to recruitment. We need to increase the number of specialist training posts to meet future medical workforce requirements. A 38% increase in training posts is required to meet future medical workforce requirements but there is no plan to implement this. We need ongoing investment in the health and social care needs of older people. That means further resourcing of rehabilitative beds, long-term community care beds and home care supports, including intensive home care packages to ensure older people do not remain in hospital longer than necessary. We must continue to invest in the development of general practice including supports for new and established GPs to employ additional GPs, practice nurses and other support staff. We need investment in a programme of GP care for nursing home patients that reflects the complexity of care required. Through ongoing investment in structured chronic disease programmes, general practice can help to reduce future pressure on hospital systems. However, general practice is not without its own capacity constraints with estimates suggesting that between 1,260 and 1,660 GPs will be required by 2028.

Unfortunately, there is no quick fix to hospital overcrowding; without concerted investment across our health system, we will likely be discussing hospital overcrowding crisis for many years to come. This is no longer a crisis; hospital overcrowding, long waiting lists and long ED times have become the norm and they are dangerous not only for patients but for staff.

Seán Crowe (Dublin South West, Sinn Fein)
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I call Ms Ní Sheaghdha from the Irish Nurses and Midwives Organisation, INMO, to make her opening remarks. Good morning, Ms Ní Sheaghdha.

Ms Phil Ní Sheaghdha:

Good morning, Chairman, and many thanks for facilitating the remote link in. I thank the Chairman and members for accepting our request to appear before them and organising this meeting this morning. We set out in our written submission the issues that, unfortunately, remain a feature of the acute hospital overcrowding, which is not only occurring in emergency departments but throughout the hospitals. We now have wards that are overcrowded, which is not a new feature and that continues to be the case. As the committee heard, the issues facing nurses, doctors and other workers in acute hospitals are now such that they were described at a meeting we held with our members last evening as akin to whistleblowing. They are asking this Oireachtas committee to make significant changes that are necessary in order to ensure we do not face this problem year in, year out. As the previous speaker said, Covid-19 did not cause this problem but it most certainly has made it worse. We now have one single workforce dealing with two different types of care delivery and, obviously, with the donning and doffing of personal protective equipment, PPE, gear, it makes the arranging of care much more laborious and the delivery of care takes longer.

Obviously, our infrastructure does not lend itself to single rooms, which means that we are constantly moving patients from location to location to ensure they can be isolated. In any event, we have an overcrowded system and a tolerance of overcrowding that needs to be tackled. In our submission, we have set out actions we believe the Government needs to take immediately to ensure the process of changing this broken system is begun. We say this with a view to the welfare of patients who are attending. Our president, Ms Karen McGowan, who is in the room with the committee today, is a working advanced nurse practitioner in one of the large acute hospitals and can give the committee first-hand evidence of patients not being treated and of conditions in our acute hospitals becoming inhumane, including having to advise patients of their treatments and give them very bad news in very public locations. They are not afforded the dignity of privacy or of having a bed in which to have a decent night's sleep. Instead, they are left in very busy environments. They do not always stay there just for 12 hours or 24 hours. In many instances, they are going for treatment and then returning to the trolley. The trolley is their permanent base in the acute hospital. As the previous speaker set out, there is ample evidence that tells us that this, in itself, can cause a person's health to deteriorate. That is not a situation that any of the people who provide the care have control over but it is certainly not an environment in which they can continue to work.

It is also detrimental to retention, which is now a real problem. We are still battling the legacy of the recruitment moratorium for nurses and dealing with a system, particularly in the HSE, that is extremely bureaucratic when it comes to recruitment. On top of that, our system is causing those who work in it to suffer burnout much earlier than they should or to make the decision to leave because they simply cannot deal with a broken system any longer. One of the areas that has been looked at over recent years, since 2016, as a result of two nurses' strikes is a measurement tool to determine how many nurses are needed in these departments. That is now Government policy in surgical and medical wards. It is termed the framework on nurse staffing. It was meant to be fully implemented by the end of 2021 with funding available in each October's budget. Unfortunately, that has not happened to the level it should have. This framework now only applies in 12 hospitals throughout the country. When we have a model that measures and determines the skills mix and number and mix of nurses and healthcare assistants needed, that should be funded because the evidence is absolutely clear that, when the framework is in place, patient outcomes are better, the cost to the State is reduced because the dependency on agency staff is reduced and retention is improved, which is extremely important right now. That is one of our big asks.

We have appeared before this committee on numerous occasions to discuss Sláintecare and the very good work that was done across all parties to determine what changes are needed in the public health system. We strongly believe that fiddling around at the edges and tinkering with changes will not work. We need the fundamental change that was set out in Sláintecare. We need the Oireachtas to take ownership of that and we need to see evidence of real reconfiguration and integration of services at every level. The days of one manager saying that his or her budget is affected and that the money, therefore, cannot be spent between acute and primary care must end. We must have real integration. This would allow the patient's journey to be paramount and would make moving someone from a hospital to a community setting much easier. Those services must be funded and put in place. That is not happening at a helpful level and pace. It is too slow and the Oireachtas must insist that this change be overseen by the highest and most senior office in the country, that of the Taoiseach, as was envisaged in the Sláintecare report when it was originally produced.

The bottom line for nurses who are working in acute hospitals, both on overcrowded wards and in emergency departments, is that they fundamentally believe that patients are affected negatively when admitted if they are left waiting on trolleys for prolonged periods. We have surveyed our members in five of the most overcrowded hospitals over recent months and, to a person, they are now saying that there are negative effects for patients, including missed care, and that they unfortunately do not believe these areas are safe places to provide care. This is known. This is not news. They are now saying that, when they raise this from the front line, somebody must start to listen and take the necessary decisions to bring about change.

That change is already designed in Sláintecare. A version of Sláintecare or Sláintecare with a different focus is not what they want. They want the report implemented as it was set out. The fundamental changes that are required, particularly with regard to improving the services that are available outside of the acute hospital, must be made and they must be made this year. We must see more diagnostics and step-down beds in the community. We must see more chronic disease management led, in the main, by clinical nurse specialists and advanced nurse practitioners, as it is now. That requires investment. We must see the real change that is the integration of care so that we do not have separate budgets for community services and acute hospital services. That mitigates against integration at every level. When HSE management appears before the committee later, members need to ask where the evidence of change is because it is not visible to the people who are dependent on our public hospitals. What they see is longer waiting times for outpatient treatments and others treatments and some not receiving treatment in the emergency departments because they get so frustrated that they leave.

In summary, no more than we did with our presentation in 2018 on this subject, we are saying that the evidence of overcrowding remaining a great problem is very obvious. We have set out the percentage differences in trolley count figures across hospital wards and emergency departments between 2020 and 2021 on page 4 of our submission. Members can see that the increase was significant. That is a continuous problem. There is also the significant issue of hospital wards now catering for additional patients with reduced numbers of staff because wards are, in the main, staffed for the bed numbers that are allocated and funded but they are dealing with additional beds constantly, as are the emergency departments, where there are patients for whom there are no nurses allocated because the areas should not be used and are, therefore, not staffed. In our submission, we have set out what this means for the staff working in those areas. We have seen higher incidences of violence and aggression and, unfortunately, the majority of those incidents are recorded against nurses working on the front line.

We have also set out in our submission that there is a role for the Health and Safety Authority, HSA, and Health Information and Quality Authority, HIQA. We were disappointed with their response when we asked them to investigate these units. We believe that these statutory agencies have responsibilities and we ask this committee to examine the responses from the HSA and HIQA to date. If strengthening of the legislation that underpins their responsibilities is required, this committee must make recommendations to that effect.

Having an agency that is responsible for the statutory safety of staff at work must mean the same thing in hospitals as on building sites, and it does not. Currently, you can work in an emergency department or hospital ward, be subject to a career-ending assault, and there is no change to your workplace. That is not acceptable.

We are happy to take any questions but we ask the committee to see our request as a cry for help. As one of our members said at the meeting last night, when the front line is screaming for assistance, somebody must listen. That is the request to the committee. Gabhaim buíochas leis an gcoiste.

Ms Catherine Keogh:

Fórsa trade union welcomes the opportunity to address the Oireachtas Joint Committee on Health on the subject of the ongoing and persistent overcrowding crisis in our hospitals. Our delegation today consists of me and my colleague at our national health office, Chris Cully.

Fórsa represents more than 30,000 health workers in our hospitals, community health system and residential and social care settings, as well as at the corporate centre of health service planning and delivery. We represent workers in direct public service employment, such as the HSE and the section 38 voluntary hospitals, as well as section 39 agencies and in the private sector. Our members include health and social care professionals and clerical, administrative, management and technical staff. We consider it one of the many strengths of this union that our members are central to the delivery of the full array of health and welfare services in Ireland.

Public discourse around our health services is frequently driven by headlines alerting us all to the hazards of growing waiting lists and the numbers of patients on trolleys. The discourse is, consequently, always stuck in crisis mode, and this contributes to a wider sense of understandable anxiety about access to healthcare when people need it. While lists and trolley numbers are useful statistical information because they illustrate the symptoms of an underlying problem, it is Fórsa’s view that it is the underlying problem that urgently needs to be addressed. The only way to tackle the ongoing and persistent overcrowding crisis in our hospitals and the underlying problems that drive it is to ensure Sláintecare and, in particular, the 96 new community healthcare networks that will allow the health service to provide appropriate care through health and social care professionals working in the community are implemented fully and without delay.

One of the eight fundamental principles of the Sláintecare report of 2017 is that patients should access care at the most appropriate, cost-effective service level, with a strong emphasis on prevention and public health. In the recently launched Sláintecare Implementation Strategy & Action Plan 2021-2023, seven projects are listed to achieve the aims of Reform Programme 1: Improving Safe, Timely Access To Care, and Promoting Health & Wellbeing. Project 1 is to implement the Health Service Capacity Review 2018, including healthy living, enhanced community care and hospital productivity. That review sets out the staffing and physical infrastructure required to meet the Sláintecare waiting time targets and outlines the necessity for the shift of care out of acute hospitals into the community and closer to a person’s home, where safely possible. The only way to avoid hospital admissions and reduce pressure on acute hospitals is through initiatives that will see care delivered within the community.

Project 7 of the Sláintecare strategy states:

The removal of private practice from public hospitals is a core principle of Sláintecare, ensuring that public healthcare facilities are used for public patients only, and that public patients can access public hospitals based on clinical need. The Sláintecare Consultant Contract, which will only permit the carrying out of public care in public hospitals from the date of implementation, is central to the delivery of the goal of universal, single-tier healthcare in Ireland.

The transition to public-only contracts for hospital consultants and State-employed general practitioners is necessary. Fórsa trade union is unequivocally on the record as being a strong supporter of the community health intervention and servicing model proposed by the Sláintecare report. Fórsa and our members played a pivotal role in the process that established community health networks, and we are actively engaged in the introduction of the enhanced community care networks.

Another ongoing cause of pressure on the hospital system is the cultural default position of GP referrals to the acute hospital system. Direct GP referral to community radiology is an example of one of the stated measures to be implemented as part of the Sláintecare implementation strategy. This would alleviate hospital waiting lists.

A final consideration Fórsa wishes to highlight is that a properly resourced home support service is a necessary component of a functioning health service. A reduction in delayed discharges can only happen when the appropriate supports exist in the community. A new report, The Irish State Post Pandemic, was commissioned by Fórsa, produced by the TASC think tank and published last month. Among other key recommendations, this report called for the provision of greater integration of Government agencies such as home care and health services.

From Fórsa’s perspective, we believe the answer to the ongoing and persistent overcrowding crisis in our hospitals is clear. The Sláintecare report and subsequent implementation plans provide both a durable solution and the roadmap to same. Sláintecare has cross-party support, citizens’ support and workers’ support. We ask the committee to consider what are the real inhibitors to its implementation. Why, five years since the publication of the initial report, are there still the same unrelenting pressures on hospitals and on our members working in those hospitals?

I thank the committee for the invitation and the opportunity to address it today. We will endeavour to answer any questions members may have

Mr. John McCamley:

I thank members for the opportunity to highlight some issues on this important matter on behalf of the SIPTU health division. We represent around 40,000 workers across private and public health organisations, including many grades involved in the delivery of emergency and acute hospital services. These grades include nurses and midwives, healthcare assistants, paramedics, porters and diagnostics staff.

Over the past two years, healthcare workers have gallantly worked through the unprecedented events that have tested the foundations of our health services and those working in it. They now face a return to the pre-pandemic overcrowding crisis that is developing in our hospitals nationally. In many hospitals the numbers presenting in emergency departments have drastically increased, having a knock-on effect on the rest of the hospital and community services. While issues with overcrowding have always had a detrimental effect on healthcare workers, the years of the pandemic have led to increased feelings of burnout, fatigue and low morale. They now face yet another crisis, and we are receiving increased reports of healthcare workers considering their roles. Coupled with this, the normal delays around recruitment could cause the situation to deteriorate further.

SIPTU represents a number of grades, and how the crisis is developing can be seen uniquely through their experiences. These can be placed in four main areas: pre-hospital emergency services, that is, ambulance services; emergency departments; inpatient wards; and community services.

Staff members working for the National Ambulance Service and Dublin Fire Brigade provide pre-hospital emergency services to the public and are crucial to the delivery of care and emergency services in our communities. For example, the HSE National Ambulance Service provides emergency services, intermediate care transport, mobile intensive care ambulances, neonatal intensive care and aeromedical services. We are seeing an increase in call volumes to these services. In our submission, we provided a number of figures. For example, in a comparison of January 2019 to January this year, calls have increased by more than 5,000. It is a fair assumption that any increase in call volume would have an impact on the availability of ambulances, but this combined with the delays at emergency departments, EDs, has caused additional pressures on services and ambulance crews.

During the pandemic, turnaround times increased due to the introduction of non-Covid and Covid pathways in EDs, with ambulance turnaround times ranging from one to five hours. This has resulted in ambulances being dispatched from further away to deal with the non-availability of ambulances nearer. The national average turnaround time at EDs stands at around 54 minutes, though there are examples of much higher times laid out in our submission. For example, in Letterkenny University Hospital on three occasions in January this year, ambulances could not leave for between seven and 14 hours. In University Hospital Waterford, it was between four and five hours on eight occasions. A number of other incidents are outlined in our submission.

It must be stated categorically that the delays are not the result of the tireless effort of the staff in any of these emergency departments but an overall systems failure in dealing with a number of areas that I will touch on later in this submission.

It is frequently stated that the unique nature of the emergency department is that it does not close. It is open 24-7 and patients can arrive at any time with any type of condition. Members of the public know they will be seen by dedicated and skilled professionals, albeit with increased waiting times. As a result of this, the ED has become a choke point for wider issues within the health service. While it is crucial that those issues particular to EDs are resolved as a matter of urgency, there is a need to look at alternative pathways to care.

SIPTU representatives have noted an increase in the number of complaints around staffing in emergency departments, in particular but not exclusively from nursing and healthcare assistant members, in the past few months. There is no doubt that staff are under increased pressure and the HSE and health employers need to do more to fill deficits in EDs. Additionally, radiographers are seeing an increase in cases, with cases in one Dublin hospital up 30% compared with 2019. There has been an increase in difficulties filling deficits for radiographers in some locations. We believe this is down to offering short-term contracts instead of permanent contracts.

While reliance on agency staff is always a feature in the health service, if recruitment and retention are not given priority, there will be additional reliance on agency staff along with increased costs to the Exchequer. Other locations have had difficulties with regard to staffing in catering and household. Overcrowding and the need for increased transfer of patients have also affected the availability of portering grades which are essential in the transport of patients within a hospital.

Healthcare workers in EDs have seen an increase in the number of patients waiting for a bed, with numbers recently exceeding those in 2019. It is highly likely that being left on trolleys for a long period can have a significant knock-on effect on patients' health. The HSE and health employers, including the Department of Health, need to do more to develop additional bed capacity in acute hospitals to relieve the emergency departments.

To increase turnaround in beds in an acute hospital, the provision of proper public community services is needed, either in a residential setting or with home care packages. Through the years, we have seen a cycle of temporary increases in home care packages only for the funding to be reduced in tandem with the hours allocated to a patient, resulting in them needing to go back to the ED. SIPTU members regard the delay waiting for home care packages to be one of the biggest factors for delayed discharges, although the allocation of a bed in the community is also a major factor. Housing alterations to cater for patients can feed into those delays as well.

Pathways also have to be developed within the community to deal with patient needs, which will reduce reliance on emergency departments, such as the expansion of primary care centres and minor injury units. Additional utilisation of pre-hospital care by ambulance staff can also reduce the need for a referral to the emergency department, for example, the expansion of community paramedics.

We have outlined a number of areas in which work needs to take place. These include the implementation of the ambulance service review on roles and responsibilities which will result in the further professionalisation of the ambulance service; funding to be made available for additional ambulance staff and vehicles; the expansion of community paramedics and other pre-hospital care initiatives; fast-tracking the filling of deficits within emergency departments for nursing, healthcare assistants and support grades; incentivising roles for ED staff, with a view to stemming the drain of staff from the service; and express roll-out of phase 2 of the task force on safe staffing in all EDs to assist and maintain adequate staffing of nurses and healthcare assistants.

Other areas include the expansion of enhanced care teams into EDs to free up healthcare assistants currently carrying out enhanced care; implementation of the radiographer review recommendations to deal with adequate safe staffing for radiography departments and advanced practice; full roll-out of the Sláintecare strategy across the health service; continued investment in the roll-out of home care packages in line with Sláintecare and HSE service delivery plans, with focus on delivery of hours via direct HSE employees; a clear commitment from Government to direct provision of home care services, including a more focused emphasis on HSE recruitment of home care support assistants; and an increase the number of publicly-owned community beds to reduce reliance on private nursing homes. I thank the committee for the opportunity to make our submission.

Seán Crowe (Dublin South West, Sinn Fein)
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I ask Deputy Durkan to indicate whom he would like to reply.

Bernard Durkan (Kildare North, Fine Gael)
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I welcome our witnesses to this important meeting. The issues they have raised have been discussed in the committee since the beginning of the year. We all acknowledge the tremendous work done by the health services over the past two years. Challenges came day after day and the medical personnel stood up to the challenges. We need that recorded because otherwise the challenges ahead cannot be faced.

I thank the witnesses for their opening statements. All of the issues they raised have been addressed by the committee since the beginning of this year because it is recognised that we can no longer have a haphazard approach to health services. We have an increased population and increased demand at every level and we need to do something about it.

My colleagues will speak for themselves but all members agree that it is not sufficient to go back to the people again and again to say we are very sorry but we cannot help them because the system does not work and we are in competition with everybody else in the world for personnel, staff or whatever the case may be. That does not wash any more. We have to do something about it.

What do we do? We enlist healthcare as the leading issue. We request that particular reference be made to the fact that Sláintecare has to proceed as was indicated. We noted that people resigned from the Sláintecare co-ordination committee and were assured that everything in the garden was rosy. We presume that is the case but we do not know. However, we know for certain that we do not have a separate budget. We cannot do the things the witnesses want to do. We do not have a budget to do so.

We are not the Health Service Executive. The HSE can do that and has to do so. The HSE now tells us that more money than ever before is available. It tells us again and again that money is not an issue. It is all there. Everything we ever wanted is there. It is now a matter of deciding that we address the issues. Hospital waiting lists are one issue of many. I get frustrated when we repeatedly say to the public we are very sorry that the situation is the same as it was last year or has got worse. What do we do?

Other countries are having problems with competition for staff. The reason for that in the nursing area is that nursing is heavy, hard work. It has been especially tough going over the past two years. In order to ensure we retain staff, we have to pay them. If that is the cause of the problem, money is available. What is the cause of the problem in the future?

Sláintecare must proceed. Any interim measure must be within the template of Sláintecare. We have said that again and again at this committee. We accept that progress must be within the template of Sláintecare in order that actions are not taken that cut across Sláintecare and render it useless. We mean to create a service that is acceptable, robust, available and accessible.

I will depart from my usual approach of addressing specific witnesses and instead speak to all of them. Do they know of anybody out there who is deliberately frustrating the onward progress the Minister and the HSE say is possible? Is it the HSE? Who is it? We cannot continue to make excuses. It is not acceptable to us as public representatives or to the general public. There is a notion nowadays that everything takes four or five years. That is utter rubbish. The Chairman and all of us around this table know that.

That is not true. It is possible to take measures that take effect in the next couple of months, so that is what we need. It is as simple as that. If it does not happen, we will be back to where we were. We have a plan for the future and great ideas but we are going to do nothing. That is what it means. Urgent progress is required. In any queue, the waiting list is whatever length it is - I am not going to go into the one million people waiting at the moment - and you have to start doing something about it. That queue has to be shortened, so you have to start at the two ends of it - the outer end and the immediate problem - and they must converge quickly. Whatever steps are needed to do that must be put in place now. That will be in line with the template set down in Sláintecare and that must happen. It is no good us saying we do not have Sláintecare ready yet so we will wait two or three years until it is up and running and do it then. That is not acceptable either so we must start at the beginning and end of the queue and converge. If that does not happen, we are facing a disaster because there are many challenges ahead.

I have been involved in the health service in one shape or form for a long time, as have all other members here, and we were told for years we did not need any more hospital beds. We were told repeatedly there was no need for hospital beds, there were already too many beds, we should get rid of them and it would be much more efficient to do without them. Well, now they know and everybody knows we need hospital beds.

We need to provide a service to the people when they want it. It is no good telling somebody to come back in four or five years, depending on the illness or immediate concern. We need to reassure the public. It is one of those things that needs to done as a matter of urgency. We need to reassure the public we are conscious of the position and have every intention of doing something about it in the current year, not next year or five years' time. We cannot tell members of the public to come back in five years' time and we will look after them then. That is outrageous; it is crazy. I have never seen it work in any other organisation and I have been looking at organisations for a long time. I will not specify what needs to be done. The witnesses all know what needs to be done. The money is in place. The HSE knows the money must be released strategically to provide the services that are needed.

There are people who say we cannot do that. This does not arise. There are no situations where something cannot be done. I remember how I was told by institutions five or ten years ago that something would take five or ten years. Where have we got to? I was looking at a case recently where a nurse who qualified outside this jurisdiction wanted to become involved in this country as a matter of urgency. Dealing with this kind of thing has been handed over to a private organisation. It was done six months ago and that was the last time they ever heard of it. We cannot go on like that. It is inefficient, ineffective and is not working. All the comments about the system being broken are correct. It is broken and is not working. However, it was able to work for the past two years in possibly a miraculous fashion. The health service in this country delivered in a way that was not expected of it. It was not expected of it because the health service has been dumbed down. Everybody criticises the health service. People working in the health service know it and do not expect anything else. We as politicians know that if someone is always being criticised and nothing is expected of him or her, you will get nothing from that person and nothing will happen.

The time has come to deal in a meaningful way with the issues that are emerging, and by that I do not mean in six months' time; I mean now. We need to get the response soon from the HSE and all the organisations we dealt with in January. We do not have a budget, we cannot enforce it, but we can highlight it, which is what we have done, and this committee was ahead of everybody else. Everybody was anxious going into the new year. With some subsidence in the virus, and while it has not gone away and is still around, we need to act now. That is all I want to say. I did not direct anything at individuals. I am merely saying that all those involved need to act now.

David Cullinane (Waterford, Sinn Fein)
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I pass on my appreciation to all the members of the organisations represented here today for the significant work they have done over recent years. Most of the witnesses have been before this committee a few times over recent years and we have spoken about the levels of burnout, stress and anxiety the members of their organisations face. I acknowledge that. The people on the front line and across healthcare with whom I speak are sick and tired of politicians giving them a clap on the back and telling them how great they are. They want us to solve the problems, put the capacity into our healthcare system and deal with the long-term issues, because far too often we focus on quick-fix and short-term solutions.

One line in the IMO's opening statement sums up what was in most of the opening statements, "Unfortunately, there is no quick fix to hospital overcrowding". That is the first thing we must accept. There are no quick-fix solutions. If we continue to chase quick-fix solutions, we will not solve the problem.

Will the witnesses tell me about the human consequences of hospital overcrowding? I take the point made by the witnesses from Fórsa that sometimes there is too much concentration on overcrowding and waiting lists and there are underlying problems that create that, but waiting lists and overcrowding are real and have an impact on people. Does Ms McGowan work in the healthcare sector?

Ms Karen McGowan:

Yes, I do. I am an advanced nurse practitioner and work in a very busy emergency department.

David Cullinane (Waterford, Sinn Fein)
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I received a response to a parliamentary question a number of weeks ago that I thought was chilling because we all know about the levels of overcrowding in our hospitals. Some hospitals are worse than others and maybe there are issues in individual hospitals that must be dealt with as well as structural and capacity problems. The response told me that in the month of January, almost 1,100 patients over the age of 75 were on a hospital trolley for more than 24 hours. Some of them were on trolleys for more than 48 hours. Given that Ms McGowan works in an emergency department in a busy hospital, will she outline the impact of overcrowding on patients - older and younger people and children?

Ms Karen McGowan:

That is a good question. The environment in which we are working in emergency departments is very much out of our control. As previous speakers have highlighted, our doors are open 24-7. The indignity of what patients endure in these emergency departments is horrendous. We witness the trauma these patients experience. Our trauma pales in comparison with what these patients endure, and every day it is getting worse. This is simply not being managed and it is getting worse.

The Deputy spoke about quick fixes. Our emergency departments keep throwing us life lessons year after year and we are not learning from them. Quick fixes will not fix this. We have a solution in Sláintecare and it is not just about acute care. From community to acute care, it is the solution we want and it needs to be implemented. The environment in which we are working is horrendous and patients are enduring so much trauma.

David Cullinane (Waterford, Sinn Fein)
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When I read all the opening statements, I found common themes in all of them in respect of solutions. For me, it is really worthwhile when we have witnesses and organisations come before an Oireachtas committee and not only outline the problem but also give us their insight into the solutions. As Deputy Durkan said, we know we need more beds so we need more inpatient bed capacity. If we do not have enough beds, patients who have to be admitted to hospital cannot be admitted quickly enough because the recovery or inpatient beds are not available.

As a consequence, many of them end up on trolleys. We do not have enough community beds, as we know, which means that there are knock-on consequences in terms of step-down beds, care in the home and all of those issues. Those are the points made by Fórsa, which we all accept. We do not have enough GP capacity. The witnesses referenced that.

If people cannot get access to a GP in or out of hours, they have no choice but to go to an emergency department. It strikes me that huge numbers of people are going to emergency departments who should instead be treated in the community, but they are not being treated in the community because the capacity is not there which puts more of a burden on our emergency departments.

The key to fixing a lot of the problems is workforce planning and a workforce strategy. We need to train, recruit and retain more professionals. We cannot fix the problems in our healthcare system if we do not send out a very powerful message to people who are training that we want them to come and work in the public system, that we have listened to the issues they raised regarding retention, recruitment and the reasons people are not coming, and that we have fixed these problems. If we do not fix them, we will not hire staff in the numbers that we want and we will not be able to deliver on the healthcare the people need.

Can the witnesses address workforce planning and recruitment? Consultants are represented by the IMO. I ask Dr. Molloy to outline the difficulties they face and any other points he wants to make. I will put a quick point to SIPTU following his response.

Dr. Mick Molloy:

As a consultant in emergency medicine in a busy emergency department, I can tell the Deputy exactly what the impact of waiting and trolley times is. It is death. That is what the impact is. A seminal paper was published earlier this year by the ex-president of the Royal College of Emergency Medicine in the UK. Two years of admissions in the UK were studied, along with 430,000 deaths in the UK system. Researchers were able to show that for every 82 people who were delayed in getting to a bed on a ward for longer than six hours from the time of presentation to an emergency department, one extra person died because of the delay. It is fairly simple. The study was carried out very scientifically over a huge population. It showed that people who got a bed on a ward more quickly were less exposed to – I do not use this phrase lightly – the torture of being in an emergency department. It is a 24-hour operation. The lights are on. When people are sick they want the lights turned off and a place with peace and quiet. There are many staff moving around and there is a lot of noise. The Geneva Convention recognises that not allowing a person to sleep and exposing him or her to loud noise is a form of torture, and that is what is happening to these people in emergency departments. People tolerate that for short durations. We know that people who have been exposed for 24 or 48 hours are not getting sleep for that period which dramatically affects their ability to survive an illness.

With respect to workforce planning, quite a lot of work went into this in recent years in the national doctors training programme which identified the numbers required in each specialty over the next ten years in order to staff the service. That is great, if people have confidence in working in the service. People are choosing to work elsewhere because they cannot see the level of investment in the service to guarantee them the ability to do their job. Surgeons are appointed to hospitals without any operating time. That makes no sense. Why appoint a surgeon if he or she cannot operate? People are appointed to community health organisations where there is no base from which to run clinics. Again, that makes no sense.

A lot is required in the service. I draw the attention of the committee to a report from the Department of Health from 20 years ago on acute bed capacity. At that time, it recognised the need for 5,000 extra beds. At that time, there were 11,862 inpatient acute beds. We now have less than that. We had a population of 3.5 million then, but the population now is over 5 million and is growing on a week-to-week basis. Sitting and talking about strategies and plans are great, but they are only good intentions unless we actually generate the hard work needed to implement them.

David Cullinane (Waterford, Sinn Fein)
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I want to put a question to Ms Ní Sheaghdha. We are tight on time and I want to give her as much time as possible to respond. One of the issues that arises with staff I meet is the lack of safe staffing levels. We know we have a safe staffing framework and a skills mix framework. I have raised this issue with the Minister several times recently. He has told me that the money is there, and it is not an issue and is being implemented. Is it being implemented? Is the money there? Are there wards or healthcare facilities in the State without safe staffing levels today?

Ms Phil Ní Sheaghdha:

Yes, 12 hospitals out of all of the acute hospitals have been funded to implement the safe staffing strategy on surgical medical wards. The remainder do not have it. In 2019, €5 million was allocated but was not spent. We know that to get the framework implemented over three years will take a minimum of €10 million per year. Last year's budget did not allocate €10 million. The budget for 2019, 2020 and 2021 should have allocated €10 million. To date, €15 million has been allocated. We know the savings that come from implementing the framework, as I set out earlier, are significant. It is now Government policy.

In our view, the framework which measures how many nurses and healthcare assistants are required and what mix is needed on surgical and medical wards needs to be underpinned by legislation. Otherwise, it will just be a policy that sits on a shelf and somebody will decide not to allocate the money that is required every October. Fundamentally, we know that it works and that where it has been implemented it saves on agency costs and improves retention and patient outcomes. Fewer people are readmitted to hospital when we have the correct nursing staff levels because they get their care on time.

Phase 2 of the framework on emergency departments is now being examined by University College Cork, led by Professor Jonathan Drennan. This will be the first time anywhere in the world that staffing levels for emergency departments will be examined in this way. That needs to be funded and implemented quickly across the 29 hospitals.

Nurses went on strike in order to ensure we had a measurement tool and funding to implement safe staffing. That was one of the fundamental issues they raised and felt strongly enough about that they took industrial action. The settlement of that action related to a Labour Court recommendation which sets out that over three years the funding must be made available to implement the safe staffing strategy, but that has not happened over the three years in question, namely 2019, 2020 and 2021. Today, 12 hospitals have implemented the framework on surgical and medical wards. It is not good enough.

Seán Crowe (Dublin South West, Sinn Fein)
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Okay. I need to move on. Deputy Cullinane may be able to come in during the second round.

David Cullinane (Waterford, Sinn Fein)
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Unfortunately, I could not ask questions due to time constraints. If I can come in a second time, I will.

Róisín Shortall (Dublin North West, Social Democrats)
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I welcome the witnesses. I thank them for their presentations, and thank them and all of their members for all of the work they do to keep the health service afloat, not only over the past two years where their contributions were outstanding but on an ongoing basis before and since.

It is remarkable that so many people have referred to the fact that there is a solution. We talk about these problems a lot, and have talked about them for donkey's years, but there is a solution which many have identified, namely Sláintecare. The issue is the slow implementation of that and the lack of buy-in from some people involved who are central to the health service. I do not think the committee needs to be convinced of that. Many of us were involved in drawing up that strategy.

What kind of engagement are the unions having, as key organisations within the health service, with the Government and, in particular, the Minister regarding the implementation of Sláintecare? Have there been meetings about that in recent times? I would be interested in hearing in their response what engagement, if any, they have had. That is the critical thing.

The slogan of Sláintecare is "Right Care Right Place Right Time", and that sums up in six words very well what we need to do in the health service. We have spoken about providing care at the earliest possible stage and at the lowest level of complexity. We know that within the health service the vast bulk of activity relates to chronic illness. About 70% to 80% of chronic illness can be perfectly managed, and is best managed, within the community.

Ms Ní Sheaghdha spoke about the commitment we are supposed to have to chronic illness management.

We have been talking about that for 20 years and it is the key to unlocking many of the logjams within the health service. There was mention of the need for clinical nurse specialists and advanced nurse practitioners but why are we not doing this? It seems to be blindingly obvious that this is where the emphasis should be within the health service. Why is the Government not rolling out the chronic illness programme and why do we not have those key senior nurse posts in place to the extent required?

Ms Phil Ní Sheaghdha:

First and foremost, it is a feature of underinvestment over many years in the training of advanced nurse practitioners. We should remember that in 2013 there was a moratorium on recruitment. Ms McGowan, who is in the committee room today, is an advanced nurse practitioner and to get to that level takes an investment of nearly seven years. Recruitment must be featured around investing in advancement for those who are in post currently but we have never done that. We have never had a recruitment policy that goes beyond one year. Currently, if a director of nursing has notification that somebody is going on maternity leave, retiring or resigning, it can take up to six months to replace that post. That does not mean there is a workforce plan that is investing in building for the future.

The Minister has recently announced an increase in advanced nurse practitioner posts for the community for the management of chronic disease. There is some good work starting in the Department of Health in respect of virtual wards and bringing that care out of hospital into people's homes.

Róisín Shortall (Dublin North West, Social Democrats)
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Do we know at this stage how many of these types of posts are necessary for the full roll-out of chronic illness management?

Ms Phil Ní Sheaghdha:

Currently we have 2% of the total nursing population. The projection from the Department is that it will go to 3%. We know, with the ageing population, this must be much higher. We believe strongly that we need to have in the region of 850 advanced nurse practitioners working and operating with teams of clinical nurse specialists.

Róisín Shortall (Dublin North West, Social Democrats)
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How many are there now?

Ms Phil Ní Sheaghdha:

There are 420 but they are not based in the community. There are very few based in the community.

Róisín Shortall (Dublin North West, Social Democrats)
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They are based in hospitals.

Ms Phil Ní Sheaghdha:

Yes.

Róisín Shortall (Dublin North West, Social Democrats)
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When will that change so care will shift to the community?

Ms Phil Ní Sheaghdha:

My point is it takes a long time and much investment but we must increase the numbers. This year, the percentage will increase to 3% of the total nursing workforce population, which is a start. That investment must not dwindle. With every budget we will still be arguing for further investment in advanced nurse practitioners. That should be a standard.

Róisín Shortall (Dublin North West, Social Democrats)
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Yes.

Ms Phil Ní Sheaghdha:

The workforce plan should be funded in advance.

Róisín Shortall (Dublin North West, Social Democrats)
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Sure. We have been talking about this for 20 years and very slow progress has been made. It is just so frustrating. The whole area of social care is being completely downgraded and this is where it is now. If we want to deal with upstream issues, we must invest properly in social care also. Unfortunately, it gets very little attention at a senior level within the Government.

We have spoken about workforce planning and Dr. Molloy has made the point it is not just about numbers. We need to find out the issues that prevent good recruitment and retention of staff. There has been much research done in the area and we are getting a presentation in the next few weeks on consultants. The Irish College of General Practitioners had representatives before us talking about the need to have a working group set up to identify those blockages. We know from research done that the number one reason people do not stay is because they want a proper work-life balance, which is not available to many people within the Irish health service.

They also want a clear commitment from the Government that it is serious about reform, which is not available either. Money is clearly an issue and it is undoubtedly the case that the two-tier pay scale for consultants was very damaging to morale. To a large extent we are moving beyond that now. Witnesses may shake their heads but the Sláintecare contract is now being offered. It offers a very good salary of between €140,000 and €252,000 for regular working hours to provide that kind of work-life balance that so many doctors are seeking. What exactly is the problem with the contract from the perspective of the IMO?

Dr. Mick Molloy:

We have called for a full discussion on that recruitment and retention crisis in our consultant workflows, including the terms of any new contract. Talks were under way under an independent chair. That chair was appointed to the High Court and we have been calling for a new chair to be appointed so talks can recommence to deal with these matters. It is difficult to understand, when we are waiting for talks to start again, why the Government is already reneging on previous agreements such as the restoration of cuts from before. If the Government is refusing to honour current contracts, it does not breed much trust for people to enter into a new contractual arrangement.

The Deputy noted I was shaking my head. Moving forward to Sláintecare does not solve the problem for the people who had their salaries cut in 2012. They will now have had ten years of a reduced salary and pension benefits and they will not be replaced by a sudden uplift in the salary when they sign a new contract. It has nothing to do with private practice. It means that group of people have been penalised through no fault of their own and just by the nature of the date they were appointed. I am one of them. By the nature of the date of my appointment, I should have left the country and stayed abroad because I would have been more valued in the system. I stayed in Ireland and worked on a temporary contract arrangement of six months here, four months there and two months over there. I was working around the system, which meant I had no permanent contract. By the time I got a permanent contract, I was subject to this 30% cut in salary. There is no plan to have that deficit addressed in my pension fund or agreement with what is on the table now. It has not even been discussed with the Minister at this point.

Róisín Shortall (Dublin North West, Social Democrats)
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Many public service workers took cuts in salaries during the crash.

Dr. Mick Molloy:

I refer specifically to consultants who took an individual and extra cut that did not apply to anybody else. It was over 30% at that point-----

Róisín Shortall (Dublin North West, Social Democrats)
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Many people were not compensated for a loss in salary and pension contributions.

Dr. Mick Molloy:

I am not talking about compensation for a loss in salary but rather pension entitlements over a long time. It means the person who came before me in this job would have a pension based on the full salary.

Róisín Shortall (Dublin North West, Social Democrats)
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Yes. That two-tier approach was very damaging for many people.

Dr. Mick Molloy:

Somebody who comes next year, or a junior doctor who never had that cut, would have a full pension the whole way through but we will not.

Róisín Shortall (Dublin North West, Social Democrats)
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That is accepted. There are issues like that in teaching and nursing, as well as many different areas. That needs to be addressed separately. There is a Sláintecare contract on offer now.

Dr. Mick Molloy:

There is no offer. It is pushed in a similar way-----

Róisín Shortall (Dublin North West, Social Democrats)
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Sorry. It is on the table. I do not necessarily want to get into that. I accept fully that the process stopped in the middle of January when the chair was appointed elsewhere.

Dr. Mick Molloy:

That was December.

Róisín Shortall (Dublin North West, Social Democrats)
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Right. It is hugely remiss of the Government that it has not replaced the chair and got talks going again. It is holding up so much. We fully recognise that. It is also important to recognise that what we know of the Sláintecare contract, certainly in terms of pay and pension contributions, is an attractive contract.

Dr. Mick Molloy:

Let me take the Deputy back to 2008, when these contracts were first negotiated. At that point it was the co-located hospitals that was the driver for consultant contracts. Salaries were agreed but never paid. This resulted in a High Court settlement action. That is why there are reservations. These are contracts for people going forward and the process does not address issues for people in the system. They would have to choose to change.

Róisín Shortall (Dublin North West, Social Democrats)
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Sure. I am talking about going forward. The historical issues would need to be addressed separately.

Dr. Mick Molloy:

There would need to be trust by the people in wanting to take those contracts. That trust has not been demonstrated.

Róisín Shortall (Dublin North West, Social Democrats)
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I ask SIPTU and Fórsa what kind of engagement, if any, they have had in the past year with the Government on the implementation of Sláintecare.

Mr. John McCamley:

SIPTU has been very frustrated by the level of engagement for a range of matters relating to Sláintecare and the development of the service. In our submission I have outlined some of the difficulties we have had, particularly with respect to recruitment and retention. The Deputy alluded to community services and our submission refers to consideration of alternative pathways instead of people going to the accident and emergency department.

Róisín Shortall (Dublin North West, Social Democrats)
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Does someone from Fórsa wish to comment?

Ms Catherine Keogh:

I am grateful for the opportunity. At a strategic level, we have no engagement on Sláintecare. At an operational level, Fórsa is engaged with the roll-out of the enhanced community network and we have good engagement on that one particular piece. I will give a very quick example of workforce planning, which we have all mentioned. It took me three years, a motion to our conference from our members and raising it at numerous meetings at our national joint council to get one meeting on workforce planning for dietitians where there is a crisis, partly linked to Brexit, partly linked to training and partly linked to no investment. Simply through the treatment of diabetes, this group of health and social care professionals can keep people at home. Things like that do not happen quickly enough.

As part of Fórsa's submission to the European semester for 2022 and the national reform programme, we believe there is a strong case for the social partners at a high level to be given a role in the implementation of Sláintecare. We think that could be very useful in driving it forward.

Richard Boyd Barrett (Dún Laoghaire, People Before Profit Alliance)
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I thank all the contributors. I am standing in for our health spokesperson, Deputy Gino Kenny, today. I thank all the healthcare workers and those present today for the fantastic work they have done under extremely difficult circumstances. This includes ambulance drivers, porters, nurses, doctors and midwives. Across the whole gamut, they have had a very difficult time. Unfortunately, things are not improving for them, based on what they have told us. I am certainly aware of the horror stories of people spending hours on trolleys or months and sometimes years on waiting lists. It is beyond shocking. I recently met somebody who told me they would not get community mental health care for two years. I could not believe it. We are facing a mental health crisis and people cannot get seen for two years. It is a staggering level of dysfunction.

My first question is for Ms Ní Sheaghdha and Ms McGowan, as a working nurse in an emergency department. I was shocked to hear today that we only have safe staffing levels in 12 of 29 hospitals. Three years after we identified that we needed to address that as a matter of priority, only 12 of 29 hospitals have safe staffing levels. That is very shocking. What does not having safe staffing levels mean for the patients? What does it mean for the staff? I am aware of people working in emergency departments facing physical aggression and sometimes assault. Is one aspect of not having safe staffing levels that the staff are actually putting themselves in very serious physical harm's way from possible assault or attacks?

During the Covid pandemic we highlighted the failure to pay student nurses who are on work placement. I thought it was unbelievable. Leaving aside the Covid pandemic, given that we desperately need more nurses it is incredible that we are making it difficult for nurses to do their training and get through their education with knock-on consequences for our ability to recruit and retain nurses and midwives. Those studying to become nurses in the UK get £10,000 a year as a bursary. That was actually a cut by the Tories; it used to be £15,000. It is multiples of what student nurses here get. I ask Ms Ní Sheaghdha and Ms McGowan to respond to those points. I also have some questions for the other groups if I have time.

Ms Karen McGowan:

I will let Ms Ní Sheaghdha reply first and then I can give the lived experience.

Ms Phil Ní Sheaghdha:

I thank Deputy Boyd Barrett for his questions. The assault figures are fairly shocking. They were released under freedom of information and we set them out in our submission. Some 7,600 assaults on HSE staff were reported last year. That is only in the statutory hospitals and does not include psychiatric hospitals. It does not include the community or voluntary hospitals, meaning that it is much higher than that. Most worryingly, half of those assaults were against nurses. Obviously, the staffing levels contribute to an increase in the public's frustration, particularly when they are waiting. The level of assaults on staff in paediatric hospitals is higher which is of concern. There is also a higher incidence of psychiatric patients attending emergency departments and waiting to be assessed by psychiatry staff, sometimes for prolonged periods of time. A number of examples can be given of those inappropriate wait times.

Added into the mix is that the first port of call for the gardaí bringing patients with altered behaviours, drug abuse issues etc. is into the emergency department and the staff of the emergency department then have to deal with that. It is obviously an inappropriate area. We have previously requested that psychiatric admissions should be made first to the acute psychiatric units. As the Deputy has pointed out, there is another problem in that our psychiatric services are not fit for purpose.

We have a lack of services, particularly community services. That is a big problem and can lead to people with drug and alcohol abuse issues unfortunately ending up in the emergency department, which is unacceptable.

We hope this committee will look at the health and safety legislation which needs to be revised and strengthened to protect staff working in these departments. As I said in our opening statement, there are very clear guidelines for people working on building sites and if those guidelines are not met, the site closes. The reported figures are of over 7,000 people being assaulted. One of our members had an assault last year which ended her career; that is simply not acceptable. The hospital in question remained open. She was on duty for four hours after the assault because there was nobody to take over from her. Her colleagues went back into the very same situation with no change the next day.

The legislation relating to protection for nurses, doctors and healthcare workers in hospitals, particularly emergency departments, must be reviewed and strengthened. It is not acceptable to have inspection from a health and safety authority which does not recommend very serious improvements in the protection for staff working in these environments. If we have no alternative to people coming in, then the protection for workers must be strengthened and must be very clear and obvious to staff.

It is a feature of our health service that is extraordinarily unwelcome and should not be happening. One should not be assaulted as part of one's work or role. It simply should not happen. As I have said, the official numbers reported only tell half of the story because the assaults that were recorded did not include the voluntary or community hospitals.

I completely agree in respect of student nurses as the battles we had to get the McHugh report published involved protesting at the Dáil to request it be done. It is now published and we are still meeting with the HSE on aspects of it. Everything is a battle when it comes to improving the conditions for nurses, from the student right up the line. We have an expert review of nursing and midwifery in general which has just been issued to the Minister and, again, we are waiting for it to be published as this has not been done. There is a crisis in retention, in the workforce and in the conditions under which they are working. It should not be the case that nurses need to go on strike to highlight these issues. Most of the time they are highlighting the negative effects on patients of not investing properly in nursing and in midwifery. We fully agree with the point made by the Deputy.

Ms Karen McGowan:

On how staffing levels affect the service, if one does not have the right number of staff, one cannot provide the care that is required to these patients in emergency departments or on wards. That is care that is being undone or care that may be missed. There are increased incidents of pressure area care which will increase their length of stay. If things are being missed, especially with the elderly, there is an increased chance of delirium happening. That in itself also increases bed days and mortality rate. It is very significant.

On the issue of assaults at work, I have witnessed two in the past month. That is crazy. We are totally dumbfounded that we are in a health system in which this is happening. I can quote two such incidents. Everybody has a different day. It is horrendous. The health and safety legislation must be changed and strengthened to support us to be safe in our areas of work.

Seán Crowe (Dublin South West, Sinn Fein)
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I do not think we have any time left.

Dr. Mick Molloy:

Can I pick up on the Deputy’s point, please-----

Richard Boyd Barrett (Dún Laoghaire, People Before Profit Alliance)
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Could I ask one other question, and Dr. Molloy can then come back with his contribution? I ask our guests to comment on a phenomenon which strikes me. When I hear about the constant overcrowding in our emergency departments, I am simultaneously listening to the radio in the car and hearing advertisements to come to the Beacon or the Blackrock Clinic, etc., to receive emergency care there. The clear implication is that if one is in the public system, one is going to a war zone in one of our public hospitals where one will be on a trolley for hours and will be dealing with stressed staff, but if one goes to a private hospital for emergency care and can afford to do so, one will not have a problem. Is that the reality? To what extent does that reality say something about where we could get the additional capacity to resolve the problem we have in our public health system?

Dr. Mick Molloy:

All of those hospitals have a function to fulfil right now because they are decompressing the public emergency departments. If they did not exist, one can imagine how much worse the problem would be. Granted, they only operate at a limited time during the day. With some of them it is ten hours and with others it is 12 hours a day. If that volume was taken from them and placed back into the public system, it would mean it would be even worse.

To be honest, those hospitals are very much concentrated in the Dublin area. I do not work in that area but work in a smaller model 3 hospital in the country. We have a critical need to recognise the importance of future-proofing these model 3 hospitals. Just because patients in these areas live remotely from Dublin, it does not mean they deserve a lesser form of healthcare. Unfortunately, the majority of the resources seem to be directed towards the large model 4 hospitals. If one is in a smaller hospital without all of the services on site, the patients who come to the emergency department are the same types of patients who go to the larger teaching hospitals in Dublin. When someone with a fracture presents to a hospital without on-site orthopaedic treatment, one has to get involved in phone calls and remote consultations to get him or her referred onwards. In the case of somebody with a brain haemorrhage, one tries to refer him or her to Beaumont Hospital. If the patient has a myocardial infarction, one tries to get him or her into a percutaneous coronary intervention, PCI, lab. All of this requires more resources in the smaller hospital and not less.

I would like to mention a particular issue that arises. The Deputy started talking about community healthcare. Community healthcare is available 39 hours a week but is not available 129 hours a week, which is the majority of the time. When someone has an acute need outside of normal hours, he or she rings an ambulance and is brought to a hospital. There are four hospitals in the country that do not have on-site psychiatric services. I work in one of them. When a person calls an ambulance, that is where he or she will be brought. When I have dealt with that patient and have tried to get him or her into the next part of the care system, which involves referring to a hospital 50 miles away, I might call the ambulance service only to be told it will not take the patient. It will say that the patient is voluntary, not involuntary, and should transport himself or herself the 50 miles to the next hospital. There are standardised bypass protocols in the National Ambulance Service to protect and bypass the large Dublin hospitals. For example, paediatric patients or labouring obstetric patients are not brought to the adult hospitals in Dublin. We receive those patients in the hospital I work in because we have those services on-site, but we do not have psychiatric services on-site. There should be a similar bypass protocol for people with acute psychiatric emergencies to go to the places which have those services so that they are not brought to a smaller hospital which does not and cannot provide a service for those patients' needs.

Seán Crowe (Dublin South West, Sinn Fein)
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I will move on to the next question.

Richard Boyd Barrett (Dún Laoghaire, People Before Profit Alliance)
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I thank our witnesses.

Seán Crowe (Dublin South West, Sinn Fein)
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Apologies but we may have a chance return to these issues. I call Deputy Colm Burke.

Colm Burke (Cork North Central, Fine Gael)
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I thank the Chairman and all our guests for the work done, particularly over the past two years. It has been a particularly difficult time for everyone. The dedication and commitment of all of our staff in all of our hospitals and throughout the healthcare system must be greatly appreciated. I thank them for their work in very difficult times.

One of the points made in the IMO presentation was that there is a need for 5,000 additional public acute beds. We have seen the recommendation from Sláintecare for elective hospitals for-----

Seán Crowe (Dublin South West, Sinn Fein)
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We are having problems seeing the Deputy on the screen. Can the Deputy come down to the committee room, please? We will move on to another speaker in the meantime and bring the Deputy back in when he arrives. The Deputy is not appearing on the broadcasting screen.

Colm Burke (Cork North Central, Fine Gael)
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I will do that.

Seán Crowe (Dublin South West, Sinn Fein)
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I call Deputy Cathal Crowe.

Cathal Crowe (Clare, Fianna Fail)
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I thank the Chairman. I extend my apologies as I have been following the meeting remotely. I have read the opening statements and have been listening to the debate so far this morning. I join others in thanking all personnel in the front-line health service for what they have been doing. I am the son of a nurse. My mother is now retired but she has said many times over the past two years that she does not know how nurses, particularly younger nurses entering the profession, are coping with all of this. That is where I wish to begin my questioning.

Can I ask Ms McGowan whether young men and women who are in the leaving certificate year and considering college choices are put off joining the profession given what they have seen on TV with regard to pay and conditions, Covid-19 and the abuse Ms McGowan has referred to? At a time when more and more staff need to be recruited, is there a worry that many people will be discouraged from joining the profession?

Ms Karen McGowan:

That is a very good question. Based on the applications for nursing this year, there has been an increase in students applying for nursing and midwifery courses. Having said that, it is a long four years and it is particularly difficult when the circumstances in which they are working are challenging. We certainly need to retain and to keep training the nurses in the way we are doing but it is a very challenging environment and the next four years will be very challenging and telling.

Cathal Crowe (Clare, Fianna Fail)
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By a small extension to that, I was a teacher before I entered the Dáil, and we would often hear from special needs assistants, SNAs. I understand that they are in a different world but they are also nonetheless involved in the caring profession. Many people who work in that career have come to us to say that it is very demoralising.

Many of them cannot get mortgages. Have the witnesses' front-line colleagues struggled over the past two years as property prices and the cost of living have gone up? Are nurses struggling at the moment to raise loans with financial institutions to buy homes and to live near hospital environments?

Ms Karen McGowan:

I will get Ms Ní Sheaghdha to take this question as I might not have some of the statistics to hand. On a personal level they are struggling, particularly in the Dublin area. Colleagues have struggled to buy houses and have had to look further afield so the commute has increased. We cannot work from home. There is that element in recent times with fuel costs and so on. It is a bit of a worry and a source of stress.

Ms Phil Ní Sheaghdha:

What Ms McGowan has said is the picture. We have a conference coming up in May and are currently accepting motions from our delegates. The salary for nurses is very modest and the cost of living increases have extraordinarily affected their ability to live in Dublin, particularly, while Cork and Galway are not far behind. Also the price of rent is just the same as it is for everybody else living in a big city. In the nurses' view, it has not been taken into account that essential workers must live near where they work. They would be looking for essential workers to be considered when zoning legislation, particularly, is being considered, for example around the new children's hospital. We are going to need significant numbers of staff to come and live in Dublin city. We simply will not have accommodation that is affordable for them. There is a massive issue right across the cost and availability of accommodation and the very modest salaries. We either increase the salaries or we provide subsidised accommodation, or both.

Cathal Crowe (Clare, Fianna Fail)
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Our committee would like to hear more on that after the INMO conference. There is a high-profile case that I will not get into today of a healthcare professional, a front-line worker, who, owing to tiredness, would have had a road traffic accident coming home from work. Ms Hetherington wants to come in on that.

Ms Vanessa Hetherington:

That issue of tiredness is something we are really concerned about among non-consultant hospital doctors, NCHDs. We long know that their contractual hours and requirements breach the European working time directive. Tiredness, fatigue and that risk of having an accident are well known. A recent survey we carried out showed that seven out of ten of all our doctors are showing signs of burn-out. It is actually higher among the NCHDs at eight out of ten.

Going back to those risks of understaffing that the Deputy was asking about-----

Cathal Crowe (Clare, Fianna Fail)
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I have such limited time, if Ms Hetherington does not mind coming in at the end.

Ms Vanessa Hetherington:

I just wanted to make a point again about the cost of living. The way the training programmes are set out at the moment means that NCHDs often have to move every six months around the country. They often have to be two hours away from their families. They therefore have additional costs on top of their own normal family costs.

Cathal Crowe (Clare, Fianna Fail)
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I appreciate that. I apologise for cutting across Ms Hetherington. We have very limited time when we get to speak here. I want to discuss my local hospital group, the University of Limerick Hospitals Group. Perhaps Ms Hetherington can come in on that also. First I want to ask Ms Ní Sheaghdha and Ms McGowan if it concerns them that the management of this hospital group have upped sticks from the University Hospital Limerick, UHL, environment and moved 2 km up the road to an office building far removed from the clinical environment. I have been told by some people in senior management that nurses are delighted they have upped sticks and moved out of the hospital. I think it is the opposite.

When I was a teacher, our principal was based in the school, not down the road. In a local Garda station the sergeant and inspector are based on campus. I find it incredible that this move has happened, given that it is the most pressurised hospital in our system and persistently has the worst waiting times and trolley numbers. The management has been tasked with running it by the Government, the HSE and the Department of Health. This is not personal but operationally, at least, they should be based in the hospital not up in an office block far removed from where their nurses, doctors, cleaning staff and attendants are under pressure. Is it an issue? Is the INMO concerned about it? Are the nurses in UHL concerned that managers are not present on the hospital campus?

Ms Phil Ní Sheaghdha:

The thing that is most concerning nurses working in UHL is their inability to provide safe care. They have been talking about it and met the Minister for Health directly a number of weeks ago. They have looked for an independent review of the system currently in place in UHL, not the management system but the current system of patient flow. That has been refused. They have looked for the Health Information and Quality Authority, HIQA, to come and inspect the hospital. HIQA wrote to management and got a response. HIQA has written back to us saying it is satisfied with that response and feels an inspection would add further to the pressures. We do not accept that. In our submission today we have attached the letter from HIQA. We believe fundamentally that there are legacy issues in Limerick, namely that the reconfiguration did not provide sufficient bed numbers in the Dooradoyle campus. The 100 beds that were added made no difference so there is now another issue. We need to see how patient flow is being managed. We believe that requires an independent investigation which should happen immediately. We do not accept that it cannot or should not happen. We ask the committee to speak with the Minister for Health and ask him to change his mind about that matter.

Cathal Crowe (Clare, Fianna Fail)
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I agree fully. Can I go back to that question a small bit in terms of how the hospital is managed? Is it effective or ineffective to be remote from the hospital site in terms of having oversight? Does it matter to nurses? I really want to get to this. I have another follow-up question in a moment. Does it matter? Can a hospital be managed remotely?

Ms Phil Ní Sheaghdha:

Clinical management must be on-site. There are no two ways about it. We must have clinical oversight. Senior clinicians, whether nurses or doctors, cannot do that job remotely. They have to be on-site. That is a 24-7 job. They do not have the option of leaving at 5 o'clock. They are there constantly, leading their team. When the hospital is in crisis, the most senior clinicians must be on-site, even if that is after 6 o'clock.

Cathal Crowe (Clare, Fianna Fail)
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Would an elective-only hospital alleviate the burden of pressure that the mid-west is feeling at the moment? Incredibly, while Sláintecare recommended elective-only hospitals for Dublin, Cork and Galway, the mid-west and UHL, with 700,000 people funnelling through it under huge pressure, have no such recommendation.

Ms Phil Ní Sheaghdha:

The elective-only hospital as envisaged by Sláintecare - Deputy Shortall, who chaired that committee, can correct me if I am wrong - was not for the provision of day services only. The three elective hospitals that are now being developed are for day surgeries and day procedures only. They will not assist in any location. They will possibly decrease the numbers attending outpatients and day surgery but they will not assist in our battle to provide overcrowding solutions. The problem we have in our acute hospitals right now is that our day surgeries are full of inpatients. The elective hospitals as envisaged by Sláintecare in our view were never designed to close at 5 o'clock.

Cathal Crowe (Clare, Fianna Fail)
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I thank Ms Ní Sheaghdha. I am done with my questions but some witnesses are indicating. That is in your control, Chairman. If others want to respond I am more than happy to hear their responses.

Dr. Mick Molloy:

Deputy Cathal Crowe mentioned the overcrowding in the hospital. I do not believe elective hospitals will have any immediate impact on that. Over a 20- or 25-year period we might then have fewer people developing emergency problems and needing to be admitted into UHL. That type of population demographic should require an elective hospital in that area.

The difficulty at the moment is the TrolleyGAR figures. I do not know if the committee receives them. There are directives from the HSE to hospitals not to count certain patients. We do not count somebody who is put into a day care bed, a day surgery bed, or the acute medical admissions unit. That now means all that activity cannot take place on the day.

We are just displacing other people and other activities, yet it is not reflected in the figures. The true TrolleyGAR figures could be twice as high as the numbers we have, and on some days could be well over 1,000 patients. If we have 11,000 beds and 1,000 trolleys, that means we cannot accommodate 10% of the emergency admissions we have, let alone deal with elective care as it stands. There is a huge capacity issue that must be addressed by fairly rapid modular builds at this stage. If we look back to the start of the Covid-19 pandemic, China was able to build a hospital with 1,000 beds in ten days. Why can we not do something similar?

Seán Crowe (Dublin South West, Sinn Fein)
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I will move on to Deputy Colm Burke.

Cathal Crowe (Clare, Fianna Fail)
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My apologies, Chairman. The time is so restrictive.

Colm Burke (Cork North Central, Fine Gael)
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To reiterate what I said earlier, I thank our guests and all the members of their organisations for the work they have done, particularly over the past two years. It has been a very difficult time for everyone involved.

The presentation from the IMO referred to 5,000 additional hospital beds. This issue came up while I was on my way here. I refer to the proposed elective hospitals for Cork, Galway and Dublin. The report presented from Sláintecare was to the effect that they would provide day facilities only. I cannot talk about Galway or Dublin, but we definitely have a bed capacity issue in Cork. The IMO made a substantial contribution when the Sláintecare issue was being dealt with. How does it fit that into what is being proposed for these three centres?

Dr. Mick Molloy:

The question is very valid. We are almost talking about two, or even three or four, competing systems. We are talking about chronic care, acute care, emergency care and the elective hospitals' elective care, which is different again. The 5,000 extra beds was from a Department of Health report 20 years ago. We have followed that since then and looked at the trends in admissions. The international evidence suggests that when a hospital is operating at above 85% capacity it becomes less efficient, there are more mistakes, there are more problems with admissions and there are more things missed because of the difficulty in moving all the people around to accommodate them. In fact, that 85% figure is predicated on-----

Colm Burke (Cork North Central, Fine Gael)
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Is Dr. Molloy saying that the proposal of day-only care for the elective hospitals is not a workable solution and will not contribute anything to dealing with the difficulties?

Dr. Mick Molloy:

A very significant percentage of surgical procedures, 70% of them, can be operated as day case only, but there are some patients who, when they have had the day case procedure, will have a complication on the day that requires admission. Some of these elective hospitals, of necessity, will need to have overnight facilities.

Colm Burke (Cork North Central, Fine Gael)
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Does Dr. Molloy, therefore, accept that the proposal of day-only hospitals is not a workable solution in real terms if we want to deal with bed capacity?

Dr. Mick Molloy:

It is not the only answer; it is part of the answer. Additional bed capacity is always to be welcomed. It is one part of the solution, but it is not the only solution at present.

Colm Burke (Cork North Central, Fine Gael)
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I wish to move to another issue Dr. Molloy raised earlier, which was access to theatres. I was recently speaking to a consultant in the north west. She has a half day a week. She came back from the United States where she had two days of operating space when she was working in the hospital there. She tries to get three operations done in the half day. However, she has been advised that if a patient is not in theatre by 4 p.m, the procedure cannot take place and, therefore, she is finding that she is cancelling one in every three operations. How can issues such as that with theatres be resolved? There are theatres in all the hospitals and comparing their usage with theatre usage in the private sector suggests they are not being used for the same number of hours. How can that issue be overcome? I know it is a staffing issue and that it is necessary to work with staff from all sectors, but how can that issue be dealt with?

Dr. Mick Molloy:

The Deputy has identified the solution himself. It is staffing, and it requires agreement from a large group of people. It is not just doctors, surgeons and anaesthetists; it is the laboratory technicians, the porter staff, the nursing staff, the operating theatre staff and the day case staff. There have been proposals-----

Colm Burke (Cork North Central, Fine Gael)
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Does Dr. Molloy accept that the facilities in the public sector are not being used sufficiently? With regard to day care, in particular, if hospitals had the staff, they would be able to deal with greater numbers.

Dr. Mick Molloy:

We absolutely would be able to deal with greater numbers. At present, we have these operating theatre sessions in day case units working five days a week. There are proposals to operate them seven days a week, but that will obviously have staffing requirements and flexibility in work requirements. However, as the Deputy has identified with the surgeon he was talking to, there is a willingness on the surgeon's behalf to perform surgeries. When the surgeon worked in the United States, and I worked there myself, people would have had routine operations on Saturdays and Sundays. In fact, in the hospital I worked in, the patient would be admitted to a hotel the night before, would be woken up at 4 a.m. to have a computed axial tomography, CAT, scan and then be in the outpatient clinic for 8 a.m. to have the decision made on surgery for that afternoon. It is a much more condensed episode of care, not multiple episodes as outpatients. I am not sure we have the resources in our system to go to that because it is a fully-funded, private health insurance system in those situations in the United States, but there is certainly a lot more ability and efficiency to be driven in our system with the appropriate-----

Colm Burke (Cork North Central, Fine Gael)
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I will move to the issue of numbers in the HSE. The figures I have are up to October of last year. It is about having staff and then making sure they are able to work in the facilities and have access to theatres, wards or whatever. In December 2014, there were 103,028 working in the HSE and, last October, there were 131,000, which is a 27.7% increase. I know we are looking for more staff. However, we have additional staff, but the question is whether they are able to function and access theatres, procedure rooms and so forth. Is enough being done in trying to deal with the staff we have as regards making sure they are able to do all the work they want to do?

Dr. Mick Molloy:

The Deputy mentioned very large figures. The numbers employed in the HSE and the health service overall do not all work in hospitals. Going back to the Sláintecare model, many people have been hired in the past year to address the chronic care in the community programmes.

Colm Burke (Cork North Central, Fine Gael)
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I will give Dr. Molloy the figures for the community. There is a 27.7% increase in HSE staff since December 2014. The increase in public health nurses is 4.05%. It has gone from 1,480 to 1,543, an increase of 60. The figure for home help has gone down from 3,703 in 2014 to 3,552 in 2021. If we are focusing on community care, we must have the staff and that does not appear to be happening.

Dr. Mick Molloy:

Sure, but I do not believe that reflects all the staff working in the community. There are community social workers, occupational therapists-----

Colm Burke (Cork North Central, Fine Gael)
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I accept that, but I am talking about public health nurses now. There is an increase of 4%.

Dr. Mick Molloy:

That is a question Ms Ní Sheaghdha would probably address better than we in the IMO. However, looking specifically at the hospitals, there have been increases in hospital staff over the period, but we have been going through that Covid scenario where we have had buddy staff working arrangements for bringing Covid patients from one ward to another, up to radiography, into X-ray suites or into operating theatre suites. We have hired a lot more cleaning staff to deal with Covid. It has not been the ideal time to look at how efficiently the hospitals work because it has been a completely different work practice with the personal protective equipment, PPE, and having people monitor people putting PPE on and off, which technically is not a very productive job but is necessary during a public health emergency.

Colm Burke (Cork North Central, Fine Gael)
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In fairness to the HSE, the overall number of junior doctors and consultants increased by 36% in that period.

Ms Vanessa Hetherington:

There is absolutely no doubt that the number of doctors has increased but that does not mean those increases are sufficient.

Colm Burke (Cork North Central, Fine Gael)
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I accept that. I am concerned about appointing people who are then unable to get access to do the work they want to do.

Ms Vanessa Hetherington:

That all goes back to the capacity issue.

Colm Burke (Cork North Central, Fine Gael)
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That goes back to the issue I raised initially, which is about having a day facility only and not having inpatient beds.

Ms Vanessa Hetherington:

The day facility is one small answer to the solution. The issue is capacity across the whole system. If elective surgeries are increased, the day cases will be good and we will stop cancelling elective care but capacity within the hospital system will still not be sufficient, even for the emergency care that we need.

Ms Phil Ní Sheaghdha:

Can I answer the question on staffing?

Colm Burke (Cork North Central, Fine Gael)
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If I may, I will ask the first question as it is for Ms Ní Sheaghdha. She mentioned the bureaucratic problems in the HSE. Will she expand on that? How can the bureaucracy that nursing and other staff must put up with be resolved over the next two to three years?

Ms Phil Ní Sheaghdha:

For the record, the October 2021 census versus December 2019 census shows an increase of 0.4% in public health nursing. It shows 16 additional whole-time equivalents. In that two-year period, eight public health nurses were added each year when we are trying to build community services. It is not 4% but 0.4%.

Colm Burke (Cork North Central, Fine Gael)
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My figure was from December 2014 to date, which shows there was a total increase of 60 staff.

Ms Phil Ní Sheaghdha:

At the moment, we have 1,537 whole-time equivalent public health nurses employed.

Colm Burke (Cork North Central, Fine Gael)
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Yes.

Ms Phil Ní Sheaghdha:

The staff increases, as my colleague from the IMO said, are largely reflected in the new services. There are many new services in which nurses and other healthcare professionals now work that were not there prior to Covid. The modest increase is staffing those services.

To answer the question in respect of acute-only hospitals, the TrolleyGAR, which is the HSE's trolley count figure, only reflects patients in EDs. Our count reflects and counts patients who are admitted on trolleys anywhere in the hospital. That is why the figure is usually higher. For example, today we have recorded over 500 patients on trolleys, 80 of whom are throughout the hospital in various units and corridors. The HSE does not count those whereas we do.

It is important to look at why theatre time is not provided, which was the question originally asked by the Deputy. That is usually because there is no bed available for the patient who requires a bed post surgery. Many patients return post procedure to a trolley in ED for emergencies. Surely that is not what we are advocating. We have surgeons who work in private and public hospitals so that goes back to the contract. I am not getting into that discussion but there are issues relating to public-only contracts and we support Sláintecare's position on that.

It is important if acute-only hospitals are concentrating on day cases that we state clearly that patients who require admission will have to be put in an ambulance and transferred to a hospital where they have an inpatient bed. If the day surgery hospital is the model and it closes at 5 o'clock on a Friday evening, there will be patients who will require care over the weekend in some instances. That again will put further pressure on the acute hospital. The model should be to provide inpatient beds on a 24-7 basis because that will reduce waiting lists and release the pressure on the acute emergency hospitals and the departments that are currently under such pressure.

In respect of bureaucracy, as we are saying, particularly in the reference to recruitment, it is so difficult to get through the red tape and recruit. Many hospitals still rely on agency staff because it is so difficult to replace staff and get through the bureaucracy that has become the machine of recruitment in the HSE in particular. The voluntary hospitals have a little bit more control. We need to get that cleared because if someone wants to work and is willing to come to work, bureaucratic obstacles should not be placed in his or her way. I hope I have answered the Deputy's question.

Annie Hoey (Labour)
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I thank the guests for their presentations. I was struck by Ms Ní Sheaghdha comment that the HSE does not count certain patients on trolleys whereas the INMO does. It seems most unethical and immoral that the HSE does not count the figures but the INMO does. The HSE seems to be grossly neglecting its responsibility to have accurate figures. We know the INMO counts these patients but we should be shocked to learn that the HSE does not count them. It is unacceptable.

I have a couple of questions on Sláintecare. Do the witnesses have confidence in the current Sláintecare personnel given the hiccups that its various teams have had over the past while? Are they confident that we will achieve the roll-out of Sláintecare as envisioned, needed and promised or will we end up with a piecemeal or hodgepodge version of Sláintecare that will not serve anyone? Are they confident we will get Sláintecare as envisaged or are we all jumping around hoping for the best?

Ms Vanessa Hetherington:

Our simple answer is "No". We have such huge capacity issues across the health system. While no one can question the value of Sláintecare, where is the capacity? As many as 2,000 additional consultants and 5,000 additional beds are required, yet all we are talking about here are small day-case hospitals in three areas. There is no plan to recruit additional consultants to the scale required and we cannot even recruit and retain the consultants we have.

Dr. Mick Molloy:

We are five years into the Sláintecare proposals. The previous chief executive of the HSE said that it should have been front-loaded with a dedicated build early on in play to generate public confidence, early wins and support. Five years down the line, there does not seem to be a willingness to invest in Sláintecare. It is the same as every other report that has come before. The Department of Health has produced some fantastic reports but they have not all been implemented. If they were implemented, we would not be here having a discussion about capacity. A report compiled by the Department of Health 20 years ago recommended an additional 5,000 beds. Had those beds been put in place, we would be having a discussion, one about a four-week waiting list rather than the current four-year waiting list in some services.

Ms Phil Ní Sheaghdha:

We do not see universal access based on need at the moment, nor have we seen it for the past number of years. We certainly do not imagine it will happen any time in the future unless there is fundamental change to the implementation of Sláintecare, inclusive of, at the highest level of the Government, responsibility for implementation. We have gone further than that in our submission and said that this is fundamental. Ms McGowan works in a hospital and can give a first-hand account of patients not being treated in a manner that would be classified as dignified or safe in most of our emergency departments. That is not due to any fault of those who work in these departments but simply because of the environment, overcrowding and missed care. The long waits on trolleys, as stated earlier, are now causing problems for recovery and people are having negative outcomes as a result.

In addition, we now have cross-infection with Covid and airborne disease. Imagine 520 people on trolleys today in overcrowded environments with an airborne pathogen in the environment. It is simply wrong. It is inhumane. Unless there is real action taken to implement and fast-track Sláintecare, it will not change. We cannot change it but we will continue to highlight every single day what is inappropriate, what is inhumane and what is simply not tolerable for patients or for staff.

Ms Catherine Keogh:

Fórsa is a strong supporter of Sláintecare and we would still be very hopeful it can be implemented, but that will not happen within the four walls of this room. It has to be a Government decision and, as Ms Ní Sheaghdha said, we need the involvement of the Taoiseach. I mentioned earlier, and it is worth repeating, that our view in Fórsa is we need a high-level role for the social partners. This is something for the whole country; it is something for every citizen in the country. Citizens want it and workers want it. We asked in our submission and I am still asking what is the real inhibitor. It is not us and it is nobody in this room. I would still say that, yes, I can see Sláintecare being implemented but it will take a whole-of-government approach. It was a whole-of-government approach that introduced it but it needs to be driven at the highest level.

Annie Hoey (Labour)
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I thank the witnesses. I have only been in this role for two years and we have had Covid in the middle of all of that. However, it seems this predates Covid. It seems we are constantly talking about what could be, but I do not know where the movement is coming from to make that a reality. Maybe that is because I am being cynical. We in the Labour Party are enormous supporters of a single-tier healthcare system, so it is very frustrating, and I can only imagine how frustrating it is for the witnesses. I am sitting here, looking at the whole thing, and it is immensely frustrating.

I want to raise two other issues. Is it fair to say overcrowding and what the witnesses are describing is having an impact on recruitment? I think it is having an impact, particularly on nursing, and I do not know that we have fully got to grips with this in terms of the impact it is having. The witnesses might be able to expand on this. I talk to a number of student nurses and midwives and my mouth nearly hits the floor whenever one of them says, “I am going to stay and try to work in emergency.” I reply “What?” because it seems crazy to me. It is unusual for me to know someone who says they are going to stay here. It is fair to say it is impacting on recruitment but perhaps the witnesses would expand further on that. Core pay is a core issue but I also think we are not getting to grips with the wider issue. We talk about overcrowding in terms of it being bad for the patient and so on, but this obviously has a long-term impact on our ability even to roll out Sláintecare because we are just not at it, so to speak.

Dr. Mick Molloy:

I will give an example. I went to Australia two years ago for a conference and made a point of going to a particular hospital in Perth to meet some medical colleagues. We have 700 interns a year, which is the first year after coming out of medical school. In that particular year, 380 of the 700 left Ireland to go to Perth. They did not see their future working in the Irish health service. They saw there were better terms and conditions, lifestyle and work-life balance in Australia, and Australia has been a major beneficiary of our medical graduates for the past ten years. In fact, there are probably more medical graduates from Irish medical schools now working in Australia than there are in Ireland, such has been the volume of exports. That obviously stopped during Covid, but there are now a large number of people pooled up who are all trying to leave, which is going to lead to a big issue as to where we get the middling 30, 35 and 40-year-old group of doctors who we would see as being the future of our health service in the country, because they are not going to be here. They will be abroad getting family life and structures set up abroad, and it will make it very difficult to recruit them back.

If these are the people who are now being made to work excessive hours and not getting their rest breaks, and we are saying we want to try to recruit them back to the country, they will not have trust in that as an employer of choice because they have had a different service and a different experience overseas. We have to compete with that. We have to look at that and ask how we structure career prospects for these people. We are currently saying people are appointed to a job for two years but they are going to spend six months in Dublin, six months in Waterford, six months in Wexford and six months in Clonmel. How do people manage a family life like that? It is very difficult, yet that is what we are expecting people to do. On the other hand, if they go to Australia, they work in one city, one hospital, for five or ten years in a row.

Annie Hoey (Labour)
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In regard to workforce planning, we are getting bubbles of people, an injection of funding goes into an area and it then bubbles up. However, I will not go into workforce planning. When talking about trolleys, it was said that the patients are not counted and, therefore, staff are not assigned. I want to make sure I heard that correctly because that would mean staff numbers do not take account of the fact there are going to be so many people on trolleys in different hospitals. Is my understanding correct?

Dr. Mick Molloy:

Working in the emergency department, that would be a very common problem. Emergency departments, as an environment, in general have between 12 and 20 spaces and they can have between 50 and 60 patients in them at any one time, but they are staffed for the 12 to 20 spaces, not for the 60. If we have a sudden surge tonight at the department I work in and I go looking for additional nursing staff, I will be told they are not available and there is nowhere to find them at short notice. It is okay if we want to book agency staff for next week or the week after for planned leave periods but we cannot get them at short notice, which means the staff who are there have to work harder and are under a lot more pressure, not getting their breaks and not even getting toilet breaks at times because of the volume of work in those emergency departments.

Annie Hoey (Labour)
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That is crazy. No wonder we are goosed. I have listened to this whole thing and I have read the submissions. As I said, I am at this for two years, which is only a short time. Every single time we are discussing this and every time the witnesses and this cohort come in, my mouth is just hanging open. It just seems crazy and, I would say, immoral, unethical and inhumane on both patients and staff. It is crazy we are standing over this. It seems absolutely crazy.

Ms Vanessa Hetherington:

To add to that, over the past five years, 3,000 doctors have left the medical register to take up positions abroad, and that is not even including the ones who have retired. We have probably around the same number who are on the register but working abroad, and they will probably never come back. It is a huge issue. We are crying out for doctors and the biggest problem is the working conditions they are in. They are junior doctors. They had experiences in training where they were working excessive hours. They are burnt out and fatigued, and they are just saying they trained and are out of here, that they are not going to put up with what their colleagues and superiors are doing.

Ms Phil Ní Sheaghdha:

On staffing, the lack of a funded annual workforce plan means the plan is very ad hoc. We have to refer very regularly to the Workplace Relations Commission for increased staffing when the volume of patients increases. Every day, as the Irish Medical Organisation has just pointed out, we have sometimes two wards' worth of patients for whom there is no allocation of nurses. Even worse, we have examples where trolleys are being moved from emergency departments, EDs, into different areas so they do not form part of the count. To our mind, that is absolutely scandalous. That is not looking after the patient. That is making sure the trolley count figure is low and that is simply not acceptable. We raise that with each hospital manager in each site when it happens because our figures, regardless of where the trolley is, are counted on the basis that that is the true and accurate figure, which must be recorded because the consequences for patients and the consequences of not having proper staffing are that care is not delivered.

Ms Karen McGowan:

There is an age-old problem with overcrowding and it is not going away. We had Covid and then we had hope with the vaccination, and that curbed it, but there is no vaccination that is going to curb this overcrowding. There is hope with Sláintecare and there is a pathway to get out of this. That is how we need to retain our staff, make it more attractive and improve the conditions we have.

Martin Conway (Fine Gael)
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I thank our guests. We have had an informative discussion, although one might feel we are going over old ground. I listened to Ms Ní Sheaghdha's engagement with previous speakers, particularly on the issue of UHL. We all agree there has been significant Government investment in the hospital, including in the emergency unit and the 60-bed modular unit. As a politician for the region, these are the things people asked for, as well as the 96-bed unit, which, in real terms, will provide only half that number because of the decommissioning of certain wards and so on. I have thought long and hard about what the problem is in Limerick, which is a problem that does not seem to be as acute in other areas. Ms Ní Sheaghdha spoke about the flow through emergency departments and the issue of delayed discharges. In particular, she spoke about the lack of on-duty clinical management at times. Will she elaborate on that lack of clinical management and how bad it is? What knock-on effects does it have in terms of the situation in emergency units and what we are seeing in Limerick?

Will Ms Ní Sheaghdha also comment on the review? Her opening statement indicates that HIQA has more or less washed its hands of it, saying it does not believe there is any merit in its carrying out a further inquiry. Based on that, I agree with her that it should be done by somebody independent. If that is the view HIQA has taken, what is the point in commissioning it to undertake a further inquiry? I would like her comments on that and perhaps a suggestion as to who should carry out an independent inquiry.

In terms of other facilities, the challenges in Limerick are obvious but there are challenges in other areas as well. What is the significant problem in Limerick that does not exist in other areas? Why is Limerick constantly at the top when it comes to numbers on trolleys? Other areas have problems in this regard but do not seem to hit the same numbers. Of the 520 patients periodically on trolleys, as Ms Ní Sheaghdha referred to, at least 20% of them are in Limerick. I am trying to figure out what is being done differently in other areas such that the problem is not as acute as it is in Limerick. I would like to hear her thoughts on those points.

Ms Phil Ní Sheaghdha:

My point in respect of clinical governance is not directed at Limerick; it is in general. We know that the 24-7 nature of healthcare delivery means that clinical teams must be led by senior clinicians. We note that admissions, and the ratio of attendance versus admission, are higher in some hospitals than in others. We looked further into that and asked the HSE for statistics. We are disappointed that the emergency department task force meeting has not been held, despite our seeking it, because it would give us a lot of this information and, from that, we could determine how matters might be improved. For example, if the attendance to admission ratio is higher in some hospitals, we have to look at why that is so. If it happens between 6 p.m. and 2 a.m., which it does in some hospitals, we must look then at the seniority of the admitting doctor. If consultants are on duty during that period, we find, in many instances, that the admission rate reduces because they have the clinical confidence to say to a patient that he or she can go home and come back to the outpatients department tomorrow or be sent for further referrals, if necessary. It is about clinical confidence and the seniority of the clinician making the decisions. When we see increased admission rates between 6 p.m. and 2 a.m., we must ask that question.

Furthermore, we see many patients attending who have not been seen in the community by GPs, largely, the latter tell us, because they do not have that capacity. We are seeing an increase in children being admitted and attending hospital emergency departments, particularly in the out-of-hours period, whose parents say they have not been able to access GPs. There is a whole load of issues and the nub of it is there is no one problem that can be fixed at a site like Limerick. There is history there whereby reconfiguration left it with a lot of problems. The independent review must take into account the availability of beds in Nenagh and Ennis and how they are being used, as well as what services are being curtailed because of the lack of beds on the site in Dooradoyle and whether services for older people could be supported. The most recent statistics we have seen show there is a higher number of over-75s attending there. The independent review should and must take all of that into account and we also need to look at how patient flow happens through a region as opposed to just concentrating on a particular site. Last week, there were four discharges from one of our major acute hospitals between Friday and Monday.

Martin Conway (Fine Gael)
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Was UHL the hospital in question?

Ms Phil Ní Sheaghdha:

No, it was one of the major Dublin hospitals.

Martin Conway (Fine Gael)
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From the INMO's engagement on this issue and what Ms Ní Sheaghdha is saying here today about the lack of senior clinical management to do the discharging at certain hours, is it fair for us to conclude that this type of senior management is not in place at critical times in Limerick?

Ms Phil Ní Sheaghdha:

I think it is fair to say that we have to look at the times at which admissions take place. When we have an agreement in place - which we do, namely, the escalation policy - and any hospital has overcrowding to the level we have seen in all of our hospitals since last November, we then expect there to be very regular ward rounds focused on discharge and, in addition, an examination of instances, which we know are happening, where patients are being admitted because they cannot access diagnostics. We have examples of patients being admitted on a Friday for a scan on a Tuesday.

Martin Conway (Fine Gael)
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I accept that and I know it is a problem nationwide, but it is a much bigger problem in Limerick.

Ms Phil Ní Sheaghdha:

The point of looking for an examination is for us not to conclude matters ourselves but to get independent experts looking to see what are the problems.

Martin Conway (Fine Gael)
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I accept that. However, based on our engagement here this morning, and I put this to-----

Ms Phil Ní Sheaghdha:

I would say there are a lot of questions to which we need answers. We need experts to go in, lift up the bonnet and have a look. We will gladly co-operate with that if there are matters relating to nursing.

Martin Conway (Fine Gael)
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Does Ms Ní Sheaghdha believe there is resistance to the type of independent inquiry that would do that kind of unearthing?

Ms Phil Ní Sheaghdha:

It has been refused. We have asked the Minister and he has refused.

Martin Conway (Fine Gael)
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For the record, I have asked the Minister the same. I also asked the chief executive of the HSE, when he was here two weeks ago, and Mr. Robert Watt whether they have confidence in the management in Limerick, to which both responded that they absolutely do. I pose the same question to Ms Ní Sheaghdha. Does the INMO have confidence in the management at UHL at this moment in time?

Ms Phil Ní Sheaghdha:

I am saying that what we are looking for is an independent review of all the patient flow issues. I am not going to comment on the management at UHL or elsewhere until such time as there is independent scrutiny into all of the aspects of how patients are dealt with from the time they attend the emergency department to the time they are discharged. That is what we are looking for and what we are interested in happening.

Martin Conway (Fine Gael)
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While we are awaiting confirmation of such an independent review, which we all will keep seeking, what can be done by senior management immediately to try to deal with the ongoing diabolical situation whereby up to 100 people are on trolleys at UHL? If Ms Ní Sheaghdha were to pick two or three actions that need to be taken immediately to deal with that, from her experience and the information she is getting from her people in the hospital, what would they be?

Ms Phil Ní Sheaghdha:

We must have a greater focus on discharge. We also need to make sure we are cancelling elective procedures. Right now, unfortunately, we cannot provide elective work and emergency work at the same time in overcrowded hospitals. It is not the ideal but we must look to the private sector to provide assistance in regard to elective work when it cannot be catered for in the public hospital system.

What happens is patients are phoned on a daily basis to say they are due to come in that day but there simply is not a bed. Rather than that happening-----

Martin Conway (Fine Gael)
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I take it, given-----

Ms Phil Ní Sheaghdha:

-----over and over again, there should be planning for what we know we will be overcrowding in most of the hospitals right up until the end of March, as we have said already on the record. In addition, the arrangement of cancellation of electives and assistance from the private hospitals should have been, and could still be, extended beyond the timeframe that is currently provided for.

Martin Conway (Fine Gael)
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If the Minister goes ahead with the HIQA review, I take it that Ms Ní Sheaghdha's members will not co-operate with that.

Ms Phil Ní Sheaghdha:

We co-operate with any review. However, what we believe is necessary in the area - given the history in relation to reconfiguration in the Dooradoyle site with Ennis and Nenagh and how those sites operate and interact with each other - is an independent review of all matters, particularly the matter of patient flow and what blockages are there and if they can be fixed.

Martin Conway (Fine Gael)
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I think Dr. Molloy wants to come in.

Dr. Mick Molloy:

There are a number of issues arising from UHL, one of which is the reconfiguration. Two smaller emergency departments were closed and now the patients are being brought on an extended journey to UHL. If those patients arrive late into the evening, there is an HSE target time of six hours from the patient arriving to discharge, which could end up being 2 a.m., 3 a.m. or 4 a.m. At that time, there is often great difficulty in trying to get those patients back home. The default in that scenario and the safest thing to do is to admit those patients at 3 a.m. or 4 a.m. rather than discharging them into an area with no public transport and no ambulance that can convey them back home because of the shortage in the ambulance service. Therefore, we have a structural difficulty. If the hospital were able to engage ambulance services to work predominantly for the hospital on a 24-hour basis to take the patients home again-----

Martin Conway (Fine Gael)
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I get Dr. Molloy's point, but one would have to think that this is the case in other areas as well and is not exclusive to the reconfiguration.

Dr. Mick Molloy:

The reconfiguration was specifically in that area. It has not really applied in most other parts of the system as yet.

Martin Conway (Fine Gael)
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Is it the case that in other hospital groups, people can be discharged in the middle of the night and get home safely?

Dr. Mick Molloy:

Not always, but the volume is higher in this case because UHL is treating patients from what were three hospitals. If one looks at the volume of attendances to UHL, it is one of the highest attendances to any emergency department in the country. It is higher than many of the hospitals in Dublin and yet the bed base in that hospital is smaller than the bed base in those in Dublin.

Martin Conway (Fine Gael)
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When I ask people in the mid-west-----

Seán Crowe (Dublin South West, Sinn Fein)
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Senator Conway is way over time.

Martin Conway (Fine Gael)
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That is fine.

Seán Kyne (Fine Gael)
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I was following deliberations from the office, but I was in and out because I had a number of things in the Seanad as well. I thank the witnesses for attending this morning and all the work their staff have been doing every day, but particularly during the Covid period.

The INMO submission on overcrowding states that nearly 7,600 assaults on HSE staff were reported last year, of which 5,800 were physical, 41 were sexual and 1,700 were verbal. Obviously, one assault is one assault too many. Is there a figure with regard to the influence of alcohol? Was alcohol a contributing factor in these assaults? Not that it is in any way an excuse, of course, but I wonder if it is a contributing factor in a percentage of cases.

Ms Karen McGowan:

It is a contributing factor and drug abuse is as well. However, I do not have the breakdown of that. I do not think it is available. It is something we would need to look for. However, it definitely contributes to a huge amount of assaults on nursing and medical staff in the hospitals.

Seán Kyne (Fine Gael)
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I am conscious of the sort of Friday night and Saturday night revelries that go on, and end up with people under the influence in emergency departments, in the context of what is happening to Ms McGowan's staff.

Ms Karen McGowan:

That is happening and it is not just a Friday night and Saturday night issue. For example, we had an assault on Monday. There is no predictable time. One needs to think of people who are in a horrendous environment for a prolonged period of time. They may have a mental illness. It is a form of torture, as previously highlighted by colleagues. There is only so much people can take and then they break. That is no excuse either, but everybody has a breaking point. When that happens, it is unpredictable. In the emergency environment, it is very dangerous.

Seán Kyne (Fine Gael)
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Absolutely. I would like to return to the discussion on the retention of graduate nurses and doctors in this country. No single issue is solely to blame for this problem. Issues like pay, the cost of living, work pressures and the draw of living abroad have to be considered. Do we have any figures on the percentage of nurses and doctors who eventually return home? It might be their plan when many of them go out that they would return home. Do we know how many actually come back after a period of time abroad?

Dr. Mick Molloy:

We do not have the figures on that. The Medical Council keeps the register and many people who have re-registered have not been off the register. The numbers are small. It tends to happen when people are in their 40s or 50s and looking at a different settling period in life. We do not have hard figures on that. By walking into hospitals and looking at the profile of the staff, one can see people in their early to mid-20s and people from their 40s and 50s on. The group in the middle seems to be quite small.

Ms Phil Ní Sheaghdha:

Just to answer that from a nurse and midwife perspective, we survey our graduate nurses the January before they graduate every year. We have done that for the past four years. Every survey indicates the same thing, which is that they want to stay in Ireland working in the Irish public health service for at least the first year post graduation to consolidate their training. It is the system that is forcing them out. Some will decide to travel and some will decide not to travel. Last year the retention was improved but, again, one has to take into account all of the travel restrictions.

We are also seeing many nurses attempting to return. Again, there are delays in registering with the Nursing and Midwifery Board of Ireland, NMBI. There are some delays in getting registered that can be corrected. That is a simple enough fix. If that is delaying the return, it needs to be fixed. Whatever it takes to invest in additional staffing, and whatever the NMBI needs, must be looked at because that is a simple enough issue to fix. When people want to return, we should be making it as easy as possible for them to return. We also had a programme whereby if staff returned to work in the Irish public health service, there were incentives. As a trade union, we have had to pursue those incentives because they are not paid. The promise is made, and the circular is there, but then one has to follow it and pursue it via the industrial relations channels. If we are serious about making it attractive to come back, all of the agreements that are in place must be implemented and promoted as an incentive and enticement to come back.

Seán Kyne (Fine Gael)
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That is certainly not good enough. If someone wants to come back and is promised incentives but does not get them, word will go back to people in Australia, Canada or elsewhere that Ireland is promising but not delivering on its promises. That is not good enough. We might have to try to follow that up with the Minister as well.

Dr. Mick Molloy:

I apologise for interrupting the Senator, but there is something I forgot to mention. There is another group that is hidden and forgotten in this, and that is the group of Irish students who go to Europe to gain their medical degrees. While they get all of the technical knowledge in the various courses through the university and get a degree, they have difficulty integrating back into the system here because they have not done the Irish legal system in their medical training and they have not worked in the hospital system to understand what the processes are for managing certain types of patients here. We developed a programme with University College Dublin, UCD, to try to help to bridge these doctors back into the working system. We put a proposal to the HSE but we have not been able to get it funded. There are hundreds of Irish medical students who have already spent a period of time in Europe getting a degree and want to come here, but the UK system has developed a process for them to integrate into the UK. We are losing them to the UK when we could actually do with them here.

Seán Kyne (Fine Gael)
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We will take that up as well. Ms Ní Sheaghdha said earlier in relation to a question about Limerick that 100 beds made no difference. I do not want to misquote her. Is that because there were not enough beds, there was not enough staffing, there was not enough utilisation or there were other issues at stake? What did she mean in that case? Obviously, we are all advocating for beds. Some 100 beds is not insignificant but she said it made no difference. Can she expand on that?

Ms Phil Ní Sheaghdha:

Apologies, what I should have said is that it made no difference to the overcrowding.

We still have a chronic overcrowding problem. That is why we are saying that in most cases increased capacity helps. When it does not, it poses a question. That is why we are looking for the independent review to examine why that increased inpatient bed capacity did not improve the overcrowding situation, as one would have imagined it should have done.

Seán Kyne (Fine Gael)
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Perfect.

As for the elective care issues, I think Dr. Molloy or someone else stated that we really need 24-7 inpatient beds in conjunction with elective hospitals. We have this debate in Galway because there are plans for an elective hospital at Merlin Park and for the emergency department at University Hospital Galway, UHG. Depending on traffic, there is a serious distance between them. Effectively, we have a day hospital only, with no inpatient beds, yet we have one of the highest levels of overcrowding. Certainly, we did before Christmas and the neighbouring period, when one in eight patients in Galway, or 12%, was on a trolley, yet we had no acute beds under the winter plan because there was no physical space. An elective hospital is proposed with the promise of acute beds on the never-never. I am concerned about this. I have always been concerned but I am even more concerned about the testimonies here that we really need inpatient beds in conjunction with elective hospitals.

Dr. Mick Molloy:

The two things go hand in hand. There are four streams of healthcare, as we mentioned earlier: chronic, acute, emergency and elective. The elective patients are the ones who tend to suffer because their care can be postponed. The other elements tend to be a little more immediate and take place in the emergency department or the outpatient department. People in cancer treatment and people needing cancer surgeries have to get that care immediately. It happens straight away. However, when people are put on a waiting list, they remain on a waiting list for a long time, hence the need to separate the two groups of patients. Unless there is a significant build in the inpatient facilities, we do not have the capacity to deal with all those elective patients immediately, so those elective hospitals do have a role. A lot of this can be dealt with as day cases but not all of it. Some of it will still require the benefit of a large inpatient facility with additional critical care capacity. Cardiac bypass or cardiac transplant cannot be done as a day case. All that work will still need to be done.

Critical care capacity needs to be enhanced. There was a report in 2009 suggesting our critical care capacity should be 550 beds. After Covid, I think up to 340 beds is our plan at the moment. We will still be well short of what we need in critical care capacity to deal with the volume of the service required at present, so both those elements are required. In the Senator's region in Galway, UHG needs significant expansion in its emergency department. Having been involved in two emergency departments that were new builds, I suggest that very close attention should be paid to the plans that are developed. In both the facilities in which I was involved the places were cut down in size before they were opened. We have now seen the need for them to be increased in size. We should therefore be very careful when the plans are put down that they are not cut back to save some money here and there. If the plan is for 50 or 60 spaces, it should be 50 or 60 spaces. That is what is required. Any of the hospitals in the United States or the UK that function well have significant numbers of spaces for patients to be managed. We expect many of our people to sit on chairs in corridors, which is inappropriate. We have many people waiting in waiting rooms while other patients get their treatment, but they get their antibiotics and fluids while sitting in a waiting area commingling with the patients who are waiting to be seen, which is not acceptable.

Ms Phil Ní Sheaghdha:

There are 54 patients admitted to Galway hospitals today for whom there are no beds. Mayo has 27, Sligo has 13 and Letterkenny has 46. That healthcare group has a chronic overcrowding problem, and one hospital cannot help the other. Clearly, if there are 54 patients on trolleys, that are almost two wards on trolleys in the emergency department, and nothing else will happen in that hospital because it cannot. They are not day cases; they are inpatients. They have been admitted because they are sick enough to require hospital care.

Seán Kyne (Fine Gael)
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Yes, and, as it stands, the Saolta healthcare group has no plans for inpatient beds in Galway. Governments often get blamed, of course, in respect of funding, but funding is not available unless plans are put forward and progressed. There are effectively no plans by Saolta for inpatient beds at UHG. They were not even provided under the winter plan. There is no physical space and there are still no plans.

Seán Crowe (Dublin South West, Sinn Fein)
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I am conscious that others want to come in. I will let them in in a moment.

I have a couple of comments to make. I have been one of those people who has been on a trolley. I have been in an emergency department where there were no free trolleys or chairs. I have been there with a loved one who was dying in the hospital system. People have their own experiences as to how good or how bad the system is in that regard. I had just last week a man in my constituency office who said people have this idea that they will be able to get a cup of tea or something to eat in an emergency department. Someone can be nine hours in an emergency department and the vending machine will be empty. The man in my constituency office said the only thing left in the machine when he was there was sugary popcorn. This is an elderly man who was seriously ill at the time. There are all these lived experiences.

What we are talking about this morning is the overcrowding crisis in our hospitals. There has been collective agreement, judging from many of the submissions, that the solution is Sláintecare. As the witnesses will probably be aware, every two months, following the collapse of the oversight group for the implementation of Sláintecare, the committee has tried to bring in the two chief executives, Paul Reid and Robert Watt, to discuss that. In their latest submission to us they said 87.9% of the Sláintecare goals are on track. The witnesses say clearly in their submissions that this change is not visible. We in the Opposition hear every day that more money is being put into the health service than ever before, but is that view of Sláintecare and its roll-out borne out in the experience of the witnesses' members? I am conscious that what we have heard today is a clear cry for help about assaults on staff and so on. There is clearly something we as a committee can do about that. It would be interesting to follow up on the health and safety legislation, the amendments to it and so on. If the witnesses have suggestions for amendments they feel need to be made in that area or something positive the committee could do, we will certainly follow that up, including with the chief executive and the head of the Department of Health. We will have them in here in the next month or so. What is the witnesses' experience of Sláintecare?

Mr. John McCamley:

As outlined in our submission, we just find progress incredibly slow. That is not unusual for the health service in respect of implementing reports and reviews, and a number of speakers have alluded to that. We certainly have a fear that the slowness in dealing with these issues and the implementation of Sláintecare is having an effect on our members. In preparation for our submission, we spoke to our officials and local representatives across the country. We have reports back from people in the emergency services who are now contemplating just leaving. These are people who have a number of years' experience and who are valuable to the service now saying they will either just leave it entirely for a different career or go abroad.

That is right across the grades, including nurses, midwives, healthcare assistants, radiographers and ambulance staff. It is very frustrating for us, particularly in those areas. The struggles we undertook to get student nurses and midwives something for carrying out clinical placements and proper travel allowances have been alluded to but there are other grades, including radiation therapists and radiographers, who do not receive anything when doing clinical placements. These are areas in which there are chronic shortages. There is going to be an issue with the delivery of radiation therapy because of the lack of radiation therapists who treat cancer patients in the country. That is an area that is going to come to the fore because of the waiting lists and what has happened over the last two years. We are seeking a review into that. A review has been granted but it is progressing incredibly slowly. Among our members, there is a general feeling that there is slowness in trying to develop anything. When we do get an independent report, the implementation of that report is often painfully slow. The main battles relate to the implementation of reports rather than getting reports done. In some cases, as others have indicated, it is very difficult to even get reports agreed. As I have said before, there are definitely issues in respect of morale and burnout. These need to be resolved. We need action from health employers and the Department of Health in that regard.

Seán Crowe (Dublin South West, Sinn Fein)
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I am conscious that two members have indicated they wish to speak but does anyone else wish to contribute?

Ms Catherine Keogh:

I would like to respond on behalf of Fórsa. I do not want to go over all of the ground because I am conscious of the time but we saw the response of the health unions to the health emergency during the pandemic. What the committee is hearing from us this morning is that this is the other health emergency. It does not need to take five years. I mentioned that we have had operational engagement with the employers in respect of parts of Sláintecare but there has been no strategic involvement with all of the unions. That needs to happen and it needs to be driven and focused. The union side will not be found wanting. We were not found wanting when it came to the pandemic.

One of the key issues for Fórsa, which is a flaw at the moment, is that there is no health and social care professional adviser in the Minister's office in the Department of Health. There are 26 or 27 health and social care professional grades. The HSE has a beautiful document called HSCP Deliver 2021-2026. Much of Sláintecare will be delivered through health and social care professionals, HSCPs. One example of such a professional is the clinical measurement physiologist in a hospital. I am going to get the terminology wrong and will be murdered by my members. The work these physiologists do on echocardiograms leads to early discharges. We have been trying to get a report from 2010 implemented, which would involve looking at workforce planning in respect of these vital grades.

Health and social care professionals are years behind our nursing colleagues with regard to advanced practice. If advanced practice was introduced for physiotherapy, occupational therapy and speech and language therapy, with the right numbers and physiotherapists operating at an advanced practice level, orthopaedic waiting lists could be cut. The Minister gave a commitment to Fórsa nearly two years ago that an adviser would be brought in to advise him on health and social care professionals. How can anyone implement a system-wide reform involving a multidisciplinary approach without someone giving advice? We call on the Minister to make good on that promise as part of driving Sláintecare forward.

Dr. Mick Molloy:

If you look at Sláintecare over a long period of time, the idea of providing care in the community should displace some activity from the hospitals but, right now, we have a crisis in hospital capacity. Our colleague, the previous speaker, mentioned the need for physiology measurements such as echocardiograms in hospitals. If Sláintecare was taken to its ultimate extreme and there was free and open access to healthcare across the system for every patient in the State, general practice would be overwhelmed. There would be a group of people, usually men in their 40s and 50s, who do not now get examined suddenly being diagnosed with conditions. This will immediately result in more referrals to hospital for acute care. Over 30 or 40 years, that will all balance out but, in the beginning, there will be a surge in demand for services unless we can front-load and get those services and beds in now. Our biggest concern about Sláintecare is that we are not looking at the two sides at the same point. We are looking at chronic care and almost ignoring the crisis that is now happening because we are focused on that chronic care. Right now, we have a crisis in emergency and acute care that we need to address, in addition to Sláintecare.

Ms Phil Ní Sheaghdha:

On implementation, the Chairman has said that the information he has is that 82% of the aspirations have been implemented but one only has to look at the overcrowding figures and the evidence from our members to see that there are admissions to acute hospitals for diagnostics. Diagnostics are not available in the community to any level that would alleviate the problem of the necessity for GPs to tell people to go to hospitals, sometimes at 6 a.m., in order to be in the queue for CAT scans and other diagnostic tests. It simply is not working. The making of diagnostics available outside of acute hospitals is too slow.

Likewise, 82% of all care of the older person long-term care services have been privatised. We saw what happened during the Covid pandemic, we saw what the Oireachtas committee on Covid recommended with regard to revisiting that issue and now we see the HSE's service plan, which was published last week, not making any reference to undoing the privatisation of long-term care. In fact, from the manner in which it is set out, I believe the service plan will further reduce the availability of long-stay public beds. Sláintecare makes very clear recommendations in respect of the public service providing acute and long-term care. That is certainly not happening and will not happen if this year's service plan is anything to go by.

Sláintecare also recommends regional health authorities and the integration of hospital and community care. They should be acting as one but that is not happening. We have separate budgets, which is certainly an issue on which Sláintecare is very clear. There is no evidence of change in that regard. Likewise, the recommendation on devolving decision-making away from the centre is not progressing. We have put those questions in our submission. When the committee has an opportunity to meet the HSE, we request that it put those specific questions.

Maria Byrne (Fine Gael)
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I thank all of the witnesses very much for their presentations today. I was watching from my office because I have been in and out of the Chamber. I will confine my questions to University Hospital Limerick, UHL. Senator Conway has already asked some of the questions I wanted to ask. There are 562 beds in the hospital. An extra 60 have recently been provided. It has been stated over and over again how they have not been of benefit with regard to the number of people on trolleys and waiting lists. It has been acknowledged this morning that UHL has some of the longest waits on trolleys.

I want to look at the area of neurology nurses, of whom there is a shortage. An extra three were taken on in UHL recently. Sometimes, if people can be treated and given pain management, they do not necessarily need to be taken into hospital. Is that an area that needs further investment? I know there is still a shortage.

How many beds do the witnesses believe are needed in the UHL group, which covers six hospitals? St. John's Hospital only has ten beds for procedures. There was a proposal at one stage when Deputy Harris was the Minister for Health. Consideration was given to including 120 replacement beds in the capital programme. There was room on site for them. These 120 beds would also accommodate those who were already there, leaving approximately 90 beds in the hospital for procedures. Do the witnesses have any comments in that regard?

Seán Crowe (Dublin South West, Sinn Fein)
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Who would like to respond to that? They will have to very quick because we are supposed to finish at 12.30 p.m. I will bring in Deputy Cullinane before the witnesses respond.

David Cullinane (Waterford, Sinn Fein)
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I echo points made about University Hospital Limerick. There is a need for a full independent review into that hospital. That is not to apportion blame. There is a crisis in many acute hospitals but there is a real problem in Limerick. There are accountability issues as well. While we rightly acknowledge the capacity issues in hospitals, and it is our job as politicians to make sure the health service is properly equipped, has the resources and staff and that policies are in place to ensure hospitals are fit for purpose, there is also a need for accountability and it seems to me there is a lack of accountability in some hospitals. In fact, there is a lack of accountability across the HSE. There is a need for this committee to call for and support an independent review into what is happening in Limerick because it is not fair on patients or staff. Every week we hear horror stories of patients waiting far too long.

My final point relates to something in the opening statement from the INMO. The fact we have become desensitised to what is happening in our hospitals and hospital trolley waits is something in and of itself. The INMO rightly said we should take a zero tolerance approach to emergency department waits. Such an approach being adopted by Government, Opposition and across the political system means we have to commit resources and, when they are committed, any failures in management need to be addressed. It is unacceptable that day after day and week after week the trolley figures are published and are the same if not worse. It is not being resolved. I echo and support the calls made for a review into University Hospital Limerick.

Dr. Mick Molloy:

The figure of 85% capacity has been discussed a lot. That only relates to large hospitals. We have quite a lot of moderate-sized hospitals in our model 3 hospitals. They are not supposed to operate at beyond 75%. Smaller hospitals should not be operating at more than 65% because that means they are able to cope with a sudden extra five or ten people. At the moment, there are days when the whole system is operating at more than 100%. That is not safe and is dangerous for everybody involved. To get that figure down, we need to increase capacity. We are asking for urgent modular build as soon as possible rather than waiting for a ten-year capital plan. It has to be immediate. We have been discussing this since 2000, when the Taoiseach was the Minister for Health, and it has not changed. There are fewer acute beds now than there were then.

Ms Phil Ní Sheaghdha:

I will answer the question on neurology and beds. There is a requirement for additional specialist nursing in a lot of chronic disease management but neurology is particularly remarkable. Unfortunately, the level of diagnosis in that area is increasing. Certainly, there is a need.

On bed numbers and what we believe is necessary, the Sláintecare report sets out that we will need increased inpatient beds but will not need as many if we get the community piece right. We advocate getting that piece right, doing it quickly and looking at the acute bed increases set out in the capacity report.

In respect of the areas that have been reconfigured, we have had the mid-west reconfiguration, which saw a reduction in beds in Nenagh and Ennis and in the times they are open, especially in their emergency departments. We need to look at whether that was the right model. When we did not increase the bed numbers in Dooradoyle, it clearly was not. We need to look at what is needed, given the increased population and need and the slowness in implementing community change. We will not prescribe it here. We are saying we need an independent review to examine that matter.

Ms Karen McGowan:

On the point about clinical nurse specialists and advanced nurse practitioners, it needs to be funded, particularly in Limerick. We did an audit on an advanced practice internal clinic. It saved 8,740 bed days in its service. That is massive. That is what advanced practice can do and how effective it is. That is why this needs to be supported and pushed by Government.

Seán Crowe (Dublin South West, Sinn Fein)
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I thank the witnesses for their contributions. I echo the thanks offered to their organisations' members, especially but not exclusively over the Covid crisis. We all appreciate the work the witnesses and their organisations' members continue to do.

The select committee will meet in public session at 9.30 a.m. tomorrow, Thursday, 10 March.