Oireachtas Joint and Select Committees
Wednesday, 18 May 2022
Joint Oireachtas Committee on Health
HSE National Service Plan 2022: Discussion
Apologies have been received from Deputy Colm Burke. At today's meeting, we will be discussing the HSE National Service Plan 2022. From the HSE, we are joined by: Mr. Paul Reid, chief executive officer; Ms Anne O'Connor, chief operations officer; Dr. Colm Henry, chief clinical officer; Mr. Liam Woods, national director of acute operations; Mr. Stephen Mulvany, chief financial officer; and Ms Yvonne O'Neill, national director of community operations. They are all very welcome.
All witnesses are 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. If the witnesses' statements are potentially defamatory in respect of an identifiable person or entity, they will be directed to discontinue their remarks. It is imperative that they comply with any such directions.
I call on Mr. Reid to make his opening remarks.
Mr. Paul Reid:
I thank the Chairman. Good morning members. I thank the committee for the invitation to meet with it to discuss the HSE National Service Plan 2022. The plan outlines the health and social care services that will be provided to the people of Ireland in 2022 within the allocated budget of €20.7 billion, which includes: additional investment in new measures, including the winter plan, of €310.3 million; and additional existing level-of-service funding of €727.4 million, including €286 million pay-cost pressures for funding increments of €39 million, €364.4 million for existing levels of service and demographics and €77 million in respect of 2022 full-year costs relating to table 4 of the National Service Plan 2021.
The plan also outlines additional once-off investment specified for Covid-19 costs of €697 million including: €497 million to cover Covid-19 responses, including but not limited to, vaccination, testing and tracing, personal protective equipment, and hospital and community Covid-19 responses; and €200 million to cover acute and community-scheduled care access, waiting lists and waiting times, including use of public and private hospitals. In addition to submitting a national service plan, we have also submitted to the Minister a capital plan of €1.045 billion allocated in 2022, which includes an ICT capital plan of €130 million. The national service plan focuses on the delivery, improvement and reform of healthcare services while continuing to manage a Covid-19 environment, and it is prepared within the strategic context of Sláintecare, the HSE Corporate Plan 2021-2024, the Minister’s annual statement of priorities, and the winter plan.
Healthcare reform is focused on the need to change models of care and increase capacity to reduce waiting times, especially for those with urgent and complex care needs. The focus of the 2022 waiting list action plan is for waiting times for hospital procedures to be reduced to a maximum of one year by the end of 2022, and the maximum time an outpatient will have to wait to be assessed by a hospital consultant to be 18 months by the end of the year. In 2022, we are operationalising additional bed capacity, including capital and staffing, as follows: the final 308 acute beds from the 2021 national service plan, which included the approval of 1,146 beds; opening a further 72 acute beds in 2022; completing an additional 36 critical care beds; and completing an additional 258 community beds.
Reducing our dependence on the current hospital-centric model of care and supporting capacity building in the community is key to realising the vision of Sláintecare. This will, over time, reduce visits to and admissions from emergency departments and should lower emergency department waiting times more generally.
Through the enhanced community care programme and related programmes during 2022, we are progressing several initiatives, including completing the roll-out of 96 community healthcare networks, CHNs, establishing 30 community specialist teams for chronic disease management and completing the roll-out of 30 community specialist teams for older persons. Through our reform programmes in 2022, we are supporting people to live full lives in the community, with access to a range of person-centred community services and supports across their life spans and care needs. This will enable increased access to care and supports at home and in the community, thus reducing the requirement for long-term residential care and acute services. We are working to ensure compliance with standards and to reduce the number of people living in institutional settings by providing more appropriate community-based accommodation. This includes 120,000 additional hours of personal assistant supports, while 30,000 additional hours of home support are being delivered in disability services and an additional 2 million home support hours are being provided for older people this year. This will expand and enhance supports for people to live self-directed lives in their own communities.
The profound impact of the Covid-19 pandemic on mental health and well-being is evident across every sector in Irish life. We are continuing to reform mental health services and to improve access, with the focus in 2022 including: continued development and implementation of the agreed clinical programmes and new models of care; reducing waiting times for adults, children and young people; and improving the availability of and accessibility to services through increased provision and improved community mental health services. The foundation of a modern health service is integrated patient-centred care facilitated by collaboration between service users and all those working to deliver health and social care services. Implementing real and sustained reform at scale is complex and must be progressed in tandem with meeting the challenges of delivering day-to-day services.
Despite the extraordinary pressures and challenges faced by healthcare staff during the pandemic, much progress has been made on adapting service models in line with Sláintecare and principles of integrated care. It is also fair to say that challenges faced by the health service and experienced by service users before Covid-19 were exacerbated significantly by the pandemic, particularly with respect to access to local community support services, for example, including day services for older people and scheduled care in our acute hospitals. We are, however, always focused on delivering reform and enhancing the patient experience. This includes: improving service access across primary, community and acute services; addressing waiting lists and waiting times; increasing the range and capacity of services delivered to patients in community settings; increasing bed capacity; addressing health inequalities; focusing on health promotion; and ultimately bringing us closer to the delivery of Sláintecare, as set out in the Programme for Government: Our Shared Future.
I thank the witnesses for being with us. I also thank them for their tremendous work during the Covid-19 crisis and the lockdowns and the commitment they gave to their work in the health services, for so long and, undoubtedly, at huge cost.
I do not propose to go through the entire service plan because it contains approximately 170 pages. That is for another time. My questions are simple and straightforward. My first query concerns the waiting lists, and especially the acute and special needs elements of those lists. Apart from the service report, to what extent can we expect a serious attack to be made on the waiting lists during this plan?
Mr. Paul Reid:
I thank the Deputy for his kind opening comments, which always mean a great deal to the people working in our services. Regarding the waiting lists, the service plan has a specific reference to a €200 million allocation to enhance access to care plans and to give funding to a whole range of initiatives to address waiting lists. The plan launched by the Minister set out a range of actions. In summary, these are a combination of ways in which we set out to strengthen capacity in the public service. Equally, there are ways in which we plan to utilise the National Treatment Purchase Fund, NTPF, and the private hospital system for increased capacity in this period. Additionally, there is a suite of measures to reform clinical pathways in respect of how people receive their care. This is the approach and the actions contained in the plan.
We have had a horrendous four months of impacts on the hospital system from Covid-19. Those impacts affected many of the actions we had set out. We have a range of actions, however, that set out measures in the context of recurring funding to be allocated, and that will, ultimately, require further funding in the service plan for next year. There are also actions that require only non-recurring funding. Some of the actions to be undertaken are dedicated to addressing the issue raised by the Deputy in the other part of his question regarding people with special needs. This provision has been allocated in the context of some elements of our community. Additionally, a portion of this allocation of funds will be primarily targeted towards the assessment of needs process and to addressing the challenges we have in respect of disability services.
Therefore, a range of actions and initiatives will be undertaken, including reform of how we deliver services. An example would be people receiving care perhaps not having to wait for a specialist advanced nurse practitioner, ANP. These are some of the ways we are looking at this aspect. I refer to new ways of dealing with outpatients and inpatient day cases and of doing scopes.
I thank Mr. Reid. I know these intentions are genuine and I agree this is the right way to go about it, but we in the midst of a waiting list crisis. These date back several years. It is has been indicated to me that children or adults with special needs are being told they are on a five-year waiting list. I cannot understand how that could have happened. I speak as a former member of the old Eastern Health Board. If this had occurred in that era, there would have been an instant reaction. There could not have been a situation whereby the parents of a patient might be told their child was on a long-term waiting list. Something would have been done about it. I need to know now what is being done to address these issues. I refer to those issues that are current and to previous ones as well. To eliminate a waiting list or a queue, it is necessary to start at both ends at the same time.
Mr. Paul Reid:
I will start and then ask my colleagues to come in. On the scale of the challenge the Deputy just set out, it is not acceptable or good enough for anyone to have been waiting for these lengths of time. It is, however, a function of the many legacy issues that we need to resolve. Strategically, the right direction to take is that set out in the various elements of the Sláintecare plan. These include reducing the pressure on our acute hospital system, delivering more services, and more outpatient services, in the community, having more intervention teams helping in the community and enabling more access to GPs and primary care for diagnostics to reduce the pressure on hospitals. These are the right measures to take strategically.
The legacy problem we have will not be solved in the first year of the service plan. We have been in discussions with many other health administrations, including in the UK, that have also been severely impacted by the effects of the pandemic. This has impacted us, but we now have a good strategic plan that is funded. The implementation of the plan, though, has faced challenges in the first four to five months of this year. There is also a strike today. The actions set out in this service plan, however, are the right ones to pursue strategically. It will take time to bring this plan to fruition and there will be a multi-annual approach in respect of resolving some of the chronic issues we have with waiting lists. This process is about reform and changing the pathways in which people see their care being delivered.
What steps have we taken, for example, to provide services in our public hospitals outside regular hours? I refer to using operating theatres for ten, 12 or 20 hours, or whatever the case may be, to reduce the backlog. Mr. Reid said this is not going to happen in a year. In a year's time, the waiting lists will still be what they are now, with another year's worth of patients added. The process will have repeated in the same way in two years' time. Rather than allowing things to continue in this way, it is imperative that we use emergency measures to deal with the existing backlog and to prevent it from increasing.
Mr. Paul Reid:
I will address two elements of the Deputy's questions and then I will pass over to my colleagues, perhaps to Dr. Colm Henry, to talk about how we will reform the clinical pathways and some of the work we are doing in this context. Deputy Durkan is correct, though, that we must first get on top of day-to-day demand. If we do nothing, it is estimated in the plan that approximately another 15,000 people will be added to the waiting lists.
We want to address that by staying ahead of it this year. That is our intention.
On the wider aspects, Dr. Henry might talk about some of the reforms and more embedded ways of doing things so that we can get and stay on top of demand for future years.
Dr. Colm Henry:
I thank the Deputy. Part of our initiative to address waiting lists is to consider new ways of providing access to care rather than relying on traditional referral to consultants in hospitals with lengthy waiting lists. For example, we are expanding throughout the country a virtual fracture clinic that began in Tullamore hospital. This means that rather than waiting three weeks and making repeated visits to an in-person fracture clinic following an uncomplicated fracture, and that with the provision of extra physiotherapy and advanced nurse practitioners, we can provide next-day virtual fracture clinics with appropriate advice. The outcomes are as good and there is a high degree of patient satisfaction. This reflects much of the work that has happened since the pandemic began. We have seen a huge rise in the number of virtual clinics, all of which enjoy great satisfaction and very good outcomes and come under the governance of existing clinical pathways. This is one example of many pathways we are trying to expand and promote that involve diversifying the types of healthcare settings and professionals to which people can gain access to achieve the same outcome, perhaps more quickly and satisfactorily.
Mr. Paul Reid:
I will answer, after which Mr. Woods or Ms O’Connor might want to comment. The budget is not sufficient to do all that has to be done. In one year, we will not address the really serious legacy issue we have concerning our waiting lists but we will start the process. We had a short-term action plan from September to December when we were coming out of one wave of Covid. We saw a 5% reduction in the waiting lists. The current plan seeks to have what would be the biggest ever reduction, namely, a reduction of 18%. As already stated, we have been challenged in the first four months but the aim behind the plan is to start to make significant progress this year. However, no single year will be sufficient. Much of the additional funding we received in the past couple of years, which was very welcome, has supported us with recruitment, but it has also been targeted at addressing Covid and its impact on us, whether that was through testing, tracing or vaccination, and also the dual pathways we have had to put into our hospitals. It will be a multi-annual plan. It sets out to address the issue in a way that we have not done before, and it sets out to make progress sustainable. Mr. Woods might elaborate.
Mr. Liam Woods:
On the point about the use of facilities at the weekend out of hours, we are funding the use of theatres and diagnostic equipment over the weekend on sites through both direct HSE funding and NTPF funding. On the Deputy’s point, there is no financial issue for us at the moment in seeking increased access for patients; the challenge is a capacity one. Therefore, we are investing in all the capacity we can, including through using our own spaces as best we can over weekends and evenings. That is being funded additionally through NTPF funding and direct HSE funding under our access-to-care plan to the extent that this can be done.
The importance of the pathways is that effectively implementing those that Dr. Henry referred to redirect the flow to some extent and brings people to the most appropriate place more quickly. However, we are using our facilities out of hours and will do as much of that as we can this year, because the key challenge is capacity.
I need to ask about the capital plan regarding new facilities and hospitals promised, over several years in many cases. Are we in a position to accelerate in this regard? The population of the country is increasing. The number of people who will require treatment of one kind or another will increase and we will have to increase the standard and availability of services in line with that. If not, we will have the same problem with a backlog in five years’ time, which is not acceptable. Have we adequate capital funding? It would appear that we do.
The role of NTPF funding is recognised, but we need an emergency response to the issues ahead of us at this stage. It is not acceptable to have people on a five-year, two-year or one-year waiting list. We have to get away from that. Anything of help could be an improvement, but the fact of the matter is that we are long past the stage at which this became an emergency. What part of the plan incorporates an emergency system to deal with the growing problems as they arise, knowing that we have lost some key people from the health services in the past three months? Perhaps we might be told why they sought to relocate.
Mr. Paul Reid:
I will address a few points if I can. We can do nothing other than fully agree that the waiting lists are unacceptable and that we have to manage our way through. However, we have to start the process. We certainly have been impacted over the past while.
On the emergency approaches, I did not respond to one of the Deputy’s earlier questions. He is correct that one approach is to increase theatre utilisation. There are good examples of hospital groups that have put in place change-management processes that account for the whole flow across the hospital. It is not just a matter of addressing the use of theatre but also of increasing the flow throughout the hospital, which increases theatre utilisation. Working with the services, Dr. Henry is finalising a plan with us that will start to address, across a range of hospitals, theatre utilisation, good practice, good processes and how we can replicate these across the system. I apologise to the Deputy as I meant to respond to him earlier.
On emergency-plan approaches, the action list the Minister launched for waiting lists involves a process overseen by me in the HSE weekly, and jointly with the Department fortnightly. It is integrated into the service in terms of the allocation of funds and expected delivery on foot of any incremental funds got for measured delivery against the targets for reducing waiting lists. A new governance structure and oversight system are in place to do what is required.
The Deputy is correct that we have a very significant legacy in the acute hospital network, for sure. On his question in respect of the capital plan, the plan is a real one. We have a €1 billion capital plan. Our capital plan is significantly consumed by some of the major strategic projects that the Deputy will be familiar with, especially those that have featured over recent years, including the children’s hospital, the national forensic mental hospital in Portrane, and the additional 120 units for the National Rehabilitation Hospital. These represent a very significant absorption of capital but we have a range of initiatives to start addressing some of the real legacy infrastructure issues. For example, Galway hospital has significant infrastructural challenges but so too do many other hospitals. We have a limited capital envelope, it is significantly absorbed by some the major projects, and we are trying to utilise it on a multi-annual basis.
I welcome Mr. Reid and his colleagues. I wish well those who are leaving us or changing roles. We do not want to announce something that has not been publicly announced yet but there are many rumours going around. If there are changes in people’s roles, the best of luck to everybody involved.
I wish to start with page 37 of the national service plan, which refers to maintaining an acute laboratory workforce and equipment to support the required testing capacity. My first question is on medical scientists. Mr. Reid has rightly stated over the course of recent months that medical scientists, as well as many front-line healthcare workers, went above and beyond the call of duty. In fact, he very much praised the systems designed and built to roll out testing capacity in this State. Obviously, medical scientists were part of that. They were working at the high end of it. Much pioneering work is being done, as I am sure Mr. Reid would acknowledge. Could he acknowledge that medical scientists played a critical role in testing and creating the architecture for Covid testing over the course of the pandemic?
Mr. Paul Reid:
I have two responses. First, there is nothing hidden regarding new roles. Ms O’Connor is due to take up a new role as managing director of one of the groups within the VHI. We wish her well. Her loss will be huge but thankfully she will not be lost to the health system.
As the Deputy mentioned, I sent out an internal communication that, based on our commitment to Sláintecare, Mr. Liam Woods will take up a new role as implementation lead to ensure that from a line perspective, they are integral in terms of inputs, design and ownership of execution.
Second, in regard to medical laboratory scientists, I recognise again, as I have done very publicly, that the role they have played throughout Covid-19 has been phenomenal. Their response, commitment and the sacrifices they and many other healthcare workers made has been exemplary. For example, if we take the infrastructure commitment that they and others brought us from, we had the National Virus Reference Laboratory, NVRL, at the start of this pandemic with a capacity of about 600 per week. We have moved to a capacity of more than 300,000 in terms of Covid-19 testing. That did not happen just by putting infrastructure in place. There was also a process, change management and people's commitment.
Is it also fair to see that most clinical decisions are based on such things as images, scans, bloods, urine samples and spinal taps, all of which are prepared and analysed by medical scientists? They also play a critical role in the roll-out of acute healthcare services.
Mr. Paul Reid:
Yes. I was just recognising where they brought us from in a kind of wartime of Covid-19 but on a day-to-day basis, as we can see from the impact of the dispute today - Mr. Woods communicated publicly on it this morning - it has a significant impact on the running of the health system not only in terms of waiting lists but also emergency departments and flow-through in hospitals. They have a very significant day-to-day role.
I refer to the recognition Mr. Reid has just given them, which I accept in good faith. They are critical to the roll-out of acute services. The issues they are raising have prevailed for a decade or longer and they have been in and out of the Workplace Relations Commission, WRC. We are being told that the resolution of this issue would cost about €10 million a year. The last time Mr. Reid was before an Oireachtas committee, he was with Mr. Robert Watt and there were questions - I will not get into the rights and wrongs of it - about a secondment of one individual which would have cost €2 million a year. The money was found to enable that to happen and it has since been paused. We are being told that it would cost €10 million to deal with 2,000 medical scientists who have a claim. Why are we at a point where they are engaged in industrial action? My understanding is that they paused any industrial action during the pandemic because they wanted to make sure they were in place to do their best, as Mr. Reid acknowledged they have done. Why is this issue not resolved by now? What steps will Mr. Reid and the HSE take to resolve it?
Mr. Paul Reid:
There is a legacy history to this of well over a decade, as Deputy Cullinane said. There are pay parity issues in regard to the grade referenced and the biochemists and career pathways. When industrial action happens, in particular strike action, it is inevitable that there has been a breakdown in industrial relations discussions. There were discussions up to and including yesterday in the WRC. Our commitment is strong in regard to the WRC commitments. It would be an engagement between ourselves and the Department of Health. The Department of Public Expenditure and Reform has a key role in this as well. Our commitment is to stay in the room and try to resolve this.
The committee obviously needs to agree to it but it would be important for it to write to the Department of Public Expenditure and Reform and the Department of Health about the need to resolve this issue, and we have said it to the HSE. There needs to be negotiations to bring this to an end because it is going to have a big impact on acute services. Already we are hearing about the possible cancellation of procedures, which is unacceptable. We all want it to be resolved.
In regard to Sláintecare, which is covered in page 16 of the HSE National Service Plan 2022, central to any plan are targets, timeframes, resources to ensure we can achieve the targets that are set and meet the timeframes as well as planning and proper supports and processes to realise targets. Taking some of the big ticket items in Sláintecare, what is the timeframe for completion of removing private healthcare from public hospitals?
Mr. Paul Reid:
On Sláintecare, there is a range of policy and implementation issues and our role is to execute any policy decisions. Policy decisions are there on reducing private practice. A key part of that is the ongoing consultant contract negotiations that have been going on for a really long time.
I am looking for a timeframe. If there is not a timeframe as in "the HSE does not have a timeframe as to when this will be completed", that needs to be said. I know there are complexities in all of these issues in making them happen. I have a number of questions which are similar in their ask. Is there a timeframe that the HSE is working to for achieving the target of removing private healthcare from public hospitals?
Is there a timeframe on this specific issue that the HSE is working to so that Mr. Reid can tell me that on that date, which is the target that has been set, it will realise the objective of removing private healthcare from public hospitals?
Let us move onto the roll-out of free universal GP care. We have got to the point where we might have the six- and seven-year-olds done. There are talks on that at the moment. What is target for realising the objective of universal GP care for all?
Mr. Reid can comment because we are being told that he and Mr. Watt, as co-heads of the overall delivery of Sláintecare, are the two key officials that will deliver on Sláintecare. That is what we have been told; that is Mr. Reid's job. One of the key elements of it is universal healthcare. I am not saying it is not complex. Any plan has be underpinned by a target and a timeframe. What is the timeframe?
Mr. Paul Reid:
I am being straight and frank with Deputy Cullinane. A key policy decision for Government is the funding that will be committed over a multi-annual basis to give full access to GP care. The policy decision has been, as Deputy Cullinane said, to start to fund it for six- and seven-year-olds this year and we are executing that.
On the targets in Sláintecare for waiting times, it is a maximum ten week waiting time for an outpatient assessment or appointment, 12 weeks for an inpatient or daycase appointment and ten days for an acute diagnostics appointment. What is the timeframe to realise any of those objectives?
The 2022 target which was set in the Minister's waiting list plan was a maximum waiting time of 18 months by the end this year for an outpatient appointment and 12 weeks for an inpatient daycase. Are we on track to meet that target? Does Mr. Reid believe at the end of this year that target will have been met?
Mr. Paul Reid:
That is our commitment and our challenge to meet this year. Obviously, we have been severely impacted in the first four months and we are going to be severely impacted today but that is what our funding is mobilised to do. That is what we are allocating the funds to the system to deliver. That is what we are measuring our system against.
I have one final question and then I will make a brief comment. In regard to recruitment, which I believe is central to realising all of these issues, we had a lengthy discussion the last time Mr. Reid was before us on the commitment to recruit 10,000 staff. There was a comment that we could, as a minimum, recruit 5,500 and maybe more. Has that changed? How close are we to reaching that target of 10,000? In Mr. Reid's view, will that target be met by year-end, that is, a net addition of 10,000 staff in the health service?
Mr. Paul Reid:
What we set out very clearly when we were last before the committee was that achieving that is a function of what we can achieve in the market. We have the funding to do it. We set out that we believed 5,500 was a baseline that we will achieve. To give a very real update on it now, on average we have been recruiting slightly more than 600 per month net since the start of the year, which puts us at about 170 over the baseline. We are running on track, above that baseline. We are not running on track to the 10,000. We are going to review the whole process with the Department and the Minister at the end of May. However, there has been an encouraging first few months of our recruitment process. That will include international overseas recruitment of nurses and very significant new recruitment processes for consultants.
I will make a final comment. I will not speak in the second round. We are all committed to Sláintecare and want to see it happen as quickly as possible. Nobody doubts the complexity of many of the requirements to make it happen. We will not remove private healthcare from public hospitals unless we resolve the talks with consultants, yet a chair still has not been appointed and there is no sense of when that will conclude. That is central to it. We will not achieve universal general practitioner, GP, care unless we increase GP capacity. I would imagine we need to change the GP contract to ensure there is greater flexibility about funding and how we resource GP surgeries, which has to be a quid pro quo. We are stuck in talks regarding provision for six- and seven-year-olds. There is still no resolution to it and it is frustrating. There seems to be no clear timeframe. I have tabled parliamentary questions about the timeframes. I have been told we need to do planning, to look at the consequences of rolling out free GP care, at what demographic changes might happen, and about all sorts of work that needs to be done. I do not know if it is being done, but it is central to Sláintecare and I am concerned there is not sufficient urgency about it.
I am concerned about the targets set for waiting lists. They are ambitious but I do not see the needed resources to meet those targets. I wish Mr. Woods the best of luck in his work with rolling out the regional health areas. I have concerns about what they will be. I think they will be central to achieving those targets. I have a final point for Mr. Reid. The problem with the targets set is that there are no local or regional targets. We set national or State-wide targets where everybody is responsible but nobody is responsible. Unless we start to drill down into each individual hospital and health area, the targets will never be met, because there are hiding places for hospitals. We have to get real about the accountability if we are to have any chance of reaching the targets. I thank the witnesses for attending.
Mr. Paul Reid:
I have a few comments about GPs. We share the concern about the availability of GPs and the pipeline. We see an increased number of GPs coming through training programmes and we are working with the Irish College of General Practitioners, which now has the training capacity needed. We will thankfully see increasing numbers coming through that pipeline in the next few years but it is still a real issue. We have provided significant funding to support GPs through the winter plans and Covid. GP access to diagnostics has significantly improved their capacity and capability and is good for people using the services.
Regarding the commitment to provide for six- and seven-year-olds, negotiations are happening through and with the IMO. I am confident we will reach a conclusion on that process.
Regarding waiting lists, resourcing and local targets, we are providing resources. Some is supported by the recruitment I just spoke about.
I agree that accountability is much stronger. We can have a national target and need to look at how it is broken down. I chair a weekly meeting. We look at the funding when we agree it. Each hospital group and hospital has made submissions for money from the access to care fund. We allocate it based on delivery commitments and we measure each hospital group against those. Things happen, as they did today, but we have a targeted focus for recurring and non-recurring funding.
I thank the CEO and his team for coming. It would be too easy to pass by the notion that Covid has probably been a good news story for the HSE. It is not over yet, but if someone had asked two and a half years ago if the HSE had the capacity to roll out more than 9 million vaccines, maintain our hospital system to some degree and keep our healthcare system moving during that period, with all the commitments required from personnel and the leadership required from the management and board, there might have been some questions about it. I do not think there are any questions about it now, which needs to be acknowledged. This will be the chief executive's first opportunity to move into a greenfield setting to some extent and set about implementing the things I imagine he wanted to do when he was appointed chief executive. Covid arrived soon after that. How close is the HSE to normality?
Mr. Paul Reid:
Normality is always relative in health systems. I thank the Deputy for his comments. I worked in the private sector for 30 years and the public sector for 12 years. I have never seen any organisation implement so much change over such a short time, with so many people and such a great impact. That is what happened by the response of our health teams. I recognise that publicly and thank the Deputy for doing so. Having said that, we know the challenges we still face. We were able to track during Covid that the public's trust and confidence in the health service strengthened, though it could be said to have started from a low base. We know it is always fragile and could collapse quickly, but we want to build on it. A key issue for our board is continuing to build trust and confidence.
We spoke about some of the challenges that are ahead of us already. Sláintecare is the right direction for the health system. It is about relieving the legacy pressures on the acute system by doing things differently in the community service and increasing capacity regionally. The other issues arising for me as CEO, which I set out at the start and which we have made progress on, include accountability. We want to strengthen accountability in the health service. Things will go wrong and we should support people when things go wrong, but equally, we have to have an accountable system that has open disclosure and holds systems to account where things should not have gone wrong. That is something we want to strengthen, and that involves performance management, which we are rolling out and has not been rolled out fully across the health service to date. It involves another range of strands concerning management accountability and clear lines of responsibility. Those are some of the issues, as are waiting lists and Sláintecare, which we spoke about. Value for money and the best use of taxpayer funds committed to us by the Government form a key issue. We want to give confidence to our funders, the public, that we are providing the best value for money in return.
A big challenge we have had and which I set out when I came in is engagement with our stakeholders who work with us. There was a great example of that during Covid, with trade unions, representative bodies, Government and Oireachtas Members. The public heard a much-strengthened voice from the health service. That is good for us for the future. We will all have different challenges and disagreements at times, but the health system needs to have a more unified voice. The public has told us that is what they trust.
Mr. Paul Reid:
It is a year since that happened. A PwC report set out a range of actions. Those included recruitment for two key strategic roles at a national level and a range of cyber roles. We have recruited significantly for our IT service. We are having real challenges in getting cyber specialists to come in. We have implemented a range of initiatives, about which I prefer not to talk publicly, that strengthen the security of our network, controls, authentication processes and who can access what and from where. We have initiated training for staff to promote greater awareness.
Mr. Paul Reid:
Yes. We are always in discussion with the Department of Public Expenditure and Reform on the sizing of roles, particularly on the two senior roles we are trying to attract candidates for, which would be at a national level. Many private organisations are paying significantly for these roles in the UK.
Mr. Paul Reid:
My experience in the public service is that it is a challenge but sometimes you get people who want to commit to public service at different times in their careers. We are working hard with an international recruitment agency to try to attract candidates. There are some advantages we will be trying to sell and demonstrate as part of the process.
Mr. Paul Reid:
It is a challenge, and I know that Members of the Oireachtas are aware of this, not just in terms of cyber but to attract people from the private sector into the public service. Our roles are quite public and not too many people value coming in or see it as an advantage to come in. There is an issue around the public accountability we have, which I understand.
Mr. Paul Reid:
I reassure the Deputy that we have acted on and completed a range of initiatives and that there is another range of actions that will be completed throughout the next quarter and this year. The recruitment process for two senior specialists will take time. It will take up to nine months to recruit those people. That is the reality of going to the market, getting the sizing there is on the market and recruiting somebody. When you go to the external market, people will most likely have at least a three-month clause for coming in.
The oversight of Sláintecare is in the hands of Mr. Reid and the Secretary General. The last time we had the Secretary General and Mr. Reid before the committee, the Secretary General said that he and Mr. Reid would be answerable to the Cabinet. What arrangement have they made to give comprehensive updates to the Cabinet on the roll-out of Sláintecare and when will the first presentation of that be?
Mr. Paul Reid:
There are ongoing updates to the Cabinet committee on health, led through the Department of Health and the Secretary General. They would provide regular monthly updates to the Cabinet committee on health. Separate to that we will be in front of this committee on a twice monthly basis, and that is our commitment until we hear any other request. The Cabinet committees have met and they would have received updates on Sláintecare and regions.
Mr. Reid talked about openness and transparency and I get that. I just want to gesture towards the following point and I do not want a response to it. There are a number of outstanding reports and investigations that have not been published and that would be a concern for committee members. These reports and investigations range from issues like child and adolescent mental health services, CAMHS, to nursing homes and that kind of stuff. I just want to alert Mr. Reid to the fact that these are on our radar, although I cannot go into detail on them now.
I want to raise the issue of the medical scientists' industrial action, which is taking place today, and it should not have come to this. Every test, as previous speakers have said, is critical and dependent on the role of the medical scientists. They made a presentation to us yesterday that was pretty factual. This is going back an awfully long time and there are recruits being brought into the system who are significantly less qualified but getting more pay. One of the lines they gave us was that the Department of Public Expenditure and Reform does not fully understand what is going on and that, if it did, these people would not have been allowed to strike. There is a suggestion of a communications issue between the HSE and the Department of Public Expenditure and Reform on the importance of their roles. There is also a suggestion that they are leaking to the private sector and even to other better paid positions within the public sector.
I had constituents on to me in recent days about my local hospital, Tallaght University Hospital, and the Chair would have had the same communications as we represent the same constituency. These people have had procedures and appointments cancelled because they were dependent on tests being carried out. This is an issue that has its origins back as far as 2001 and a lot of iterations since then. The HSE says it is engaging in the WRC and all the rest of it but this should not have happened. The laboratory is the pulse of a hospital. There are very few procedures, aside from scans and X-rays, that are so connected with every procedure that has to take place in a hospital and so many procedures simply cannot take place without them. Will the HSE give us some sense of the urgency with which this is being dealt? Their claims are serious and they are earnest and well-qualified people who see less qualified people coming into different grades in the system and getting paid more. Will the HSE give us some serious answer on how this will be resolved, when it will be resolved and what steps it is taking to ensure further industrial action, which the medical scientists have said will have to take place, will not take place?
Mr. Paul Reid:
I will ask Mr. Woods to comment because he is directly involved in this but I have spoken earlier about the role the medical scientists have played. It is always a breakdown when strikes happen and I have been involved in industrial relations for all my career, but we are engaging in the WRC. I would not agree that the Department of Public Expenditure and Reform is not aware or that we may not have communicated through the Department of Health or with the Department of Public Expenditure and Reform on the seriousness of the issues. We would collectively be aware of the impact of this so we would have represented that, and the Department of Public Expenditure and Reform is well aware.
Mr. Liam Woods:
The Deputy’s analysis of its impact on the hospital system and the primary care environment is that where there are extensive volumes of tests coming from the GP environment into hospitals, that is immediately disabling and I agree with his comments on that. There are other laboratories outside of hospitals that would also potentially be affected, including the blood transfusion service, which is not affected today because it is exempted in dialogue with the Medical Laboratories Scientists Association, MLSA.
The impact is immediate and severe. While there are some derogations in place for urgent and priority work from working with the MLSA, to answer the Deputy's question directly, we were engaging in the WRC yesterday with a view to resolving the issue and we will continue to do so. We cannot approach a situation where there will be two days of action next week without serious consequence for patient safety in the health environment. The challenge before us is to resolve this before we move into further stages of escalation. I am sure members are aware from MLSA statements and from its observations to members that there is a further proposal for three days of action beyond that. Our commitment is to be engaged and directly involved in urgent dialogue to resolve the problem. We have done so and will continue that until we have a resolution.
Mr. Liam Woods:
There is a public sector pay issue involved within the overall dispute, which is a matter for public pay policy. There are some matters on which we would broadly be of a common mind The commitment of lab scientists, which has been referred to earlier, in Covid response and in overall support to the hospital system, is unquestioned. I do not want to get into the detail of the discussions we have had and will have in the WRC but I fundamentally take the view that we must resolve it now. We cannot allow a break of two days in service within hospitals.
I thank the witnesses for all their ongoing work. I want to pay tribute to Ms O'Connor. I have known her for many years, both locally on the northside of Dublin and at a national level, and her service has been exemplary.
She has provided outstanding leadership within the public health service and she will be a huge loss to it. I wish her well in her new career and thank her for all her work. I also wish Mr. Liam Woods well in his new role. I am sure we will be engaging on that shortly.
There has been a fair amount of talk about what happened during Covid. The HSE showed its best side during Covid in terms of how it as an organisation and all of the staff responded. Everybody adopted a shoulder-to-the-wheel approach which was outstanding across the board at all levels within the HSE. Two key principles were followed during Covid. The first was that we effectively had a single-tier health service for a long period during those two years. That made a huge difference. The second was that services were available free at the point of use. I have thought about this quite a bit since. Let us imagine a situation where the Government or HSE decided that people would have to pay for vaccines. It is unthinkable that only those who could afford it would be vaccinated. That would be a two-tier system. Let us imagine that only people who could afford to do so could take Covid tests. There are people who had multiple tests. That is also an unthinkable scenario. The principles underpinning Sláintecare are to have a single-tier health service that is free at the point of use. We saw those principles in action and how well they worked. The concern is that we are now moving way from that. Thankfully, we are moving away from the particular pressures of Covid - the big ones at any rate. Given that we would not for one moment think of doing things differently during Covid, why are we reverting to a two-tier system in which money talks and it is tough luck for those who cannot afford it? We need to preserve the lessons learned from Covid about those things that worked very well.
I will not go into individual services, as we normally do with the service plan. There are many issues we could ask about in relation to staff, waiting lists, etc. There are common themes running through the problems in the health service and we need to look at some of those overarching themes.
On Sláintecare, I sometimes get the impression that Sláintecare is in one place but the real day-to-day health service is somewhere else. The Sláintecare stuff is theoretical and many of the elements of that are not being implemented. There are reasons for that. The difficulty in recruitment and retention is a major stumbling block to implementing Sláintecare. I am also concerned about the talk of a ten-year implementation plan. We are halfway into that. It is not an implementation plan that achieves implementation in ten years but a staged plan. Notwithstanding Covid, a great deal of time has been lost in terms of that implementation plan. I am not saying that is the fault of the HSE. This has to come from Government, as it must provide the funding and policy direction.
The overarching issues are principally to do with recruitment and retention. Why are those problems there? Why is it so hard to hold on to people and to get people in the first place? This can be a self-fulfilling prophecy because the more people leave and the more vacancies there are, the harder it is to stay because of the increased stress levels. We have seen a large number of people leaving. One has to ask whether there is a cultural problem. I am not sure what the answer is and what solutions the HSE is bringing forward to address the critical problems of recruitment and retention. Will Mr. Reid talk to us about that?
Mr. Paul Reid:
I will ask Ms O'Connor to respond separately to the Deputy's kind comments and on the Sláintecare initiatives.
On the Deputy's first point, I do not disagree with her. I have often used the same example of universal healthcare in terms of what happened in Covid. The Deputy used the example of testing and tracing and vaccination. During that period, these were free, as the Deputy said, and prioritised based on need. We worked down through the sequencing on vaccination and testing and tracing. Those are classic examples of what a public health system should be about. They are really good ones for us to leverage.
The second part of Deputy Shortall's contribution was on some of the themes and a concern she has, on which I do not disagree with her, that Sláintecare can be seen as something separate as opposed to being embedded in the line system. That is part of the approach in terms of new governance structures, with the Secretary General, Mr. Robert Watt, and I overseeing it, our line management teams having responsibility for it and Mr. Woods coming to work in a role to make sure the line is engaged in the design and implementation of it. However, let us stand back from the Sláintecare process, change management for regions and what happened during Covid and is in place now - Ms O'Neill and Ms O'Connor might want to comment on that - and look at some of the core fundamentals that we have had to put in place. Enhanced community care is happening and that has been a combination of factors. As regards community health networks, 96 teams are to be in place and over 50 of them are now in place. We have been resourcing the community specialist teams, for example, for older persons and chronic diseases and illnesses. Approximately 1,500 people of approximately 3,100 people have already gone into them. The National Ambulance Service now plays a new role. It does not only provide paramedics 24-7 and bring people to acute hospitals but treats people outside of the hospital system, including in nursing homes. We played a new role during Covid in providing supports and commitment for nursing homes. As I said, one of the examples in Covid, which we are trying to embed and leverage, is a single integrated process between primary care and GP care and the acute services. One of the ways we have done that is giving GPs access to diagnostics. There were 140,000 last year and we are up-----
I am sorry to cut across Mr. Reid. Time is very short. I know those things are happening but the difficulty is in filling those teams. Will Mr. Reid go back to the problem of recruitment and retention?
Ms Anne O'Connor:
I thank Deputy Shortall for her comments. They mean a lot to me. In this room, the Deputy goes back further with me in my career than probably anybody else.
In terms of culture, the Deputy is correct. There are a couple of issues in terms of teams. Part of our challenge is that we are growing services in all different care groups. We are competing and there is an internal competition taking place between mental health, disability, primary care, etc. When we look at that in the round, there is something about specialisation in terms of what a population needs. We have a very professional health service compared with many other countries. We have many highly trained and skilled staff, which is great. We need those people but we have to ask ourselves what we are doing about the lower end in terms of the whole population piece. The Deputy will know this from Sláintecare. Our challenges and the bit we have to focus on is getting that lower level right. We need the specialist end but if we are not doing the lower level right, it is all for nothing at the other end because we will just keep trying to plough people into a much tighter end of the pyramid.
From our perspective, in trying to retain the staff we have has to be about local ownership in terms of staff identifying with their local unit. Our staff surveys show that people identify with their team or ward. They do not identify with the HSE if they are working in a team in Ballymun or whatever. We have to enable that centrally. The regional health areas, RHAs, will bring us back to that with more focus on the local unit, local identification and empowering people to work for their local populations. It is that sense of ownership and control that encourages people to stay and the retention is huge. Between the pandemic and everything else, that has got a bit lost. Hopefully, with the development of enhanced community care, ECC, we will get back to that.
I completely agree that the recruitment piece has to happen locally from the point of view of recruiting local people and the identification with the provision of services locally. That is why recruitment needs to be taken away from the corporate centre. I hope that will be a key part of the regional health areas.
I know Mr. Reid and his colleagues have to keep the show on the road every day, they are operating at high pressure levels and they have to have staff in place. There is a problem, however, with what can be seen as privatisation by stealth where there are difficulties or decisions taken that the HSE will bring in private companies to provide those services. That is a real problem.
I really would like to get figures from the HSE at some stage to see how much of its budget is being spent on outside organisations, be they voluntary, charitable or commercial. There seems to be a growing commercial element in HSE staffing responses. I looked at Nua Healthcare Services recently. It is getting about €75 million for the provision of disability services and another €22 million for mental health services. It is a commercial company and there are lots of others. A significant number of EY staff have been brought into the HSE. This is creating a particular dynamic. If the HSE is bringing in private companies to provide public services, it does not sit very well with existing staff and causes a lot of resentment among them. We hear that a lot. My concern is that there seems to be a trend towards outsourcing services and bringing in private providers. Could Mr. Reid talk to us about that?
Mr. Paul Reid:
There are three broad responses to that question. Section 38 and section 39 organisations are a core part of delivering services in the Irish health service, be they voluntary hospitals or many community, disability and mental health services. We work in partnership-----
Mr. Paul Reid:
Proportionately not - if the Deputy looks at our recruitment over the past two years, she will see that 13,000 extra staff in the health service, which is probably the highest number in the history of the HSE, have been recruited over a two-year period.
Mr. Paul Reid:
If one looks at our agency staff, one can see it is about 4% of our payroll. It is needed at certain times, particularly during Covid. There is also a requirement to bring in specialist expertise that we do not have. We spoke about some of it in terms of cyber security. There was a requirement during Covid. There always will be a requirement to bring in specialists for periods of time and that is what we do. Ultimately, I would not agree that we have seen services increasingly privatised. That is because we have seriously enhanced our own internal resourcing.
I will focus on a statement made over the weekend by the Irish Hospital Consultants Association. It was quite a critique of where Sláintecare is going and the state of our public health services. It was a very thorough critique of where we are. The association said that there was a severe shortage of consultants in the public health service and that 838 consultant places need to be filled. Nearly 1 million people are on some form of waiting list via the National Treatment Purchase Fund. The association says that if this continues, the waiting lists, which are at the heart of the dysfunction in our public health service, will accelerate. This situation could continue for decades. Given all that, surely the issues identified by the association must be addressed, particularly vacancies in the public health system. If they are not addressed, we will be having the same conversation next year, the following year and the following year. The waiting lists for procedures have accelerated, particularly in the past number of years because of Covid. If these issues are not addressed, Sláintecare will be largely academic.
Mr. Paul Reid:
We would not fundamentally disagree with a lot of what was said by the Irish Hospital Consultants Association at the weekend. We spoke about some of the challenges earlier on and the contributions related to many of them. There is no doubt that the recruitment of consultants is a major challenge for us. It is a worldwide market. Having said that, over the past two years, we have recruited the highest number of consultants on a full-time basis in many years. A total of 406 consultants have taken up positions on a full-time basis in the HSE. This was not achieved in many years over a two-year period so that is positive. We are aiming and have funding to recruit more consultants. It is a particular challenge in some parts of the country. In many cases, consultants want to be in urban centres. This is not just in terms of hospitals. These challenges are also seen in community services. We are working with the various colleges in terms of the pipeline and what is coming through. It is a real challenge but in the past two years, we recruited a higher number than we have done in many years. It is still a major challenge for us.
I think I covered waiting lists earlier but I restate that we have a very targeted and focused programme to start the process of addressing waiting lists but this will be done on a multi-annual basis and it will take time. We have undoubtedly been impacted by Covid, particularly in the last quarter, but we have very targeted initiatives.
We do not disagree with the argument that these are all very real challenges for the health system. Their advice is knowledgeable but we have to start and the start of the process is recruitment, which we have funding for, and a very targeted focus on funded initiatives on waiting lists. Sometimes one could come into the health system and say we can do nothing but we can, will, should and need to do something for the public. That is the approach we are taking.
My final question is about the National Treatment Purchase Fund. The Irish Hospital Consultants Association said that nearly 1 million people are on waiting lists. What percentage of the 1 million people waiting on medical procedures will be directed towards the private health system? We all agree that there is a two-tier health system in this country. There is a private health system and a public one. Sláintecare is a policy that in some way aims to introduce a universal health system. When one digs down, one can see that private healthcare is still as evident as it was a number of years ago and is still playing a significant role in the overall healthcare system. This makes one think that private healthcare will not be eradicated but will have a bigger role to play in Sláintecare. What percentage of people on waiting lists will be directed towards private healthcare?
Mr. Paul Reid:
At a national level, there is no doubt that a significant proportion of the population - over 50% - choose to have private healthcare. People choosing private healthcare is very much a part of the health system in Ireland.
Government policy, which we are executing, is to reduce the use of private capacity within the public health system. I touched on some of that earlier with Deputies. We want to do that and see that executed. I do not know the exact percentage, but it is low. We use the NTPF more and more significantly as part of the access to care fund for some of the more basic procedures. Mr. Woods can talk about that. We also use the private system now. We use approximately 1,700 or 1,800 bed days per week, which is approximately 400 patients per week from the public system. We are leveraging off private capacity to do that. Overall, the vast majority of care happens within the public system, but we have our constraints and we would like to see more capacity.
Mr. Liam Woods:
To give the committee a sense of this in percentage terms, by far the largest amount of care that addresses waiting lists is provided in the public hospital system. I am talking about acute waiting lists. To give the committee a sense of this in monetary terms, the HSE is investing approximately €1.8 billion per year in its core elective activity. That includes day-case and inpatient work. A further €200 million is available under access to care, which we have discussed a little. That is also available for investment in the public system. The NTPF is investing €150 million, some of which is coming into the public system, for example, the cataract clinic in Nenagh. There are other examples of the NTPF buying within our system. In terms of scale, however, and without going into a lot of numbers on patients treated, that is still marginal to the overall success but very important in hitting the targets for long-waiting patients. That is probably the best way to think about that. For us, the key is to enable our system to have the theatre access and the bed access to deliver on what is a growing commitment. The bulk of delivery is still in the public system. I heard Deputy Shortall's question about the growth and investment in commercial or private entities, and we can certainly respond to that. As the CEO has just said, the safety net arrangement, which is still running with the private system, sees approximately 1,800 bed days a week used in the private system for public patients. Of course, the intention of that was Covid response, and that arrangement will cease at the end of June. From our point of view, that is just an idea of the kinds of proportions involved.
Mr. Reid and his team are very welcome. It is important, as always, to reiterate our thanks for the work they have done over recent years, which continues because, clearly, the backlog has to be dealt with now, and that is important as well. I wish Ms O'Connor the very best of luck in her new role. I have no doubt but that she will bring her enthusiasm to it. I also wish Mr. Woods all the very best in his new role.
I wish to raise three issues. It will be no surprise to Mr. Reid that the first relates to University Hospital Limerick, UHL, and the continuing challenges with overcrowding and patients on trolleys for protracted periods. The hospital continues to be the worst in the country in that regard by a significant number. At the end of April the Minister for Health announced that he was requesting Mr. Reid, as CEO of the HSE, to deploy an expert team to go into the emergency department in Limerick and to assist with the situation there. Has that team been deployed? If so, what is the initial feedback from it? Mr. Reid might also tell us who heads up the team. This is a very serious situation.
Mr. Paul Reid:
I will make two brief comments, and Mr. Woods may comment further.
First, I recognise that there is an extremely strong, capable and committed management and clinical team in UHL. It has some real population density challenges that it has to manage, particularly given how the hospital group is constructed. There is one emergency department across the group, so it has real challenges.
Second, we deploy teams on various occasions, particularly to go into emergency departments and to look at process flow and organisation. In discussion with the Minister, we have sent a team of specialists into Limerick and UHL. That team is drawn specifically from our performance management team and comprises some people who are experienced in process flows and emergency department management. They go in very closely and work with the management and clinical teams. Some of those people have been deployed to UHL already. I will ask Mr. Woods to give the Senator a brief summary of what they might look at.
Mr. Paul Reid:
Each of our emergency departments has distinct and separate issues and challenges. The issues in Limerick or UHL are very different from those in Galway and those in Beaumont. We have specialists who go in and work with the teams and the knowledge we have within the system. They know the solutions, so, no, I do not agree that a separate specialist review is needed.
Mr. Liam Woods:
I will provide a little context. The position in Limerick, while it is very difficult and the hospital is under a lot of pressure, is, in fact, not unique. The attendance growth we have seen in Limerick is at the higher end of the scale nationally as to what is happening now versus what happened in 2019, so there is huge pressure on Limerick. That is particularly true of the over-75 category, with patients attending and being admitted. There is a phenomenal pressure within the hospital system in Limerick and there are already active management responses in that regard. As for the team to which Mr. Reid referred, there was an initial meeting on-site in Limerick last Friday attended by a group including clinical and some special delivery unit, SDU, support people and people from my unit. They are working out an approach to the flow issues within the hospital and any measures we can take beyond the hospital that will support both the front and the back door. That will include dialogue with staff within the Limerick-----
Mr. Liam Woods:
As for the trolley numbers, long waiters and a focus on over-75s and those waiting more than 24 hours, we would look to develop a plan. To be fair, the group had put down proposals on this prior to engagement with us. Over the next two to three weeks, that will give us a position on which we can work with the UL hospitals group and the community healthcare organisation, CHO, locally. It is between the two that we can best address the issues.
Ms Anne O'Connor:
Mr. Woods mentioned the long waiters. The most important thing in an emergency department is not the number of trolleys but how long people spend on those trolleys. Trolleys are a feature of emergency departments. If patients are admitted to emergency departments, they will be on trolleys. Our challenge is more about seeing how long people are there. When people are admitted to emergency departments, they get treatment, procedures and so on. We talked about scientists earlier. A lot of tests are done in emergency departments. It is worth noting, bearing in mind that attendances at our emergency departments among older people are rising week on week and are higher than they have ever been before, that the national average length of time somebody spends in an emergency department is now eight and a half hours. The reality is that in Limerick it is nine hours, so not that far off the national average. Yes, Limerick has the highest number of attendances and is experiencing a surge in the number among the older population attending, which it has had consistently during Covid, unlike all other emergency departments in the country. In fact, however, its throughput is not that far off other emergency departments. It is important to note that.
That is great. The witnesses might provide a progress note to the committee, perhaps in three or four weeks, as to how the impact is being addressed.
Another issue is the HPV vaccine, specifically the catch-up programme. I understand that the Minister asked the National Immunisation Advisory Committee, NIAC, for a recommendation and that that recommendation has now been sent from NIAC to him in the past two or three weeks. In reply to me in the Seanad last September, the Minister of State, Deputy Rabbitte, committed to abolishing the catch-up fees for people who did not take the HPV vaccine originally but who then decided a year or two down the road to do so. How is that catch-up programme going? Have the witnesses had any communication from the Minister to the effect that the fees should be waived?
If so, when would Dr. Henry expect that to happen?
Dr. Colm Henry:
With the HPV vaccine we had seen great progress from initial low uptake. The pandemic affected many of our established vaccination programmes. I am happy to come back to the committee with a report on the current uptake and our plans to improve uptake further. Improvement was due largely to the work of advocates such as the late Ms Laura Brennan and others who worked tirelessly and selflessly to try to promote a vaccine that saves lives. We have extended the programme, as the Senator knows, not just to teenage girls but teenage boys as well. I do not recall seeing the mentioned letter coming to the national immunisation office regarding the pricing. I will check that and revert to the Senator.
Okay. It is important. We have seen the benefit of vaccines, particularly over the past two years, when it comes to saving lives. A cost of €400 to €600 for a family whose daughter or son wishes to avail of a catch-up vaccine is no longer feasible and must be eliminated. I look forward to hearing about that.
There was an announcement by the Government of free contraceptives for girls aged between 18 and 24. Where are we with that programme? There has been €9 million committed in the service plan. How much training has been provided on the long-acting reversible contraception and have many medics signed up to it? What is the geographical spread and how is the information campaign progressing? It is a very important area of women's healthcare.
I thank everyone for coming in this morning. I will jump to my favourite topic, which is always students and students who work in the healthcare system in particular. How many student medical staff across the board are working in the HSE? How vital are student nurses and midwives or other healthcare student cohorts? Do they represent an important part of staffing in a context in which we are thinking about staffing shortages? Are they a vital part of the staffing cohort where there are staffing shortages or how do they interplay with that? I have other questions and will come back in with those, if it is okay.
Mr. Paul Reid:
I will comment briefly before my colleagues come in. The Senator referenced student nurses and midwives. Approximately 1,500 come through in the various years and at each stage of their college course. They are primarily led and supported by the colleges they come from and are deployed as part of their training at various stages, including in their fourth year. They are an integral part of the support and learning process with services. It is also key, and it has been particularly so over the past two years and this year, to offer full-time employment to all graduates coming through the programme. They are an integral part of the pipeline. We work with colleges on the work they do to ensure the learning environment is appropriate. The student healthcare workers are a core part of our health system overall.
Ms Anne O'Connor:
We do not have a number because of the number of disciplines across health and social care services. There are 23 different disciplines in the health and social care group outside medics and nursing, and they come and go. Some may be in for a year; for example, a medical student may spend a year in a service while other students could be in for just a couple of months. We have no way of knowing at any point the number across all the services.
It is important to note students work under supervision. They are critical in being there but they are supervised. In nursing, for example, they have staff whose job it is to look after and mentor students on-site. Depending on their stage of training and all that, it can be a very different picture. It depends on the discipline and the year they are in.
This is not a question of whether the HSE should remunerate them. Ms O'Connor has said the HSE does not know at a given point how many students are in the health system. They are being trained and under supervision. There has been a major conversation around student nurses and midwives and whether they should be paid or remunerated or receive stipends, etc. Should we look at this, even if it comes through the institutions? It comes within the context of the HSE's work. I hear all the time about students working in the 23 disciplines, as have been mentioned, and they do not see how they can continue or they are concerned about progress. They cannot afford to do this because they may have to take time from their other work to do this training, etc. Should there be more responsibility put on the Minister or whomever to provide stipends in order to facilitate students? Will students continue coming through the system because they are pursuing something of a vocation?
I will jump to the other two questions before the witnesses respond. I reference the Irish Nurses and Midwives Organisation, INMO, report that was publicised at its conference indicating that approximately seven staff per day are physically attacked in their work. What engagement has occurred with the INMO on this and what impact will the content of the report have on staff recruitment or retention? I will come back in with the other question, which has skipped completely out of my head.
Ms Anne O'Connor:
The question on payments is bigger than just us, I believe. Many people, including students, are struggling with costs. Student nurses, for example, get paid for their intern year or fourth year. Other students do not get paid and it would be a complex picture if students were to be paid for their clinical training. I do not know and it would be a very big decision. As I said, it is bigger than just us.
We have had discussions on the INMO report and, to be fair to the organisation, it flagged its concerns on a regular basis in terms of assaults on staff. It is something in which we have seen a significant increase, particularly in areas where we have unscheduled presentations, such as accident and emergency departments, acute mental health services, etc. We are looking at that and there was a review some years ago on the safety of staff in those areas. We are looking at that and working within the organisation and the quality and safety committee to see how we might examine the question again. There is no doubt but that there is a challenge for staff working in some of those areas and in how we continue to provide services in a safe way.
We are grappling with how to provide services to the patient and protect staff. We have a responsibility to our staff and to provide care but we must consider the matter. We have different types of solutions in different services and areas. For example, there may be security people in some departments and not others. We are examining that issue and we have spoken to the INMO about it. I do not know if it is enough to deter people from a role in healthcare if that is what they want to do. There are many people working across our services. There are many staff working in the community who may feel exposed and we have many policies relating to lone work in order to protect staff working in isolated services.
I also wished to ask about the free contraception scheme. Has the Department approved the training to support the implementation of the scheme with the Irish College of General Practitioners? Has there been any meetings with the Irish Medical Organisation on the rolling out of the scheme, which is due to start in August. I apologise but the phrase just flew out of my head before.
I thank the witnesses because I cannot imagine what the past few years have been like with everything that has been going on, particularly Covid-19. I thank the HSE for all its hard work as I imagine that period has been quite stressful.
I want to highlight the Owenacurra centre and the correspondence the committee received from the HSE yesterday justifying the decision to close it. It was detailed and provided positive news about the expansion of various HSE services in the area, but unfortunately it did not really address the central matter in the committee's letter. I am concerned that no independent report has concurred with the HSE's decision-making, and experts disagree. That includes our own Deputy Hourigan, who is an architect. Unfortunately, she is unable to be here today but she has outlined achievable plans that would allow the current residents of Owenacurra to stay in their homes. I and others have visited the centre and met the residents and families. I was affected by how passionate the residents and their families feel about this. There is also a concern the HSE's consultation process with the residents and their families has been deficient. I do not think it fits with the emphasis on community building and patient autonomy, dignity and respect that the Sláintecare roll-out was supposed to represent. Is there any possibility the HSE can reconsider the decision?
Mr. Paul Reid:
One of the key drivers of the assessment that was highlighted in previous reports was how we look at the separation of day services and people who are residents. Regardless of infrastructure and those issues, there is no doubt that, by any assessment, the rooms the residents have to live in and access for services and day visitors is highly inappropriate. We do have expertise. There is significant expertise in the HSE and we also engaged significant expertise outside the HSE to undertake the assessment of the building. As we outlined in our letter yesterday, there are issues around fire safety, asbestos, mechanical and electrical engineering, and particularly the lack of social space in the building. It is not fit. I agree with the Senator but issues around dignity and respect cannot be met within this building. We believe our strategic approach is the right one. It is supported, and the Minister has been very clear on that. That is the strategy we are working through with getting more people living in the community, with very good community services and locations. We are looking at purchasing some residential properties that can be supported for this. That has started. We are working extremely closely with the remaining residents and their families on a wide range of bases and supports to do this in a very humane way. However, our expertise has been very clear in its assessment. Does Ms O'Neill want to add anything?
Ms Yvonne O'Neill:
I am not sure I can add any real detail to what Mr. Reid said. The correspondence and the previous discussions have probably detailed the scale of the examination, the basis for the decision and the number of expert inputs there have been. There has been huge engagement with the users and families. On her own visit there, the Senator will have some of our HSE staff who have been involved in the planning for this and the support for it. Periods of change are very difficult. Across mental heath and disability services, we have been involved in a significant number of transitions from existing arrangements where people have moved from their homes after a number of years to new settings. They have been difficult, no more than they would be for any of us. One thing we have learned is that, afterwards, they will reflect that while they were very reluctant, concerned and fearful of the move, when they made the move, they understood the difference it could make to the quality of their life. Looking back they understand how much happier and better they are with the level of accommodation and supports in the new arrangements. We could probably do more with the service users and families and with people such as the committee who have genuine concerns to give them opportunities to see the types of arrangements we have put in place and how people have reflected on the fear of change but have understood in hindsight that it was in their best interests.
One of the residents' main concerns was that they would be moved outside of the Midleton area. They speak a lot about being able to walk out of the building and go down to the local shop. One man said he had gone to the folk club the previous night. Will the new premises be in Midleton? Will it be in the centre of Midleton? Will it be close to the town centre?
Continued engagement with stakeholders towards the implementation of the provisions of the Public Health (Alcohol) Act 2018 on a risk priority basis is listed as a priority for the environmental health service for 2022. Will the officials elaborate on which provisions are yet to be implemented and what factors are impeding the process?
Great. I thank Mr. Reid. Finally, the service plan refers to expanding access to alcohol and drug services in the community, including the support of individuals in recovery, expanding support for women, and expanding support for dealing with substance misuse issues when it comes to the families of individuals who struggle with addiction. That is all very welcome. Will the officials say more on the details?
I welcome Mr. Reid and the team and wish Ms O'Connor and Mr. Woods well in their new positions. I will begin with capital projects. I have engaged with the Tánaiste on the emergency department and maternity and paediatric unit in Galway and asked him to engage with the officials, which I believe he has. This is a long-running project and I appreciate it is complex. We have had commitments, and the previous Minister for Heath, Deputy Harris, received commitments from the Saolta University Health Care Group as far back as September 2018 that a planning application would be lodged before Christmas 2018. Here we are in 2022. Could I say that the planning application will be lodged this year? Can Mr. Reid say whether a planning application for an emergency department and maternity and paediatric unit in Galway will be lodged this year?
Mr. Paul Reid:
With the Senator's agreement, I will summarise the key projects. I have been chairing over recent weeks a discussion with the hospital group and with our own estates management and services to look at the timeline and pipeline of infrastructure projects in Galway.
The pressures on that service are very significant. I will give a quick summary of the key projects, some of which were just listed. Regarding the current status of the emergency department and the women and children's block, the assessment review has been submitted to the HSE. We are finalising board papers to submit to the Department of Public Expenditure and Reform this week, in addition to a preliminary business case, which we are expecting to be submitted in the coming days. That is a process that has progressed well over the past few weeks to get everybody on the same page as to the right strategic location and how to bring that through. Separately, the temporary emergency department, which involves an investment of about €13 million, is expected to be commissioned within the next two months. The Senator has asked previously about the cardiothoracic ward. That is valued at €4.7 million and is near completion. It is a 12-bed ward and will be operational by the end of June. The oncology development is valued at nearly €63 million and is at an advanced stage. It is hoped to commence the commissioning of the building in the third or fourth quarter of 2022. The orthopaedic theatres in Merlin Park University Hospital are worth about €10.57 million. Construction is complete and the theatres are currently in the process of being commissioned. They will be made operational on a phased basis from June 2022. The outpatient department in Merlin Park is valued at €12.5 million. That project consists of the replacement of accommodation for the outpatient services, which will be displaced to the emergency department and women and children's block. The issuing of the tender for this project is due in the coming weeks. I reassure the Senator that there is a particular focus on bringing all those projects through the key pipeline we have to get them through.
Mr. Paul Reid:
Yes. We want to get the business case for the emergency department and women and children's block through our board. In parallel, we are in discussions with the local authority and there is dialogue happening there. In the past, there have been significant challenges around what would go where and what it might look like when it goes in. I have asked the teams to have pre-planning discussions with the local authority, in parallel, with the intention of getting the planning application in this year. That is a challenge.
It is a challenge. It is very frustrating for all involved. I acknowledge that there will be a temporary emergency department but there is huge frustration about the delay on this project. All I can do is keep raising it, as I have been doing, within the committee, with the Minister, with the Secretary General and at a political level with the Tánaiste. I understand he has discussed it with Mr. Reid. There is huge frustration in Galway about this key project, which everybody says we need but is not progressing.
Mr. Paul Reid:
To be frank, it is a frustration, particularly for people who need to use services in Galway. They will ultimately be the ones impacted. There has been some frustration in trying to get everybody aligned on what site it should go on, where it should go and what will be in it. That is at a local level, a hospital group level and a national level. All the key players have come together and have agreed a site and location to move this through. I acknowledge that this has been frustrating.
One in every two of us will get cancer during his or her lifetime. Cancer survival rates are thankfully increasing. People are living longer so the likelihood of getting cancer has also increased. The survival rates for breast, colorectal and lung cancer patients are worse in the west than in the rest of the country, particularly for breast cancer. In HSE west, the cumulative five-year standardised net survival rate for female breast cancer patients diagnosed from 2011 to 2015 was 80%. That is compared to 85% on average for the country. Similarly, the rate for lung cancer was 16.7% in the west versus 19.5% nationally and for colorectal cancer, it was 62.6% in HSE west versus 63.1% in Ireland. There is a commitment in the national development plan to build a cancer centre in the area. It states, "In accordance with balanced regional development, a cancer care network for the Saolta region ... with a Cancer Centre at Galway University Hospital with appropriate infrastructure will be delivered." The witnesses may not have these data now but I ask for a comprehensive note on where that is at. We had a presentation in March from Professor Michael Kerin, which was well attended by Oireachtas representatives. We have lower survival rates in the west. There is a need for this centre and a commitment to it in the national development plan and Project Ireland 2040. Is there an update on that?
Dr. Colm Henry:
On survival rates, the Senator is right. However, we have seen improvements. Looking broadly at what feeds those improvements, it is screening programmes. For some of the cancers the Senator mentioned, it is also early diagnostic programmes and rapid access clinics. About half of those cancers are diagnosed through rapid access clinics, which we have for lung, prostate and breast cancer. There was a drop-off through the pandemic, particularly the first year and couple of months, in attendance at rapid access clinics. There was also a troubling drop-off, as there has been in other countries, in diagnosed cancers in 2020. The National Cancer Registry Ireland, NCRI, recorded a 15% drop in cancers in 2020, which suggests these cancers may present, as in other countries, at a later stage where they are perhaps more advanced and need more complicated treatment.
One of the actions we took in a national sense during the pandemic was to invest in and resource the rapid access clinics, to maintain as high a level of access as possible and ensure people did not present later in an upgraded fashion. We invested in our cancer services with successive winter plans throughout the pandemic in order to address the drop-off in presentations. In addition, there was a drop-off in surgical and diagnostic procedures, which was particularly marked in 2020. In 2021, there was a catch-up nationally in attendance at rapid access clinics. There was an increase in attendance, particularly at breast clinics, and there was a catch-up to the expected 2019 figures with regard to other cancer-related activity, be that diagnostic activity, chemotherapy or surgical activity.
I cannot answer the Senator's question with respect to the particular investment in Galway. I will come back to him with a specific note on it.
Mr. Liam Woods:
In the master plan for the Galway site, there is an intention for a major cancer centre. That is subject to consideration and deliberation between Galway and the clinical programme. It would then need to come into the capital plan of the HSE.
Okay. I would appreciate a note on that. In last year's winter plan, there were no acute beds identified for UHG, which we are told was due to a lack of physical space. Is that likely to be repeated this coming winter? Are there any short to medium-term plans for acute beds? Is the elective hospital in Merlin Park still planned to be a day-only facility, or is there a cast-iron commitment for acute beds in that facility?
Ms Anne O'Connor:
On the winter plan, we met with the team in the west yesterday, from both hospital and community care, to look at how they are planning their unscheduled care activity over the coming months. That will feed into the winter planning process. It is hard to believe we are talking about next winter. The challenge in the west is where to put new beds. There is not an obvious spot to land in new acute beds. The solution in Galway has to be about how we access the community beds and what those beds do. Additional beds have opened in unit 6 in Merlin Park to support the acute services run by the community. We also have beds in some of the other community and district hospitals there. There are very good examples, whether in Galway, Mayo or so on, of how the hospitals and community work more collaboratively around virtual wards, for example, and the acuity within the community. We cannot necessarily build new hospital beds. We have talked about the big capital plans but there is a lot of scope in this area. To be fair, between hospital and community, Galway is one of the more integrated areas for ensuring people are discharged.
The critical bit for us is increasing the acuity for people who are discharged from hospital or to prevent people going into hospital in the first place, by ensuring the community is stepping up with community intervention teams, CIT, and outpatient parenteral antibiotic therapy, OPAT. These are all community-based programmes to support people who are quite acutely unwell. That is what they are looking at in the west. We met the group CEO and chief officer about what their plans are for the coming year.
I thank all our guests from the HSE. It is quite a lengthy plan so I have read the parts relevant to my own region. I thank the HSE for the opening statements. I followed most of the meeting from my office because I am juggling a few other meetings, as are most Teachtaí Dála.
My questions are quite region-specific. This Saturday after lunch there will be another large protest and public meeting in Ennis on the general hospital. The feeling in the region is it should have a far more major part in meeting the public healthcare need. What can the HSE officials say to people in Clare and the mid-west about the capacity beyond University Hospital Limerick, UHL? I raised this in the Dáil just last week with the Taoiseach and have raised it with the Minister. There must be an answer in the region beyond UHL. I believe that answer is in St. Johns, Ennis and Nenagh. What reassurance can the officials give the people of the mid-west that the HSE is committed to bolstering public healthcare capacity in that region?
Mr. Liam Woods:
As an initial response on that, obviously Croom was a significant investment and that is now up and working well, thankfully - all four theatres. On overall investment in the mid-west there is strong investment going in community service to directly support UHL. The Deputy is aware, I am sure, there is a 96-bed block in process at UHL. The use of Ennis and Nenagh in support of UHL but also themselves is something we are committed to developing. We have already put services in Nenagh with that in mind. Those are contracted services supporting access to care, so there is a strong commitment to developing services across the region in both acute and community. I am not sure if Ms O'Connor wants to say anything about that. That is what I would say there.
When accident and emergency services closed in Ennis General Hospital the whole argument at the time, which I did not buy into, was we would have centres of excellence in each region and people would travel beyond their home base for certain aspects of healthcare. The problem has largely been consultant capacity. It certainly has been in the mid-west, though not to the same extent here in Dublin because within the capital there are quite a lot of consultants who have specialties in the various realms of healthcare. We do not have such a capacity in the mid-west more than a decade on. Thus the closure of Ennis accident and emergency unit based on that argument has been proved to be flawed. It does not work. I am aware the HSE has opened up a local injuries unit and there has been capacity building and many positives but is there now a feeling within the HSE that diminished capacity is coming back to haunt us and maybe there is yet again a need for accident and emergency care at Ennis General Hospital?
Dr. Colm Henry:
I might take some of that. On the reconfiguration of Ennis and Nenagh and the nine hospitals reconfigured under what was called the smaller hospital framework of 2014, it was the right thing to do for patient safety and outcomes. In 2022, and indeed when this was devised in 2014, we look at access to healthcare in terms of outcomes. Once a sign is put up that says "Emergency Department" people have a reasonable expectation the full range of services, the complexity of services and the expertise will be behind that sign to give them all the care they need. We know that with the expectations people rightly have these days we are not able to do that. That does not just apply to Ennis hospital. We have bypass now for myocardial infarctions and for stroke. We are introducing a trauma strategy that will centralise trauma into some hospitals. Generally speaking, what was replaced, largely successfully in my view, in the smaller hospital framework document was the concept of an emergency department that does everything with medical assessment units. These are operated during working hours during the week and people see defined, differentiated medical problems within the capacity and within the framework of expertise in that particular hospital. That has largely worked well in those nine hospitals.
What the Deputy said is also correct in that reconfiguration exposed a capacity issue that was perhaps especially marked in the mid-west. We had one model 4 hospital, a centre of excellence as you might put it, with all the complex range of services including a cancer centre, and then the rest of the hospitals are model 2 without a model 3 hospital in between like those in Cavan, Mullingar or Castlebar, which have 24-7 emergency departments. Since the smaller hospital framework was devised in 2014 that has been successfully implemented in those hospitals but capacity issues have come to the surface and are being identified through the additional 1,146 beds throughout the country as part of the successive winter plans.
On a safety and outcome basis I defend the reconfiguration in a general national sense. It was the right thing to do then and remains so to meet the expectations of the public around what they can expect when they do into an emergency department.
I get that and I thank Dr. Henry. However, the point is every single week UHL is breaking all numbers for trolleys. It is debated in the Dáil Chamber every week yet the outcome we have come back to again is another inquiry where we will look into what has gone wrong. I am being told by staff within the hospital that when the top brass come down from Dublin or there is a ministerial visit, trolleys are pushed down all the corridors, including the morgue corridor, to give things a better appearance. That is not how it is felt on the ground, not how patients see it and not how many of the front-line staff see it. We are really bashing our heads in the region wondering why the HSE and Sláintecare recommend the three new elective hospitals for Ireland be based in Dublin, Cork and Galway. Why is it not on the agenda, given all that incessant pressure UHL is under, and given many of the HSE's own management figures in the region are pushing for it? Why is it not being pushed forward?
Mr. Paul Reid:
I have a couple of comments. I thank the Deputy. Just to reassure him, when the top brass come down from Dublin as he describes I have been there with the team and seen at first hand the very real challenges that exist within UHL. I will say what I said earlier. I have strong confidence in the management and clinical team down there. They have some real challenges on a population basis and I wanted to publicly say I have a lot of confidence in the management and clinical teams. There are very significant challenges based on it being the only ED in the region; that is for sure. The solution is a summary of what Mr. Woods has said, namely, leveraging the minor injuries unit and the investment that has gone into Nenagh. Utilising St. John's on a continuous basis is part of the solution but also some of the community interventions that have happened-----
Mr. Paul Reid:
I am sorry, I was coming to it. The elective hospital has been subject of a review for a long time now. The assessment by all of us, including the HSE, the Department and the recommendations to Government, was based on the three sites. That assessment has been going on for a number of years now, probably.
Mr. Paul Reid:
I think the decision and recommendation that has gone to Government is for the three. I certainly would like to see that progressing based on those three sites. The business cases are being finalised for each of the individual sites by the Department. I would like to see that progressing. I think the Government decision is the three sites and that is a policy issue for Government.
I just think it is so wrong. I refer to the major urban centres of Dublin, Cork and Limerick. Every single hospital grouping has its own pressures and we get that but what the HSE is doing is building additional capacity in the groupings that already fare better than the UHL hospital group.
By not progressing an elective-only hospital in the Limerick, Clare and mid-west region, it is ensuring that their capacity stays at a rock-bottom level. Yes, there is a new 96-bed block and inroads are being made, but in terms of meeting that absolute need for an elective-only hospital, that will be lost and it will not be fulfilled, I believe, for another generation.
I want to move on with my questions because I do not have much time. Shannon Doc is an incredible out-of-hours service in the mid-west and there is a huge campaign to have it beefed up for Shannon town, which is County Clare's second-largest town. When people there have an acute health need out of hours, it means a trip to accident and emergency. They could avoid going to accident and emergency and avoid taking up a trolley in a corridor that night if there was 24-hour capacity in Shannon Doc, or certainly capacity throughout the night and at weekends. I have written to Shannon Doc and it has been very engaging and helpful, but we need someone on high in the HSE to look at this. If it is truly hub and spoke, then we need to build capacity beyond University Hospital Limerick.
I have written to the HSE and the International Protection Accommodation Services, IPAS, the authority co-ordinating accommodation for Ukrainians. There is a HSE 17-bed facility, Inisgile, at Parteen, County Clare. It was renovated in the past three years but has been lying idle. Surely this is the site for accommodation for Ukrainians but no one will answer on that. This is why, unfortunately, I have to bring it to the committee today. The witnesses may not have the answer today but I ask, in the coming days, whomever's desk it is sitting on, that they would respond to this. It is three or four weeks later and we have not even had an acknowledgement of this. The witnesses might respond. I appreciate the witnesses taking the time to be with us today.
Ms Anne O'Connor:
As an observation, and I do not know the specifics of Shannon Doc, we are acutely aware that our GP out-of-hours services are under huge pressure at the moment. It is a conversation we had ourselves only yesterday, in particular in response to the Ukrainian people coming in. The out-of-hours challenge is becoming quite stark in some areas. We can take that away. Ms O'Neill might know the details.
That is positive. I will conclude on those two specific issues, Inisgile at Parteen, County Clare, and Shannon Doc. We are floundering on some of these issues without any great guidance. If someone can respond in the coming days with an update on those two matters, I would be grateful. Ms O'Neill's comments today give me some hope.
A number of members have indicated for a second round but I will use some of my own time for a change to discuss some of the issues that have not been addressed so far.
The report refers to mesh implants and states that the Chief Medical Officer has put forward a number of recommendations. Would the witnesses be able to outline some of those recommendations?
Dr. Colm Henry:
There are two complications centres at Cork University Maternity Hospital and the National Maternity Hospital with an investment of €1 million. It is a single service on two sites and will include clinicians who have been trained by experts from Croydon. The pathway in those two centres includes physiotherapy, a pain specialism and neuro-gynaecology and, if required, the other specialties are neurology and gastroenterology. The pathway there will deal not just with removal, which it is sometimes crafted around, but all complications related to the centres. The two centres will include translabial scanners on site. There will also be optional treatment abroad if the degree of complexity is not within the scope of the complications centres. That is part of our response in our work with the Department of Health, the CMO and the services onsite.
With regard to scoliosis, we had some very moving testimony from doctors who were in the service but also from families. They were talking about the backlog and the challenges they are facing. As I said, it was moving testimony about the agony that children are going through. There have been problems within the system itself. Have they been resolved?
Mr. Paul Reid:
The straight answer is “No, not yet”. As part of the access to care fund in the national service plan, significant advance funding has been given to Children's Health Ireland, CHI, to increase theatre capacity in Crumlin and Temple Street and also to get in further resources. There are just over 190 awaiting surgery. It is very complex, as the Chairman will be aware, and it needs multidisciplinary teams for each surgery. We are anxious to tackle that and particularly anxious to get it back to the maximum four-month waiting list. There will be occasions where it will take longer but the investment has been advanced to CHI and it is finalising a plan to start to address some of that this year.
Ms Yvonne O'Neill:
The Chairman is right. The speech and language therapy services are particularly challenged. It is one of the areas we would like to target under our own community waiting list initiative and the access to care points that were discussed earlier. We have asked areas to come back with proposals under the waiting list funding to see if there are targeted programmes for speech and language therapy. The constraint around that is getting the therapy time. I should say that we have been successful in some work around psychology services for children, where, between overtime, out-of-hours services and so on, we have taken 1,200 children off the waiting list. We are trying to construct something similar for speech and language therapy but we are more constrained by the available hours. A number of the speech and language therapists are not available and they have other commitments out of hours, and we were not as successful in bringing forward some of the programmes on that. However, it is one of the priorities on our waiting list access plan for community.
Ms Yvonne O'Neill:
Helpfully, an additional €10 million was provided to support some of the current engagements that are happening with the Irish Dental Association around how we would target some additional payments so we could look at the longest waiters. That is part of the current negotiations around the Irish Dental Association and its fee rates, so we are constrained by those current discussions that are ongoing.
Another issue that came up is the waiting time for trying to get a hearing aid adjusted. I recently encountered the case of a child with Down's syndrome where it was not about getting a new hearing aid or getting tested, but just getting it adjusted, and they were talking about possibly waiting two years. Again, I am not bouncing this on anyone but there seems to be a problem with the system.
Ms Yvonne O'Neill:
With regard to accessing disability services generally, the Chairman will be aware we had some success last year in reducing the waiting list for assessments by 72%. We have been constrained by the requirement and demands on our children's disability teams this year. We are working through our access funding to see if we can target some improvements there. The experience in that individual case may also relate to accessing the team and the associated aids and appliances, but we have a very particular focus on that as well this year. We could try to make those aids and appliances more readily available.
It is a combination of both. The same team is responding to the new services and assessments and the existing services and assessments. That is where it is.
With regard to long Covid, I know the HSE is trying to collate figures. The committee hopes to deal with the matter at some stage. I know there are some centres but, while one centre might be dealing with the lungs and heart, inflammation of the brain may be involved, which requires neurological services. People are saying that the current model is clearly not working for them. People may have to go to various different services in this regard. Is that being considered as part of the plan? Do we have a sense of the number of people who are suffering from long Covid? I know it is not a medical term but there is clearly a great challenge in this regard not only in Ireland, but internationally. Are we looking at tweaking or changing the model and establishing centres of excellence that people can go to?
Dr. Colm Henry:
It is a good point and "long Covid" is the appropriate term. We call it post-Covid syndrome for those in the early stage of post-acute illness and long Covid for those with symptoms that last longer than 12 weeks. Our knowledge of this is increasing all the time. Of course, when we were living through the pandemic, we needed to devise a model of care first. The model of care we designed at that time, in consultation with the programmes and clinical leads, involved looking at the whole spectrum of illness including self-awareness, self-management, communication with GPs and specialist pathways for those who developed specific symptoms. There tended to be constellations of symptoms around respiratory problems, some neurological problems, fatigue and so on. We established a number of specialist centres. Not all of them are up and running. There are some staffing issues with some of them but Ms O'Connor has just told me that six more posts have just been approved and recruitment is under way. At least three of those centres are now up and running.
As to the Chairman's question on reviewing the model of care and adapting it to what we now know, if more knowledge comes through as people's experience with long Covid progresses and if they develop other symptoms that were not highlighted at the beginning, we will, of course, adapt the specialty centres and the expert input to address whatever needs come to light. The early impression was one of predominantly physical symptoms along with some neurological and psychological symptoms. We largely worked with the respiratory and infectious disease communities in designing these specialist centres that we refer patients to. As I have said, not all of them are up and running.
Ms Anne O'Connor:
As part of the initial work we are doing, there is a whole epidemiological study in which we are gathering all the clinical data because people present differently and we need to know more. Gathering all of that information so that we can adapt services as they develop to respond to the actual needs is a very significant part of the work we are doing. There are a lot of things we do not know with regard to the number of people out there and what they need. As Dr. Henry has said, we have started and we are developing a service now. We will continue to work on it.
There was a commitment from the previous Government regarding cervical cancer testing in Ireland. I have seen the figures and they are very low. I understand there were challenges with regard to Covid and so on but is there a plan to increase that percentage and, if so, by how much?
Dr. Colm Henry:
The rate of uptake for the cervical programme is quite good at about 78% of the eligible population. The screening age range is from 25 to 65 with increased frequency in the first few years, reflecting the higher prevalence of HPV infection in younger age groups. It broadens out to five-year intervals thereafter. In March 2020, just before the pandemic, we switched over to the HPV form of screening, which is more sensitive and less prone to false negatives. It is more reliable and picks up more early-stage changes that may lead to a cervical cancer. In recent months, we have seen attendances lower than the target figures. We are looking at a communication campaign to bolster awareness and attendance and to ensure that all eligible women aged between 25 and 65 attend for what is now a more sensitive screening programme and one which has, since 2008, picked up quite a number of cancers and tens of thousands of early-stage changes in cells which present a risk of progressing to cancer, as is reflected in the more recent report that came out only in the last few weeks. Since 2008, we have seen a reduction in the rate of cervical cancer of the order of 2.5% to 3% per year as an effect of this programme.
Dr. Colm Henry:
Our intent was to develop a centre within the Coombe hospital. That will certainly be ready in the second quarter of this year. It will not have the capacity to take over all testing, at least in the initial few years. We will continue to need to use Quest Diagnostics as a partner. This company performs all testing at the moment. It will take some years before all testing for the country is centralised in the laboratory at the Coombe. I foresee a need for a secondary partner such as Quest for some years to come. To reassure anyone who is listening, Quest provides an excellent service. That is reflected in Dr. Scally's review. We are confident that the arrangement we have with Quest will support the programme as we transition to the Coombe lab, beginning this year, and in the years to come.
Mr. Paul Reid:
The Coombe was subject to its own specific cyberattack. We have worked very closely with our technology teams to restore that link, which is currently being tested. That impacted on the testing happening in that centre. There is a specialist challenge with regard to getting resources in there as well. However, directionally, it is exactly as Dr. Henry has said. The funding is committed and construction has commenced and is well progressed. That is where we are going.
As the witnesses are probably aware, we have had a number of meetings regarding the national children's hospital. It has not come up here this morning but I imagine people at home are wondering what happens next. I know there were votes and so on but the Government has signed off on it. It will go to tender. Does the HSE have any sense of when that process will be completed?
Mr. Paul Reid:
I might ask Mr. Mulvany if he wishes to say anything but we are working very closely with our estates team, the Department and the Department of Public Expenditure and Reform to progress the business case. Some of the exploratory work necessary to facilitate the work will commence pretty soon. Tenders will then be issued and construction commenced. We will tender for some preliminary work intended to support the whole process shortly with a view to commencing next year. We are working through the timelines for the full completion of the project.
Dr. Colm Henry:
As part of the current investment, we are carrying out a survey to get a greater idea from specialist services as to how prevalent this condition is. When we devised the model of care a year ago, the only data we had was real data from different healthcare systems around the world which showed initial high rates of symptomatic post-acute syndrome followed by rapid attrition as the months went by. In other words, it seemed to disappear with time. I got some data this morning from one particular hospital in which as many as 20% or 30% of patients who developed acute Covid and were hospitalised still had significant symptoms 12 weeks later. That is the experience of one particular centre. Part of the work we are now doing, in addition to building up these specialist centres for referral, is carrying out a survey to get a greater understanding of the service needs based on the symptoms people have. Our awareness of the syndrome is evolving around the world, not just in Ireland. We know the geographic distribution of Covid from epidemiological data received from public health during the pandemic. We know that certain counties, such as Donegal, were particularly affected. The specialist services and pathways we set up one year ago reflected where we felt the highest prevalence might be, based on acute illness.
As I said, part of the work we are doing now is trying to make an impact through the numbers.
Dr. Colm Henry:
Yes. If we go back to 2020 people were very acutely ill. We said at the time it was not flu. There was a high conversion rate to ventilation on assisted respiratory devices in a ward setting. It was much higher than any other viral illness we were used to at that scale. It was not surprising that we saw a large degree of residual symptoms in people in a post-acute period for weeks afterwards. The question the Deputy and others have is about long Covid syndrome for 12 weeks or longer. It appears less strongly related to the initial acuity of the illness. We also see it in people who were not severely ill initially. It also seemed less tied to age. There is something counter-intuitive about the pattern of long Covid syndrome. It does not necessarily reflect the initial acuteness of illness and does not necessarily reflect how old or frail a person may be.
Dr. Colm Henry:
That is the cut-off. It is somewhat arbitrary but in a lot of practice, we have to use an arbitrary time for definitions. This is not unusual. The working definition is people with a documented acute illness who have a constellation of symptoms after 12 weeks. The pattern is becoming clear here and abroad with regard to what those symptoms are.
Dr. Colm Henry:
There is no relationship to the vaccine. As we know, the vaccine protects people from serious illness. The point I was making earlier is that it is not necessarily related to the original severity of the illness. We would expect people in intensive care or those in hospital for a protracted time to have post-acute symptoms for four, six or eight weeks after admission. For long Covid syndrome, there is a looser correlation with the original severity of the illness. There is a correlation but it is not as strong.
The two words that have dominated the news in recent days are "clinical appropriateness". This is with regard to the national maternity hospital, which was signed off yesterday. There is still a little hangover of an issue on it. The CEO of the HSE is answerable to the board. The board of HSE overwhelmingly approved the new national maternity hospital project. Was Mr. Reid at any of the meetings where the term "clinical appropriateness" was discussed? Will he rehearse for us again the reasons the HSE insisted on the inclusion of this term and what it means?
Mr. Paul Reid:
To summarise, the board of the HSE gave this process very detailed consideration, debate and discussion through the audit and risk committee initially and ultimately at the board where executives including me were in attendance for the whole dialogue. The board set out a range of matters it wanted reflected in the legal documents to strengthen and future-proof the national maternity hospital. Something that is reflected in the legal documents is the issue with regard to legally permissible and clinically appropriate services. The intention and driver of all of this from the HSE, and the board in particular, was to future-proof the maternity services on the campus. These maternity, gynaecological, obstetric and neonatal services will be on site with other services. We want the national maternity hospital to be protected for these services so that other services such as cardiac services would not merge into it. It was about future-proofing and strengthening the case that the services set out to be delivered are those that will be delivered.
This is very useful. The committee has had pretty comprehensive discussions under the stewardship of the Chair. A specific question was raised by a witness last Thursday who asked whether there would be an irresistible pressure on the Government of the day or hospital management of the day to state spare beds in the new national maternity hospital would be used for other purposes if St. Vincent's University Hospital and its emergency department came under pressure and there was spillover. My interpretation is that this would not be possible because it would not be clinically appropriate to the new national maternity hospital.
Dr. Rhona O'Mahony made the point that the budget for women's health is often at the bottom of the health budget and too easily conceded to other issues. Very often women's health issues become secondary issues. The budgeting is also ring-fenced. I assume this speaks to clinical appropriateness. What Mr. Reid is saying is that every service to be carried out in the national maternity hospital will be appropriate to its range of services, and that when it comes to spillover or if the emergency department is absolutely crowded a Minister or the Cabinet cannot say free beds in the national maternity hospital would need to be released.
Mr. Paul Reid:
This was the exact driver of the HSE board. It was to protect the hospital so that other services not related to those to be delivered by it would not end up being provided there in any scenario. In fairness, this dialogue and discussion happened between all parties. All parties were in agreement that this scenario cannot emerge. The intention was to strengthen all of this.
With regard to the budget, what is important in any future national service plan is that the budget is committed, as it is at present, to national women and infants health programmes, particularly to maternity and the wider services I have referenced. This was the exact driver of the discussion and the debate. It is to future-proof the hospital so the scenarios the Deputy outlined regarding other services that are not related to a national maternity hospital cannot end up being deployed in it. We are confident, with all parties, that it is protected.
Will Dr. Henry update us on the incidence of hepatitis in children? The Chair and I spoke about this recently. Without making assumptions about the committee, we might have a longer conversation about it at some stage. There are six types of hepatitis. This does not seem to connect with those six. Without breaching confidentiality, to which we are very sensitive, is it a cause for concern? It seems to be of unknown origin. What type of discussion is going on internationally on this?
Dr. Colm Henry:
Of course it is a cause for concern when something new comes along that has not been identified previously and does not correspond to existing known hepatitis cases. We have had a small number of cases in this country. I believe we have had six cases and another seven cases are under investigation. Fortunately we have very good public health epidemiological links with other countries and we are getting daily reports from the Health Protection Surveillance Centre on the patterns seen in the UK. Thankfully it is rare. Some of the children get very ill, including a relatively high proportion progressing to needing liver transplants. Tragically, some children do not survive. It is a very rare condition but nevertheless a new condition.
In the best tradition of epidemiology we are looking at all the cases for common experiences and exposures and anything that suggests a common trait between them. There is some suggestion, particularly from the UK where there have been many more cases, that it may be associated with adenovirus. It may be a reaction to the adenovirus. This is not yet a definitive position internationally. Information is being pooled all of the time. Our public health people are linking with their colleagues in Europe all of the time to pool information on the profile of patients getting the illness here, their experience and how the illness progresses. It is of concern. Perhaps by the time we speak again we will have more information because we will have more numbers and, perhaps, more outcomes from the pooled experiences of Irish, British and other cases.
I thank the witnesses for the comprehensive discussion this morning. I will go back to the termination piece.
HSE hospitals are kind of playing catch-up in this regard. A number of them are not providing termination services - I understand that only ten out of 18 were doing so up to last year. Clearly, that is not good enough. The Minister stated that the number might get up to 14 this year. I am just flagging this as something we are watching in the context of the recent debate. The witnesses may not have anticipated this question, and I would be happy with a written answer, but they might be able to give us some of the reasons this is happening.
Mr. Paul Reid:
Dr. Henry has been doing some work on this with the hospital groups and hospitals under the national women and infants health programme. We are all with the Minister on this. We have to, and want to, get all the maternity hospitals providing this key service for women, and we are committed to doing so. Dr. Henry might outline some of the rationale behind that and some of the challenges to getting there.
Dr. Colm Henry:
I will try to be concise. Yes, we absolutely want this service to be delivered in all our maternity hospitals, as is right. We are up to 11 hospitals now that are doing so, with Sligo hospital being the most recent one to come on board. For the remaining hospitals, we are working with the management and clinicians in each of them and linking some of the new consultant appointments to provision of this service. For example, in St. Luke's in Kilkenny, in Kerry, Cavan and in Portiuncula hospital, the full range of services will be provided once the new consultants are in post.
Dr. Colm Henry:
No, I am talking about consultant obstetricians. As the Deputy knows, there needs to be a hospital service at between ten and 12 weeks to provide for surgical or medical termination. A named consultant presence to take referrals for women and to carry out the terminations is essential. In the four hospitals to which I referred, this has been part of our discussions regarding the new consultants that have been provided to support the service. They must start up the service once these posts are in place. My hope is that it will be provided in those hospitals this year.
In the remaining hospitals - Letterkenny, Portlaoise, Tipperary and Wexford - there are some individual issues. We have 90 maternity units and we would like each of them to have six consultants on the rota. In the case of this particular service, it is more likely that not all the consultants and other staff would be signing up to provide it. We are sometimes relying on a small number of staff or, in particular in the smaller units, just one or two individuals to carry out the service. We are working with those hospitals, which tend to be the ones that have existing staffing difficulties at consultant level in terms of getting permanent staff on board or filling vacancies. We are working with them to link new consultant posts with the service. I cannot give the Deputy the same assurance that I can give in respect of the other four hospitals in terms of the service being provided this year.
I want to go back to the issue of clinical appropriateness and to summarise my understanding in this regard. It is about ensuring that if pressure comes from other areas of speciality within a general hospital, such as cancer care or cardiac care, or there is potential overcrowding in the emergency department, and if there are free beds in maternity, those beds simply cannot be encroached on by other professional medical services. The maternity hospital is ring-fenced, in effect, for maternity and neonatal services. As I understand it, that is the context from which the term "clinically appropriate" derives.
Mr. Paul Reid:
That is exactly it. It is about future-proofing. Obviously, the duration of this project is over the significantly long term. We wanted to make sure the service is ring-fenced, at all stages into the future, for women and infants programmes, including maternity, neonatal, gynaecological and obstetrics, in order to protect the service and ensure it is there for the future, over its entire lifespan, and will not be compromised. In fairness to the dialogue that happened with partners after the discussion with the board, everybody was committed to that principle.
Deputy Cathal Crowe referred to the issues with Shannondoc. There are similar issues with Westdoc in Galway and the expansion of GP services to my own village of Moycullen as well as to Rosscahill and Oughterard. I have heard, although I have not had it substantiated, that there may be a reluctance among Galway city GPs to carry out that expansion. They feel they have enough to do in the city and they do not wish to take on new work in those locations. Is this something the witnesses have encountered in other areas? Will funding solve it or is it an issue of whether personnel are willing to take up that extra responsibility and extra work?
Ms Anne O'Connor:
I do not know the specifics of the situation the Senator referred to but, in general, there are capacity challenges. We just do not have enough GPs, full stop, for whatever we want them to do. What we are seeing across the board at the minute - members may be hearing it from their constituents - is that there are challenges for people in accessing the services of GPs. To take on an out-of-hours service requires GPs to do many more shifts, unless they employ another doctor to take that work on from afar. For local out-of-hours services, where local GPs provide the service, to expand basically means doing more shifts. Depending on the capacity that is available, that can be a decider for them. Some out-of-hours services bring in doctors just to provide that service, rather than local GPs doing it. It depends on the specifics.
In terms of the funding available for out-of-hours services, that is something we have to look at, as I said earlier, in terms of the demand that is currently being experienced, particularly in light of the response to the Ukrainian people. Notwithstanding that, we know we have been very challenged in terms of GP service provision and this is something we are looking at in terms of GP training numbers and all of that. I imagine the difficulty with the out-of-hours service in the Senator's area is related to that broader issue as well as to the availability of GPs. My colleague, Ms O'Neill, might have more detail on that.
Ms Yvonne O'Neill:
To add to what Ms O'Connor said, the discussion is about how the overall GP provision is modelled and where the out-of-hours service starts and stops. It absolutely is about the utilisation of the available resource, whether that is the GPs who are currently in practice and-or other GPs who are not currently in practice but are providing other, out-of-hours services. To be fair, discussions are under way directly with the Irish College of General Practitioners around how best we can model the service based on the resources we have and the resources we are seeing coming through.
There is a growing population on the outskirts of Galway city and we have lost a GP from Oughterard. There were two before but now there is only one. There is an ongoing challenge in terms of the existing capacity and the lack of availability of outside assistance under Westdoc. I am not sure who it was who said at a previous meeting that there are particular challenges in Galway and the west.
Going back to the issue with emergency departments, will Mr. Reid indicate whether the HSE is committing to a hands-on approach to ensure what has been promised will be delivered? There are three major projects set out under Project Ireland 2040 relating to the Saolta University Health Care Group, including one at University Hospital Galway. Is Mr. Reid committing to taking a hands-on approach to the delivery of that project?
Mr. Paul Reid:
Just to reassure the Senator, across all our estate projects, we give strong oversight at our executive management team meetings and, ultimately, in terms of what we bring to the board and the progress we report. Specifically relating to Galway, I have taken a strong oversight role, working with the services and the teams here, to ensure we have full alignment, full understanding and progress on what needs to be done. That is necessary because the services are under such significant pressure. I will continue to do that with the hospital group and the hospital teams.
Mr. Paul Reid:
Yes, everybody is committed to the solution we have set out and are bringing forward. I would not like to underestimate the challenges in terms of planning permission and all that goes with it. There is a legitimate process we have to work through, understandably, from a planning perspective, which the Senator knows well from his previous role. We want to do that thoroughly and well in order to meet everybody's concerns.
This issue was touched on earlier but I want to put on record my support for the concerns expressed by medical scientists, a number of whom have contacted me.
They say that the action has been taken following a ballot last November in which 98% voted in favour of taking action, that up to 20% of approved medical scientist posts are unfilled in public hospitals, that medical scientists carry out identical work to other scientific colleagues who work in hospital laboratories yet are paid on average 8% less, that medical scientists have fewer career development opportunities and less support for training and education than comparable colleagues and that the role of laboratory diagnostics in healthcare is expanding significantly at this time, with ever-increasing responsibilities and workloads. With regard to addressing their concerns and preventing future industrial action, what can Mr. Woods say about engaging on this issue?
In the first instance, I thank Mr. Reid, Dr. Henry and Mr. Woods for supporting the eye clinic liaison officer and providing the funding so eye clinic liaison officers can be appointed to the various hospital groups around the country. I believe the recruitment process is ongoing.
Does the HSE have any comments on the proposals that have been made for dealing with the waiting lists in the eye care area by the North East Regional Integrated Eye Care, NERIEC, support team? Basically, it has introduced a novel approach to try to deal with eye care waiting lists. It has agreed to collaborate and to pool resources to come up with new ways of approaching it. Its members gave a presentation here a couple of weeks ago and they have asked to appear before this committee. It appears that some of the longest waiting lists are in the area of eye care, with approximately 500,000 people throughout the country on a waiting list for procedures and so forth. Has the HSE examined the proposals this group has made? What are its thoughts on them and is it considering funding it?
Mr. Liam Woods:
I am not aware of the specific proposal, but it sounds interesting. Yes, we subsequently met the body the Senator referred us to previously and those recruitments are under way. We would be very interested in our access to care resources in any event in pursuing any opportunities around change models of care delivery, particularly integrated ones.
Ms Yvonne O'Neill:
I am aware that there is very good collaboration happening between the hospital and the community. The chief officer in CHO 9 has brought that to our attention and we have been looking at supporting it through the access to care fund as well. There is a significant scale of funding in it and we have asked them to come back with some prioritised proposals to us. However, the model is a very good integrated community hospital model.
I see it very much as a pilot, if it worked in this area. Some of the best clinicians in the eye care area, such as Professor David Keegan and others, are involved in it, and they also have gleaned support from the NGO sector. If it were to work, I believe it is something that could be rolled out to the other areas. I hope the HSE will consider giving the funding to trial it on a pilot basis for a period of perhaps two years.
That is very positive. We have an ageing population and, unfortunately, an ageing population is a time bomb particularly in the area of eye care, be it diabetic retinopathy, glaucoma, cataracts and so forth. Unless we get on top of it in the next few years, we will become overwhelmed. Some would say we are already overwhelmed when there are buses bringing people to the North to get cataracts done. It is a failure of our system when that happens. Our objective should be to ensure that this type of thing does not happen and that, in fact, people would be coming from the North to us for care. That is the level I would like to see in eye care. We have some of the best brains in the world in this country. They are sought after to speak in America, throughout Europe and so forth. We should use them to eliminate waiting lists because it can be done.
I do not see anybody else indicating a wish to speak.
I thank our guests for the comprehensive discussion they had with the committee today. I wish them well in the roll-out of the plan. They mentioned the 120,000 additional hours of personal assistant supports and 30,000 additional hours of home support. I suppose it will raise people's expectations in that regard. There is also the target of eight hours in emergency departments. Following this meeting, people will say they know of someone who was there for 24 hours, two days or whatever else. The plan is in place now and the expectations of people will rise and it is to be hoped that we will be able to fulfil all their expectations.
Before we finish, I also thank Ms Anne O'Connor and I wish her well in her new role. I say that sincerely on behalf of the committee. The HSE is facing huge challenges with some of the changes and the institutional memory it is losing, but they are the challenges it will have to face in the future.