Oireachtas Joint and Select Committees

Wednesday, 15 June 2022

Joint Oireachtas Committee on Health

Sláintecare Implementation: Discussion

Photo of Seán CroweSeán Crowe (Dublin South West, Sinn Fein)
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Today the committee will meet with the HSE and the Department of Health to discuss the implementation of Sláintecare. I welcome Mr. Paul Reid, CEO; Ms Anne O'Connor, chief operations officer; Mr. Liam Woods, national director of acute operations; Ms Yvonne O'Neill, national director of community operations, HSE; Ms Breda Crehan-Roche, chief officer of Community Healthcare West; and Mr. Tony Canavan, group chief executive officer of Saolta University Healthcare Group. I also welcome Mr. Robert Watt, secretary General, Mr. Muiris O'Connor, assistant secretary and Mr Sarah Treleaven, principal officer, Department of Health.

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. Therefore, if the witnesses' statements are potentially defamatory in relation to an identifiable person or entity, they will be directed to discontinue their remarks. It is imperative that they comply with all such direction.

I call Mr. Watt to make his opening remarks.

Mr. Robert Watt:

I thank the committee for the invitation to discuss progress in the implementation of Sláintecare, the programme to improve our health service. As was mentioned, I am joined today by my colleagues, Mr. Muiris O’Connor and Ms Sarah Treleaven.

As committee members will be aware, last week, the Minister for Health published the 2022 action plan, the Sláintecare Implementation Strategy and Action Plan 2021-2023, which sets out the ongoing priorities to improve our health and social care services. This report contains many different elements, but this year, the main focus of the reform involves addressing waiting lists and the very significant waiting list plan that we discussed on the previous occasion. It is now being implemented across different aspects of the service. It also includes further developments in shifting care to the community through our enhanced community care programme, significant recruitment and establishment of various teams in providing care outside of a hospital setting, which is a key element of the Sláintecare programme. There is also further investment in innovation and enhanced capacity in terms of additional employees into the service, as well as additional beds and access to care. Implementing digitally held solutions aligns with the Government's recently published strategy. It also introduces the Sláintecare consultant contract.

In this respect, we hope to engage with the representative bodies over the next week or so on finalising the new contract. We are focused on progressing the national elective ambulatory strategy through the provision of new elective capacity in Cork, Dublin and Galway, which is important for increasing the overall capacity of the system to provide more elective procedures for our citizens. We are also focused on the realignment of acute and community services via regional health areas, RHAs, which we discussed at our previous meeting. We can briefly set out the progress in this programme.

The 2022 waiting list action plan was launched on 25 February. The plan allocates €350 million to the HSE and the National Treatment Purchase Fund, NTPF, and details 45 actions to reduce and reform waiting lists. The immediate focus of the plan is to reduce active waiting lists for acute scheduled care by 18% this year. If we can meet this projection, it will bring the number of people waiting to its lowest point in five years.

A waiting list task force has been established and is chaired by Mr. Reid and me. We meet fortnightly. A working group, comprising colleagues from the Department, the NTPF and the HSE, meets weekly to monitor progress and variance against waiting list plans, consider actions and identify issues to be elevated to the task force.

Overall, waiting lists are performing slightly ahead of the targets set out in the waiting action plan. The first three or four months of the year were difficult due to Covid, the impact of which on the system was profound and reduced the amount of care that could be provided. As of the end of April, both the outpatient and gastrointestinal, GI, scope waiting lists were performing ahead of target while inpatient day case waiting lists were marginally ahead.

We are maintaining the momentum behind the development and roll-out of the enhanced community care programme. Mr. Reid will touch on this in some detail. I will list the key achievements: 81 of 96 community health networks, CHNs, are now established; 21 of the 30 planned community specialist teams, CSTs, for older persons are established; 11 of the 30 CSTs for chronic disease management are established; 21 community intervention teams are now operational, with national coverage secured for the first time; and 139,000 diagnostic scans of various modalities were provided last year. Regarding that last, significant progress has been made this year, with more than 75,000 scans by the end of April and a further 20,000 or so by the end of May. We are on target for providing many more diagnostics in the community than we did last year, with a likely total of 200,000. More than 1,200 whole-time equivalent staff have commenced their roles and a further 650 are at an advanced stage of recruitment.

The significant advance in GP access to diagnostics is an impressive performance from a standing start. Every week, large numbers of people who would have turned up for hospital appointments are now receiving that care in the community setting through our older persons and chronic disease pathways. This is real reform happening in practice on the ground for patients.

An individual population health profile has been created for each of the 96 CHNs, each containing standardised data on the demographics and health status of the relevant CHN. This supports the identification of service needs down to a local level. This profiling is an ongoing process and will lead to much better planning. Initial external evaluations of the nine learning sites have highlighted a significant appetite for change among staff as well as positive feedback, particularly about the role played by GPs.

The Department of Health is progressing RHA implementation in partnership with the HSE and the Department of Children, Equality, Disability, Integration and Youth. We are designing six regions around the country where, rather than the system being funded on a siloed basis that separates community care and hospital care, health services will be co-ordinated around the needs of patients across all care settings. This means that RHAs will serve one population in one region with one budget. By aligning the services that we provide in each region, we will have the ability to see more clearly how a patient moves through our system from GP to hospital and back again.

The Government decision on RHA implementation, approved on 5 April, provides policy direction and a clear mandate for the RHA work programme. Given that stakeholder consultation is critical for the success of this reform, regional workshops and other engagements are planned to input into the development of the implementation plan. As was mentioned at our previous meeting, we are interested in receiving input from this committee and anyone else who wants to engage in the process. We have an open mind about where we are going with the design. There are many questions and we do not have a fixed view on them. With our colleagues in the HSE and elsewhere, we are trying to figure out exactly how to implement the plan.

The Government remains committed to introducing the Sláintecare consultant contract to hospital consultants as soon as possible. The contract remains the subject of engagement with consultants' representative bodies.

The Government decision in December to implement a national strategy of elective care centres was shared with the hospital groups and individual hospitals and a programme business case has been developed for the elective centres in line with it. The Government decision is to progress development of dedicated elective centres in Cork, Galway and Dublin and will provide elective care services for all of the population of Ireland. Work has been continuing on the development of project-level preliminary business cases for Cork and Galway, including public spending code compliant analysis, to support the delivery of care centres in an agile manner. These are expected to be finalised first, with the Dublin project business case being progressed in parallel.

The Department will continue to engage with the public and a range of stakeholders to further the goals of Sláintecare in building a better, more equal healthcare system for our citizens. These reforms build on one another and are progressing in tandem. I am happy to engage with committee members on this matter.

Mr. Paul Reid:

I thank the committee for its invitation to discuss the implementation of Sláintecare, in particular the issue of regionalisation. I wish to provide the committee with a summary update on three of the areas that we are progressing in Sláintecare's implementation: RHAs; scheduled care; and the enhanced community care programme.

Since the last committee meeting on Sláintecare, the Department of Health and the HSE have continued to progress the implementation of RHAs actively. The Department of Children, Equality, Disability, Integration and Youth has also been involved in this work. The detailed system and RHA design and the associated implementation plan, which sets out the key enabling work streams, and their objectives, milestones, activities and risks are being developed between the HSE and the Department of Health. In addition to fortnightly meetings between the Department and the HSE, working groups have been established to examine clinical corporate governance and accountability; finance, including population-based resource allocation; digital and capital infrastructure; people and development; change, communications and culture; and programme co-ordination. Six different stakeholder engagements have already taken place, with further engagements planned. In July, there will be further workshops with a wide range of stakeholders across the system at national, regional and local levels. Before the end of July, regional workshops are planned for engaging with managers, clinicians and local leadership teams.

Tackling waiting lists is a key priority for the HSE and is included as one of six key priorities in the HSE Corporate Plan 2021-2024. The corporate plan commits to delivering significant reductions in waiting lists and waiting times, working towards achieving the following Sláintecare maximum waiting time targets by 2026: ten weeks for a first outpatient appointment; 12 weeks for an inpatient or day case procedure; ten weeks for a GI scope; and ten days for diagnostics. The 2022 waiting list action plan has been jointly developed by the Department, the HSE and the NTPF and is being overseen by a waiting list task force, which is co-chaired by Mr. Watt and me. The action plan sets out the following December 2022 maximum waiting time targets to ensure progress towards the Sláintecare targets: 98% of patients waiting for their first outpatient appointments will be seen within 18 months and 100% will be seen within 36 months; 98% of patients waiting for an inpatient or day case procedure will be treated within 12 months and 100% will be treated within 24 months; and 100% of patients waiting for GI scopes will be treated within 12 months.

The action plan is supported by dedicated funding of €350 million, including €150 million allocated to the NTPF and €200 million allocated to the HSE. The plan focuses on delivering significant additional activity in 2022 and building capacity within the system to address recurrent capacity gaps sustainably. The plan commits to delivering 100,000 additional outpatient department appointments, 28,000 additional inpatient or day case procedures, 8,000 additional GI scopes and 30,000 additional diagnostics. Detailed plans to deliver this activity have been developed.

Engagement continues across the delivery system, including with the NTPF, to identify all opportunities to deliver additional activity in 2022. The plan seeks to progress longer term reform in order to address sustainably the recurrent capacity gaps that were identified in 2021 through a comprehensive waiting list demand and capacity analysis. Significant planning has been undertaken to develop solutions and outline the requirements necessary to address the capacity gaps.

Investments in the healthcare budget for strategic reform initiatives such as enhanced community care are having a significant impact. The programme was allocated €240 million for the establishment of 96 CHNs, including 30 CSTs for older people and another 30 for people with chronic diseases, to provide integrated services for people nearer to home. To date, more than 2,000 staff have been recruited or are at an advanced stage of recruitment, with more than 1,700 additional posts to be recruited for in 2022. Eighty-one of the planned 96 CHNs, 21 of the CSTs for older persons and 11 chronic disease teams have been established to date.

From 2019 to 2022, an investment of €210 million has been made available through the GP agreement to support eHealth and other modernisation initiatives and the roll-out of chronic disease management, CDM, programme to more than 430,000 people. In early 2021, direct GP access to radiology services was implemented with five private providers, with approximately 140,000 radiology tests undertaken in 2021, which has assisted in reducing the demand on hospital services. More than 94,000 scans have been carried out up to May 2022. All of these developments in community services are being delivered with increased collaboration and partnership with voluntary providers.

Photo of Colm BurkeColm Burke (Cork North Central, Fine Gael)
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I thank the officials for the presentations and for setting time aside to be with us. I begin with the consultant talks. Mr. Watt outlined there was progress on that matter. Have we a timeframe for when we might see a conclusion and an agreement on that? I am aware he cannot give a specific time but are we talking about it being within three months, six months or 12 months?

Mr. Robert Watt:

I thank the Deputy for the question. We had an engagement last year and that engagement was not successful, so we are working through the issues once again. We hope to start formal discussions next week, which I believe is the plan, and we hope to finish those up very quickly, if we can. Obviously, any negotiation depends on the ability of the parties to reach agreement and that is always uncertain, but we hope to do this very quickly if we can.

Photo of Colm BurkeColm Burke (Cork North Central, Fine Gael)
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I thank Mr. Watt. I raised the issue of theatre assistants at a previous meeting. We were to receive a report. I am wondering if that report can be made available to us.

Mr. Paul Reid:

If it has not been submitted already, we will. I cannot recall.

Photo of Colm BurkeColm Burke (Cork North Central, Fine Gael)
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I ask that it be sent on to me because I raised it previously. We are going to have significant demands now. There are many very specialised people who work in the theatre on operations but we also need that backup support. Can we have that report? The officials might outline what progress has been made on that matter.

The third issue is the elective hospital for Cork. Where are we with that because my understanding was there was a detailed plan submitted to the Department in January and we are now six months on from that. What is the timeframe? When are we likely to have the site clearly identified and a work programme prepared? I ask because tomorrow we are doing the opening of a new extension to Heather House in Cork. In fairness to the HSE, that is a 60-bed extension and the turnaround time was 18 months. The HSE started in November 2020, the site opened up in January 2021 and we have a finished building in 18 months. Where are we with the elective hospital in Cork? What is the timeframe and when are both the Department of Public Expenditure and Reform and the Department of Health going to sign off on it?

Mr. Robert Watt:

On the sign-off, we are going through the assurance process now, which as the Deputy knows is set out by the Department of Public Expenditure and Reform for projects over a certain size. We are now into that process so it should be complete over the next few weeks. We are hoping Government will sign off on all the different elements before the-----

Photo of Colm BurkeColm Burke (Cork North Central, Fine Gael)
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I worry when Mr. Watt says "the next few weeks". Are we talking about one week, two weeks or three weeks? Given the summer break, some would say that means we will not do it until October.

Mr. Robert Watt:

No, we are hoping to have all that part of the process concluded before the summer break and we will go to Government before it breaks for the summer recess.

Photo of Colm BurkeColm Burke (Cork North Central, Fine Gael)
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If it is signed off, what is the programme then for the implementation of the decision?

Mr. Robert Watt:

Then we immediately finalise the design and the procurement strategy and it goes out to tender. We will be doing that as quickly as we can, in conjunction with HSE estates.

Photo of Colm BurkeColm Burke (Cork North Central, Fine Gael)
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The 18-month turnaround on the Heather House project shows it can be done.

Mr. Robert Watt:

Yes, it does.

Photo of Colm BurkeColm Burke (Cork North Central, Fine Gael)
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Can we not set clear targets? We have significant pressures in Cork on Cork University Hospital, CUH, Mercy University Hospital and the South Infirmary. Every one of them is under severe pressure. We have had a substantial increase in population over the past 25 to 30 years and especially over the past ten years. We need that extra space.

Mr. Robert Watt:

That is the intention. The plan for the electives recognises the pressures the system is under and that we need more capacity. Additional capacity focused in this way will ease the pressure on the other facilities in the region and that is the intention. When we get through Government, we will come back with the detailed plan that has the different steps. The next milestone will be having the design and going to procurement. That will require a period and we will see what the market comes back with in terms of-----

Photo of Colm BurkeColm Burke (Cork North Central, Fine Gael)
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Where are we with the timeframe for the children's unit in CUH? I understand it is going through a planning process.

Mr. Robert Watt:

I do not know the details on that. We can come back to the Deputy.

Photo of Colm BurkeColm Burke (Cork North Central, Fine Gael)
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I ask that someone come back to me on that. There is an urgent need to upgrade and build a new children's unit in CUH. Will the officials come back to me on that?

Mr. Robert Watt:

Yes.

Photo of Colm BurkeColm Burke (Cork North Central, Fine Gael)
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The next issue is home help and care assistants. In the Cork-Kerry region there was a decrease in the number of people working for the HSE. It went from 1,800 people about 15 to 18 months ago down to 1,400. That is a drop of 400 people. Where are we now with the numbers available to provide home care, particularly as we have a growing number who require it and increasing demands? There is also the added issue of many people preferring not to have to go into nursing homes. I understand there was a recruitment campaign organised in the Cork region and 96 were recruited, but that does not replace the number previously employed who have left the region.

Ms Yvonne O'Neill:

I am not familiar with the specifics of the Cork-Kerry numbers, but overall the recruitment campaigns are active at a local and national level. We are trying at all times to maximise the recruitment, but the Deputy has rightly identified we are losing numbers overall. There are some very specific endeavours happening around the home support recruitment campaigns to try to make the terms and conditions as attractive as possible, being as proactive as possible and keeping the campaigns local, which have shown to be better for attracting people.

Photo of Colm BurkeColm Burke (Cork North Central, Fine Gael)
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On providing training and ensuring the people we are taking on have adequate training, what such programmes are in place by the HSE?

Ms Yvonne O'Neill:

FETAC is the minimum training level, so-----

Photo of Colm BurkeColm Burke (Cork North Central, Fine Gael)
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Is the HSE actively encouraging people to get involved?

Ms Yvonne O'Neill:

Yes. There are programmes where we are recruiting people and then supporting their FETAC level training while they are working with us as part of bringing them into the posts and bringing them in to train.

Photo of Colm BurkeColm Burke (Cork North Central, Fine Gael)
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When Ms O'Neill says there is an active programme about recruiting them, what format is that in? I have asked a number of people to check and they could not find where it was being advertised and who exactly was operating the recruitment. My understanding is some of that was sent out to private contractors. Is that correct?

Ms Yvonne O'Neill:

There are national programmes for recruitment, some of which are subcontracted to private providers, which would be standard across our overall recruitment endeavours. There are also local campaigns run at community healthcare organisation, CHO, level by the CHOs themselves, so it is a combination of both.

Photo of Colm BurkeColm Burke (Cork North Central, Fine Gael)
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I am receiving complaints that when people try to find where they can apply, they are having difficulty getting that information.

Ms Yvonne O'Neill:

Okay.

Photo of Colm BurkeColm Burke (Cork North Central, Fine Gael)
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Maybe Ms O'Neill will give me-----

Ms Yvonne O'Neill:

I will.

Ms Breda Crehan-Roche:

I am in Galway, Mayo and Roscommon and we have done a very vigorous campaign in relation to home helps. It was a bespoke campaign within the region and we received 52 people. Unfortunately, with the workforce it is very difficult to get people. That is a fact.

Photo of Colm BurkeColm Burke (Cork North Central, Fine Gael)
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Yes, I accept that.

Ms Breda Crehan-Roche:

As Ms. O'Neill said, we are looking at imaginative ways. We are supporting people and sponsoring people to do level 5 FETAC, and then there would be ongoing education on continence or infection prevention and control, first aid and all those things.

Photo of Colm BurkeColm Burke (Cork North Central, Fine Gael)
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It would be helpful on the approach being taken by the HSE because we have not received any information on it as public representatives. It would be helpful from our point of view if we got the programmes the HSE has.

The final issue relates to eye care in the Cork region. A brand new building has been built in Ballincollig. I understand it needs additional staff and to be equipped. There is still no clearance to equip the building. It has been finished but there is a question about providing funding for equipping the building. We have approximately 18,000 people on the waiting list for eye care in Cork. People are being offered £50 to recommend a place outside the jurisdiction. In other words, they are referring people to Belfast for treatment. I understand one can get £50 if one refers people there. I understand the buses are starting again while we have a finished building, but we still do not have the equipment for it.

Mr. Paul Reid:

I will revert to the Deputy about the specific building. I am not sure if there is a capital or resource requirement for the building in Ballincollig. We have an issue with resourcing these specialist areas. I will give the Deputy a breakdown separately about specialists in the area of eye treatment. It is a significant gap that we are trying to recruit in. I will give the Deputy the specific figures later, but it is an issue overall.

Photo of Colm BurkeColm Burke (Cork North Central, Fine Gael)
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One problem is that if a GP refers someone, there is no immediate triaging to see whether people need surgery or eye care. They are just put on the list. Can we look at that issue so that people do not feel they have to travel 300 miles or 400 miles to get treatment?

Mr. Paul Reid:

Our waiting list action plan will address 37 specialty areas and put in new pathways for people so that they can possibly be seen without needing to see a consultant. If they can see other specialists, we can avoid having the lists build up. A number of pathways are funded as part of the waiting list action plan.

Photo of Colm BurkeColm Burke (Cork North Central, Fine Gael)
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The staff in all the facilities in Cork are working extremely hard, but if there is no equipment for a new facility, then we will make no progress. If the funding was set aside, we could have this up and running by the end of the year. I would like to get clarification on that.

Mr. Liam Woods:

Regarding access to care, I think the Deputy is referring to once-off capital costs associated with equipping a unit. Those should not be problematic. We will come back to him and report on that. The cost for such a unit-----

Photo of Colm BurkeColm Burke (Cork North Central, Fine Gael)
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I have asked questions about this. The last reply I got was on 27 April, from the HSE in the south-southwest hospital group. It stated it is waiting for funding. When one gets the funding, one still has to order the equipment. Due to various shortages of equipment, there is a waiting time for it. We need forward planning. Can we set a timeline so that this will be up and running by the end of December?

Mr. Liam Woods:

We have some frameworks in place for equipment. The Deputy is right to say there have been some issues. The Deputy referred to the cross-border directive scheme. It makes much more sense for us to provide the service in Cork for the people in Munster, which would be our preference. We will revert to the Deputy about timescales and specifics about capital funding.

Photo of Seán CroweSeán Crowe (Dublin South West, Sinn Fein)
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With regard to future meetings about Sláintecare, there are very localised questions. I suggest to members that it is impossible for people coming in to have those answers. There is a mechanism if members want to ask those questions. We are not trying to trip anyone up. It would be much simpler. It is not satisfactory for members to ask questions and people not to have the answers. People could maybe look at that mechanism for future Sláintecare meetings.

Photo of David CullinaneDavid Cullinane (Waterford, Sinn Fein)
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I welcome the witnesses. As I have discussed with Mr. Reid in the past, I am a big supporter of regional health areas. I see significant potential in them. The logic of the policy to integrate primary, community and acute healthcare is strong and I support it. We had some discussion at the last meeting of the different options that went to Cabinet. I would have preferred a different option, probably a variant of options two and three, although that is obviously my own opinion. Mr. Watt said we are setting a direction of travel, so all of these processes and structures which are put in place could evolve over time, which is fair enough. I want to drill down into how that will work practically, because that is the substance of this meeting. I have a question about Navan hospital, which relates to the regionalisation issue. I see on the map for Sláintecare that it will be area A, which would contain Monaghan, Cavan, Meath, Louth and Dublin north. Part of the logic of regional health areas is alignment of primary, acute and community care, but also alignment of hospitals within those regional catchment areas. What is the official HSE policy on the emergency department at Navan? There is some confusion about it.

Mr. Paul Reid:

I am happy to clarify the position. We would say that what is happening at Navan hospital overall is a realignment of the services, with proposals to redirect some services to other hospitals, including Our Lady of Lourdes Hospital. The rationale for that are serious patient safety risks which have been highlighted to me, the board of the HSE and the Department. The risks identified include that there is no local emergency department governance in Navan hospital, no acute surgical service in place, and an agency registrar, not a specialist in an emergency department, provides care in Navan. There are significant issues relating to one of the smallest ICUs in the country. Those risks have been highlighted to me as being significant by the chief clinical officer of the HSE, the clinical lead for acute services nationally, the anaesthesia specialists in the local hospitals, surgical specialist physicians, non-consultant hospital doctors and nursing staff. That has been highlighted to me, as CEO, the board of the HSE and the Department. In my role as CEO of the HSE, I have to take those risks very seriously. I take any risks associated with patient safety and saving patients' lives very seriously.

Photo of David CullinaneDavid Cullinane (Waterford, Sinn Fein)
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I hear what Mr. Reid is saying.

Mr. Paul Reid:

I cannot ignore that and have to address it. We have aligned ourselves with the Department to progress a number of actions to make that safer. I will take full cognisance of Government's concerns, which we will address through the process we are in at the moment. I cannot ignore and will not compromise my role to address issues.

Photo of David CullinaneDavid Cullinane (Waterford, Sinn Fein)
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A senior Minister accused the HSE of "causing further concern" and went on to say that she was not satisfied with the HSE's responses to straightforward, reasonable questions. The Tánaiste said yesterday that the Ministers, Deputies Donnelly and McEntee, and others, "are not satisfied with the HSE’s responses". Is the Minister unhappy with the responses being given by the HSE?

Mr. Paul Reid:

I have heard those statements. We are happy to and will continue to address those concerns that Ministers or a Minister of the Government may have. We will address those concerns over the week. We will address them in a manner that progresses safety in hospitals. I cannot compromise safety. I am advised by clinical specialists. Obviously there are political concerns. I live in the real world. Local things are big issues for politicians nationally. I understand that. We will address those concerns.

Photo of David CullinaneDavid Cullinane (Waterford, Sinn Fein)
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I understand there was a meeting of Oireachtas Members from the region this week and that a paper was presented by the HSE with clear timeframes. The Minister says there are no such timeframes and he has not signed off on any. There are comments from Ministers that they are not satisfied with responses from the HSE. The public watching on and concerned people in Navan will see that the left hand does not know what the right hand is doing or that, at the very least, there is tension between what the Government and politicians are saying on one hand, and what the HSE is saying on the other. That needs to be clarified. There needs to be a joined-up response to this. I have my own views of what should happen at Navan hospital, but all of that uncertainty is causing real concerns.

Mr. Paul Reid:

I fully accept that. We will address all the concerns that any Minister has over the next couple of weeks.

The initial meeting that was convened earlier this week was with all Oireachtas Members in those areas and was attended by all the senior clinical specialists in the areas. They did highlight their concerns, including concerns about patient safety and lives. I cannot and will not walk away from that but I will address Government and ministerial concerns.

Photo of David CullinaneDavid Cullinane (Waterford, Sinn Fein)
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Regarding the regional health areas, I might ask Mr. Canavan and Ms Crehan-Roche to respond to my question. I am trying to understand how this could work at a local level. I can understand how at a regional level, you have a single management tier, which makes sense. You want to align your CHO services with acute hospitals. For me, it has to be more than an administrative alignment. It has to be clinical and be about patient pathways. I will give an example in my own constituency, which is the easiest one I can relate to. We have a CHO manager, a hospital manager and at least one building, if not more than one if you take mental health as well, which is located on the grounds of University Hospital Waterford. We have what is called a Dunmore wing, which is a unit housing a palliative care unit and acute beds, but we have different management layers making different decisions. It is the same across acute care, where hospital management can find it very frustrating to get step-down and recovery beds and home help packages. There are different management layers and different structures. Can the witnesses tell me how this will improve because that is crucial for me? Regarding what is happening in emergency departments and reducing waiting lists, sometimes the focus is too much on what is happening in the hospitals where we have to take two steps back and look at primary and community care as much. Could the witnesses give me some indication as to how that will work - not at a national level in terms of management but at a local level?

Mr. Paul Reid:

I will invite Mr. Canavan and Ms Crehan-Roche to talk about their experience locally in the current set-up. The Deputy certainly has described the issues we are trying to address, be they in respect of functional specialists or budget allocations, which do not benefit the patients in terms of the delivery of services. All our focus in terms of looking at Sláintecare and all the engagement we have had to date with all the stakeholders are on how this must be about the service. It is not about structures. It has to be an integrated service. One issue we are seeing at local level even now is stronger integration between acute and primary services. We have not worked through in detail what the design of that in the regions will look. I will call on Mr. Canavan and Ms Crehan-Roche to give the Deputy some good examples of where it works and what we want to replicate from a service perspective.

Ms Breda Crehan-Roche:

I will give an example because that is a good way of explaining something. When we look at Sláintecare in action, we are trying to ensure that people receive care as close to their home as possible to prevent them having to go into hospital and emergency departments. The programme is around enhanced community care, which covers three chronic diseases - respiratory, cardiac and diabetes. The integrated care programme for older persons, ICPOP, is about enabling older people to live within their communities. I will give an example. A gentleman aged 90 from east Galway, whose name is Ambrose, was not feeling well and was brought to a hospital just outside our region, which is Galway-Mayo-Roscommon. He was sent to Tullamore. The hospital discharged him because he needed medication and different follow up. He was then seen by a consultant geriatrician. He had a fall a few months later. She met him in University Hospital Galway and out of that, he did not go into hospital but went to one of our community nursing units in Loughrea and got some respite, enhanced physiotherapy, occupational therapy and various clinical supports. He was then discharged home, now has some home support and the nurses in the community look after him. It is working really well. We work very closely with the Saolta group in our community care centres as well. Tomorrow we have what is called the joint enhanced community care governance group, which is co-chaired by Mr. Canavan and me. There are various people on that, including clinicians. We find out how we are doing regarding care. For example, in April alone, the frailty at the front door programme saw 157 people. We saved 375 bed days in April alone. This stopped all those beds being taken up and these people were looked after in the community so it is working really well.

Mr. Tony Canavan:

It is fair to say that Ms Crehan-Roche and I have been working very closely on this for more than two years since both of us took up our posts because of the importance of integrating the services between the community and hospitals. We have been trying to create the environment through which a enhanced community care programme can be rolled out successfully. From a governance perspective, the key way we do it is, as Ms. Crehan-Roche pointed out, through the joint enhanced community care oversight group, which is jointly chaired by Ms. Crehan-Roche and me. It has everybody you could imagine from the point of view of delivering services within and outside the hospital meeting in a forum. It is quite a large and unwieldy forum but it is a great way for people to get to know each other and understand how their individual services work and how they can work together. Ms Crehan-Roche has already given examples of how that is rolled out in real life. We have other examples. For example, we have good joint working arrangements in radiology. Radiology is really important for a GP in determining whether a patient needs some further investigation or admission to hospital or otherwise. If that can be ruled out, again, it avoids an unnecessary admission to hospital. General X-Ray is available in the primary care centre in Castlebar. It is a regular primary care centre with public health nurses and all the other staff you would expect to see in a primary care centre, along with GPs, but we also have a radiology facility there that allows for direct referral from GPs. Patients are seen, have their images taken and a clinical decision can then be taken as to whether they need to be admitted to hospital or whether some other approach needs to be taken. We are looking to roll that out in a number of other locations. It is a key resource within the community. If we can provide that kind of diagnostic capacity before the patient goes into hospital, it removes another reason for a patient to be sent to the emergency department.

Photo of David CullinaneDavid Cullinane (Waterford, Sinn Fein)
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Could Mr. Reid and Mr. Watt work with this committee over the next number of months as they evolve the policy in this area? Mr. Woods will play a leading role in this as well in terms of rolling out the regional health areas. Obviously, I want to get it right. I would imagine that every member of this committee wants to get it right so where there is good practice, we need to build that in across the health service. Equally, we are seeing some good stuff in some emergency departments and some not-so-good stuff in other emergency departments so we need to learn from where there is good practice across the board. I know a level of work is being done at a high level in terms of the management layers but I am more interested in how that will translate into the local areas. If the witnesses could work with us on that over the next few months as it evolves, it would be helpful.

Mr. Robert Watt:

We would be very happy to do that. One possible suggestion is for us to provide the committee or any member with briefings separately where we can go through them. Sometimes this format might not be the best format for going through things with PowerPoint presentations, setting out the overall and local sense of it and giving examples of how it will work locally and how it will be different with the regional health areas. There is a lot of good practice but the question is how different will it be, and hopefully improved, with the regional health areas. We could facilitate a private session or whatever the committee thinks would be best to go through it in detail. Mr. O'Connor and Ms Treleaven are on the team and obviously Mr. Woods is now heavily involved in it. They can set out matters in more detail. There are many questions here and we are genuinely interested in hearing people's views about how we can make this better because we are going to make mistakes, which is fine because it is inevitable that we will make mistakes, but we will learn from them and through an iterative process, we will get there. Perhaps some other way whereby we can have a different type of engagement might help to drill down into the detail of it.

Photo of Róisín ShortallRóisín Shortall (Dublin North West, Social Democrats)
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It is certainly very encouraging to see stuff committed to paper. The documentation provided by the witnesses is very good. The challenge is translating that into actions and delivering. I very much welcome the fact that Mr. Woods with all his experience and his seniority has been appointed to head up the regional health area implementation body. Who else is involved? What kind of team does Mr. Woods have?

Mr. Paul Reid:

The Department and the HSE have a joint team co-chaired by Mr. Watt and me. We have the key leads in terms of acute and community care at Department and HSE level.

Separate to that I was very anxious to ensure, in the context of change management, that we have line ownership and line responsibility for the implementation of regions. As was said, Mr. Woods is a very senior and respected official within the HSE. Mr. Woods will be coming out to lead on the implementation. On foot of Ms Anne O'Connor leaving, alongside Mr. Woods will be Mr. Damian McCallion, who will take up the interim role of chief operations officer. That responsibility will, again, be within the line. As we start to put the structures together, Mr. Woods will have a network of people across the regions and CHOs - as it is at the minute - and acute hospitals, for leads within each of the CHOs and hospital groups, to support him in the implementation. We are working through a team that will support Mr. Woods. Separate to that, within the agency we have a strategic team led by Mr. Dean Sullivan, which is looking at the wider aspects of Sláintecare implementation, not just the regions element. There are a number of network leads across the country.

Photo of Róisín ShortallRóisín Shortall (Dublin North West, Social Democrats)
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I cannot see any timelines at all in the documentation. When will the HSE be in a position to set down clear timelines for the different elements of the implementation of the RHAs?

Mr. Muiris O'Connor:

The overall timeline is to have an implementation plan completed by the end of 2022, to phase in implementation through 2023 and to have the RHAs operational from 1 January 2024. We recognise the huge importance of deep and comprehensive engagement with the staff of the service, with this committee, and with all interested parties. It is our intention, with a view to having an implementation plan completed and submitted to the Government by December, to have a draft of that implementation plan ready in October or thereabouts in order that there would be comprehensive engagement and input taken on that plan at that point.

Photo of Róisín ShortallRóisín Shortall (Dublin North West, Social Democrats)
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I would like to go back to Mr. Reid or Mr. Watt on the key principles underlying this approach. Clearly, the objective is to have integrated care but we know that traditionally, the hospital sector has had all of the muscle and the lion's share of funding. There would be a downside for the hospitals if this is to be implemented in full. How is the HSE handling that from the point of view of the hospitals and the existing hospital groups? One main example of the integration is that there would no longer be the situation of delayed discharges with all of that expense being taken up with the hospital sector and no money in the community sector for home care. That is the typical kind of problem with the lack of integrated care. How is the HSE negotiating that at the moment? Has the HSE started talks with the hospital groups and with the individual hospitals?

Mr. Paul Reid:

Yes. We had a very detailed engagement just last week with all the hospital groups, some hospital leads and clinical leads, some specialists and some heads of nursing. It was a very significant engagement process to facilitate their feedback into the process.

The Deputy is correct that this is a massive change management issue. Integrating nine CHO areas and six hospital groups is a very significant change management issue. Yes, people will have a natural lens in terms of what it means for them. It is a big change management issue and as Mr. O'Connor has said we will spend a lot of time engaging with staff.

Mr. Canavan and Ms Breda Crehan-Roche are here. I believe that things are moving on very well. People can really see the benefit of the investment in enhanced community care. People are embracing the opportunity with step-down care beds, the new role for the National Ambulance Service, the pathfinder process, community intervention teams, older persons teams, and integrated care for older persons. Ms Crehan-Roche gave a very live example in that regard. I believe that things have moved on to where people can see it now in reality, as opposed to being on PowerPoint. It is hard to find any upside to Covid but if there is any upside, it is that we implemented Sláintecare at a rapid pace. I have said this publicly before. We took it off PowerPoint, we took it out of the spreadsheets, and the teams implemented it. People can see the reality now, which is happening under the change management process.

Photo of Róisín ShortallRóisín Shortall (Dublin North West, Social Democrats)
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Is there full commitment within the system on the principle of a single management team and a single budget within each RHA?

Mr. Paul Reid:

That is exactly where we are going. That has been communicated. Is everybody saying "This is the best thing that is ever going to happen"? Probably not yet. That is part of the dialogue and communications that we will be going with. As Mr. Watt described it, that is the line of flight we are heading into. There will be functional specialists within that, but it has to be a cross-cutting service.

One thing that I restate again and again in all of our workshops is that this is about the service to the patients and the users. It is not about structures, although structures are the enabler. Unless we are improving the services, it is not a corporate restructuring we should be on.

Photo of Róisín ShortallRóisín Shortall (Dublin North West, Social Democrats)
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Is Mr. Reid saying that those two principles of the single management team and the single budget are non-negotiable?

Mr. Paul Reid:

Mr. Watt may want to comment on that also. Yes, certainly I am saying that they are the core principles of an integrated management structure and an integrated service.

Photo of Róisín ShortallRóisín Shortall (Dublin North West, Social Democrats)
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I also want to ask about that important accountability piece in the context of corporate accountability and clinical accountability. I have always felt that it did not make sense for Mr. Reid to be apologising and explaining for something that was happening in south Kerry or north-west Donegal or whatever. There must be accountability at local level, both corporate and clinical. I can see there being resistance to the clinical accountability principle. Has the HSE started to look at that in any kind of detail and what kind of timeline are we talking about for having the legislation that would be required for that accountability?

Mr. Paul Reid:

Perhaps Mr. Watt will talk about the legislation aspect. I will make a couple of comments on accountability. We are addressing this in a number of ways. I have brought two papers to the board of the HSE about strengthening accountability in the HSE. It is a factor and it comes up after every inquiry or every issue. There are a number of things we will address, the first of which concerns the national incident reporting, NIR, process, which the committee will be familiar with. When we carry out certain clinical reviews, and when we review cases that go wrong, we look at them and we tend to drift into describing what happened, and then we start a process of looking to see who did something that they should not have done. This happens in sequence. We are now making sure, because it is facilitated, that this is done in parallel. It is not a "gotcha" process. It is being done in a parallel process to see what happened, what went wrong, was someone accountable, or did somebody set out to do harm. This will be run as a parallel process.

Separately, in the paper I brought to the board, we addressed the issue of accountability. When we talk about accountability it is sometimes made very simple. While I do not want to say it is complex, it is not that simple. There are a number of factors around addressing accountability. Clinical accountability is one factor, as is open transparency with the Patient Safety (Notifiable Patient Safety Incidents) Bill 2019.

Overall, we must look at performance management. We are not strong enough in that area and it is not fully rolled out across the board. We are in the process of rolling it out across the board. There must be clear lines of responsibility. We have delegated functions. We need to make sure that in all of those delegated functions people are clear on what their role and responsibility is, and what they are delegated to do and not do.

We have brought a number of strands to this, including in the regulatory area to see what professions are regulated and what are not. We are also looking to see what disciplinary process is in place. Some of our disciplinary processes go back to the 1970s and they are not fit for purpose. I would be open to challenge on that, but they are not. Some people can vet who will oversee an investigation. I do not believe this is right. There are a number of strands we want to address in terms of accountability. Perhaps Mr. Watt from the Department will address the Patient Safety (Notifiable Patient Safety Incidents) Bill 2019.

Mr. Robert Watt:

I do not have too much more to add what to what Mr. Reid has already said; he has summed it up well. Clearly, there are a number of different aspects including a clear view on the lines of responsibility, better performance management, and clear delegation. These are all of the different elements that make it up. As Mr. Reid has set out, this is the direction of travel. Work is going on that needs to be included as part of the implementation plan. That is what we intend to do.

Photo of Róisín ShortallRóisín Shortall (Dublin North West, Social Democrats)
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With regard to the performance management and the accountability, obviously there will be implications for contracts of employment and so on. Is the legislation underpinning that? When he was before this committee, Professor Tom Keane said that the single most important thing required is clinical accountability in the system. Professor Keane told the committee about his annual performance management review in Canada. They have very strong accountability legislation there.

Has preparation of that legislation commenced? I can see there being difficulties there but it is essential. Has a start been made on that legislation?

Mr. Robert Watt:

No, not specifically in respect of the legislation. As we discussed at the previous meeting, the extent to which a legislative basis will be required is unclear. It depends on how this advances. Some of the elements on which Mr. Reid touched probably require legislative change. That is certainly the case in respect of performance management and disciplinary processes because the legislative basis for identifying alleged misperformance or harm done to a person and the disciplinary action in that regard is old. The procedures are old, time-consuming and chunky. Obviously, I will not go into individual cases, but it takes many years and is very unsatisfactory. We will have to look at the legislative underpinnings for some of those performance elements and bring forward legislative changes. As ever, we want to try to do that as efficiently as possible on an administrative basis and only legislate where we absolutely have to do so. Legislation will be required in respect of some of those elements but we have not bottomed that out yet. We have not got a definitive view on it.

Photo of Róisín ShortallRóisín Shortall (Dublin North West, Social Democrats)
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It is very difficult to see how that could be done without a legislative basis being put in place. I am not looking for an answer now but-----

Photo of Seán CroweSeán Crowe (Dublin South West, Sinn Fein)
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I ask the Deputy to allow Mr. Reid to respond on that issue.

Mr. Paul Reid:

The Deputy mentioned clinical accountability. The report of Dr. Gabriel Scally on CervicalCheck set out several recommendations, separate from legislation, in respect of open disclosure and we have been rolling those out. It is a mandatory training programme across the system. That is rolling out quite well and has been embraced. I will balance my earlier remarks by making the point that we need to create a culture in which people come forward when things go wrong and feel safe in so doing, rather than feeling closed off or hiding it away. We have to find that balance of not having a "gotcha" culture but, equally, ensuring those who set out to do wrong are held accountable.

Photo of Seán CroweSeán Crowe (Dublin South West, Sinn Fein)
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The Deputy is out of time. Does she wish to ask a final question?

Photo of Róisín ShortallRóisín Shortall (Dublin North West, Social Democrats)
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I ask the witnesses to provide a note on the population health approach, which is very important. I was seeking more information on it. I ask that one of our guests send me more detail on it, please.

Mr. Robert Watt:

That is no problem. We can provide the Deputy a note on that.

Photo of Róisín ShortallRóisín Shortall (Dublin North West, Social Democrats)
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I thank Mr. Watt.

Photo of Gino KennyGino Kenny (Dublin Mid West, People Before Profit Alliance)
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I thank our guests for their attendance. Regionalisation is a good thing but most of the people watching these proceedings want to know whether it will deliver in respect of community care, primary care and overall healthcare. It is extremely important that delivery is at the heart of regionalisation. Accountability and democratisation are very important in the context of healthcare.

My first question is for Mr. Reid. What difference will regionalisation make as compared with what we have now?

Mr. Paul Reid:

This was asked earlier. In terms of its core principles, the first is that there is an integrated service. As Ms Crehan-Roche stated, it is that patients or users are getting care they need for their requirements closer to their home. If they need different pathways, such as needing further care elsewhere having gone to a primary care centre, it is a more seamless process. It is a handover rather than a hand-off experience for the patient. There are many issues that have to be addressed to solve that but those are the core principles.

What will make the service better will be our continued investment in the community service to support acute services. That does not mean there will not be investment in acute services. We have to continue to increase bed capacity and put new pathways in emergency departments. The improvement will relate to the enhancement of services such as primary care centres, for example. Last week, I visited primary care centres with the teams of Ms Crehan-Roche and Mr. Canavan. I saw an acute wing within a primary care centre where radiology services were taking place, with specialists from the acute services. That was happening within the primary care centre. Some of the referrals from that process happen within the primary care centre, such as in the context of speech and language therapists, occupational therapists or rehabilitation. It is about that integrated service with fewer hand-offs, as well as an integrated management structure to ensure that is the way we operate.

Photo of Gino KennyGino Kenny (Dublin Mid West, People Before Profit Alliance)
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When is it expected that regionalisation will be fully implemented? Obviously, it will take years. Is there a timeline for when regionalisation will have an impact on people's lives?

Mr. Paul Reid:

I know our colleague Mr. O'Connor just clarified that 2024 is the target for the full implementation of regions but we are not waiting until 2024. What is happing on the ground today is integration, co-ordination and patient care. Ms Crehan-Roche and Mr. Canavan just gave examples of that. For example, the National Ambulance Service has a new way of delivering care not just through emergency departments but in people's homes. That is operating in Blanchardstown and will shortly go into Mr. Canavan's hospital in Galway. Advanced paramedics and specialists in acute services are going out to treat people in their homes. That is happening now. We want to see it rolled out across the country.

The community intervention teams are in place, as are the integrated teams for older persons - we saw many of them last week - and the chronic disease management teams. Community intervention teams are multidisciplinary teams. While it may take us until 2024 to have a structure and an organisation and a population-based health allocation of budgets, we are not waiting until then. Our enhanced community care programme is about doing this now.

Photo of Gino KennyGino Kenny (Dublin Mid West, People Before Profit Alliance)
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Mr. Reid is saying it is happening already and it will be incremental until it is fully functional. I am guessing it will take several years, however, until the six regions and the 96 CHNs are up and running and fully functional.

Mr. Paul Reid:

To clarify, 81 of the 96 CHNs are up and running already. All of the 21 community intervention teams are up and running already. They are part of us building towards regions. We are not waiting for 2024 for those to be in place. As Ms Crehan-Roche mentioned in response to another Deputy, we had almost 140,000 cases last year in the context of community access to diagnostics,. We have done almost 100,000 already this year. Those are patients who would most likely have gone to an emergency department but are now not doing so and will probably not end up on a list. That is a practical example of what we are doing now.

Photo of Gino KennyGino Kenny (Dublin Mid West, People Before Profit Alliance)
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Does Mr. Reid believe this will have an impact on waiting times? Obviously, nearly 1 million people awaiting procedures is just not acceptable. I know there have been mitigating circumstances. I understand that. For a person awaiting an operation to be told he or she will be waiting four or five years for a procedure is just not acceptable. Can the HSE, through regionalisation or whatever one wants to call it, alleviate the waiting time for those waiting years for a simple procedure for which, in another European country, they may have to wait less than six months?

Mr. Paul Reid:

I will ask my colleagues Mr. Canavan and Ms Crehan-Roche, who are operating on the ground, to give their view.

Mr. Tony Canavan:

There is no question that this type of approach will have an impact on the length of time people wait. In our hospital systems, people wait in emergency departments. There are people waiting in emergency departments right now to be admitted to hospital. I believe the enhanced community care programme that we are rolling out, along with the chronic disease management programme in communities and the regionalisation about which the Deputy has been asking, will directly impact on both the numbers of people waiting in emergency departments and the length of time they have to wait to be admitted. Given the growth in activity in hospitals and the numbers of people attending, that is really important because this is not a fixed target; it is a growing one. We will have to be better able to deal with these capacity issues as we go forward. I believe the regional health areas give us a fighting chance of that.

The Deputy specifically asked about waiting lists for elective procedures. I have no doubt that this approach will streamline our approach to the delivery of elective care. It does require capacity both on the community side and the hospital side to be able to deliver on that, but regionalisation will allow us to consider the needs of our specific populations and direct the resources that are available either on the community side or the hospital side towards those services in order to ensure people are processed through the system quickly or, perhaps, processed through alternative sources of care, which are important. The regional health areas make that happen.

Photo of Gino KennyGino Kenny (Dublin Mid West, People Before Profit Alliance)
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My final question is to Mr. Reid. It relates-----

Photo of Seán CroweSeán Crowe (Dublin South West, Sinn Fein)
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Does Ms Crehan-Roche want to contribute on the same issue?

Ms Breda Crehan-Roche:

The Deputy was talking about regions. It is happening; it is working. With regard to the three chronic diseases, related to cardiology, diabetes and respiratory care, we have integrated care teams. We now have appointed consultants who are 50% in the hospital and 50% in the community. They are joint appointments. Next week we are to have patient engagement and service user engagement for COPD, asthma, type 2 diabetes and cardiovascular conditions. We want to hear from those affected and their carers how we can do things better and give them the best possible care. There is an awful lot of joined-up work happening. It is really working on the ground. It is Sláintecare in action.

Photo of Gino KennyGino Kenny (Dublin Mid West, People Before Profit Alliance)
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My final question is for Mr. Reid. It concerns several statements over the weekend by two unions, namely the Irish Medical Organisation, IMO, and the Irish Nurses and Midwives Organisation, INMO. Their statements were about the long working hours of their members. They expressed concerns over overcrowding in accident and emergency units and safe working conditions, not only for the members but also for the public. The IMO made the extraordinary statement that 97% of its junior doctor members will vote for possible strike action. The European working time directive is being breached consistently and the doctors are working illegal hours. It is unacceptable in a public health system that junior doctors who have gone through the procedure of becoming qualified are being subjected to this pretty awful situation. When junior doctors get into the health system, they become so burnt out and disillusioned that they leave the country. Why is it acceptable for a set of workers such as junior doctors to be subjected to these awful conditions? If it were any other set of workers in the workforce, there would be absolute uproar. I just do not understand why this cannot be solved, particularly by the HSE and Department of Health.

Mr. Paul Reid:

Regarding the pressures experienced by our junior doctors and front-line healthcare staff in emergency departments and across our acute hospitals in particular, we are very anxious to work with the trade unions. We continue to work with the trade unions on how to address, alleviate and mitigate some of the issues.

On junior doctors, Mr. Watt may want to comment but I understand the Minister will set up a working group to examine some of the issues and determine how we can jointly address some of the concerns raised.

On the European working time directive, we have local oversight in respect of breaches or where things needed to be put in place to mitigate them. We monitor and oversee these. There has been significant progress over recent years in this regard but I accept there are breaches.

To give some context, one does not have to go too far in the EU or UK, or elsewhere throughout the world, to see the long-term impacts being experienced this year owing to Covid. We are still experiencing these. Right now, we have 477 Covid-positive patients in hospital. We are still living with very real pressure on our healthcare system on top of the normal pressures we deal with.

Specifically on non-consultant hospital doctors, we are of course concerned about addressing the issues highlighted and committed to working jointly with them. Non-consultant hospital doctors, NCHDs, do leave the country at various stages of their internship or postgraduate studies. We have done some early analysis and found the vast majority stay. A significant proportion of those who leave return after a short number of years. There are issues. People leave and return for different reasons, but we are anxious to address the concerns raised. I am not sure if Mr. Watt wants to make any comments.

Mr. Robert Watt:

Everybody shares the Deputy’s concerns. Mr. Reid has articulated some of the responses. The Minister is establishing a group to address a number of the specific issues brought to his attention. The Minister intends to announce its composition this week or next and the specific issues that will be addressed. Absolutely, we need to reform and change the current system. It is not sustainable. The Minister is committed to addressing those issues.

Photo of Martin ConwayMartin Conway (Fine Gael)
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I thank our guests for attending today. As always, I acknowledge the work they do continually on behalf of our health system. Mr. Reid has just alluded to Covid. It certainly has not gone away. That nearly 500 people are Covid-positive in hospital all the time is very serious. The public sometimes loses sight of that fact. It is important that we continue to remind them that this pandemic is still very much among us.

On the regional structures, I agree the policy is correct. I am glad we now have a clear timeline for their establishment and implementation but Joe Public would assume all this is happening anyway. I am just looking for an example. I welcome the fact that, as Mr. Reid has said, the process has already started and that we are not necessarily waiting until 2024. On the discharge policy for discharging somebody from an acute hospital into a community structure, nursing home or whatever, how will today’s protocols and policies differ from those under the regional structure when established? What will be different?

Mr. Tony Canavan:

I am not sure it is a question of policy so much as practice.

Photo of Martin ConwayMartin Conway (Fine Gael)
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Policy leads to practice.

Mr. Tony Canavan:

That is correct, but I anticipate significant changes. We are already starting to see changes in the practice around discharging. First of all, there will be a joint focus on the problems. Therefore, if the problem is associated with accessing appropriate care in the appropriate location at the right time, it will be jointly focused on by teams working on the community side and also the hospital side. It is not just a question of waiting until the patient is ready to be discharged and then looking to see where we can move the patient to; it is a matter of planning actively from the day of admission on both sides so we are not just dealing with the hospital care but the full pathway of care for the patient.

Photo of Martin ConwayMartin Conway (Fine Gael)
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My point is that people would assume that happens already.

Mr. Tony Canavan:

It might be a reasonable assumption but the provision of care is very complex. Individual patients often have very complex needs. An elderly patient might require geriatric care but also might have an orthopaedic issue. Providing care for both in one location is not always that simple. While there is some joint working taking place, I believe the regional health areas essentially mandate that joint working such that we no longer see a split between a hospital problem and a community problem but a shared issue that we are in place to jointly manage. One of the key differences is that there will be a cultural shift as well as a practical shift.

Photo of Martin ConwayMartin Conway (Fine Gael)
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On another point, on the regional health areas, how will it impact positively on reducing waiting lists by comparison with what is happening now?

Mr. Tony Canavan:

Many of the people who are on waiting lists currently are awaiting diagnostics. For example, they may be awaiting an X-ray or some such procedure. Then there are many workarounds in place to have patients seen. A GP might refer a patient to the hospital and he or she gets put on a waiting list while waiting for diagnostics. The patient subsequently becomes more unwell and returns to the GP, so the GP sends him or her to the emergency department and the system becomes dysfunctional in that way. If we can empower GPs by providing them with greater resources in the community and giving them direct access to those types of diagnostics, we avoid the situation where those workarounds take place.

Photo of Martin ConwayMartin Conway (Fine Gael)
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Again, people have a realistic assumption that that would be happening anyway.

Let me move on to the situation in the mid-west, specifically around the UL Hospitals Group.

Deputy Cullinane received a very interesting response to a parliamentary question he submitted. While the average waiting time is 11 hours, in Limerick University Hospital it is 15 hours, which means people in Limerick must wait an extra 30% longer. My question on elective hospitals is for Mr. Reid. I note that Cork, Galway and Dublin have been identified as locations for elective hospitals. Surely the demographics in the mid-west make the case for an elective hospital? Why is an elective hospital not being considered for the mid-west?

Mr. Paul Reid:

Mr. O'Connor may also wish to comment. From our perspective, the Government decision of last year was to move forward with the three business cases for Cork, Galway and Dublin. That is the current policy. The decision was based on population densities, demographics and the assessment of the elective needs.

Photo of Martin ConwayMartin Conway (Fine Gael)
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Have any discussions, even informal ones, taken place with the private healthcare system or providers on the establishment of an elective facility in the mid-west?

Mr. Paul Reid:

There have been no formal discussions at national level. I know there has been engagement at local level with some of the hospitals and organisations in the region. I certainly have not been engaged in discussions with private providers.

Photo of Martin ConwayMartin Conway (Fine Gael)
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There has been informal contact between the HSE and the private sector to explore, or at least have preliminary discussions on, the possibility of a facility in the mid-west. Is that correct?

Mr. Paul Reid:

No. I certainly have not had any national engagement, formal or informal, with a private operator.

Photo of Martin ConwayMartin Conway (Fine Gael)
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There has been engagement at local level.

Mr. Paul Reid:

I understand there has been some. They would always put forward proposals.

Photo of Martin ConwayMartin Conway (Fine Gael)
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Yes, that is fine.

Mr. Robert Watt:

On the elective hospitals, as Mr. Reid said, the Government has decided a policy for Cork, Galway and Dublin. That is the policy we are now implementing.

On the private initiative, I have seen a proposal, which has been circulating for a while. I do not know the extent to which people have engaged but there is a proposal that I am aware of.

Mr. Muiris O'Connor:

We are working very closely with the planning of the elective hospitals and ensuring alignment with the regions. We are working to ensure that eligibility to access the elective hospitals will not be confined to the regions in which they are located and there will be a much wider equivalent opportunity to access across all the regions. The detail must be worked out. If certain weighting thresholds, as set out in Sláintecare and so forth, were exceeded, there could be an automatic eligibility for people all over the country to access the particular elective that would be appropriate.

Photo of Martin ConwayMartin Conway (Fine Gael)
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I understand the review taking place in the hospital in Limerick is coming to an end and the work is almost done. Perhaps Mr. Reid will share with us some of the findings or outline the briefings he has received. This is clearly a live situation as there are in excess of 100 people on trolleys in the hospital almost every day, even though we are in the summer period. What information on the review has Mr. Reid received?

Mr. Liam Woods:

I will respond to that question. There is, as the Senator said, a team working with Limerick University Hospital recently and we would be happy to share that review. It is too early to name specific things that are happening. Work has been done to look particularly at patient flow, egress into the community and community support around patient flow. Specific actions in those areas are being countenanced right now. We will bring back something more substantive but there is work under way right now.

Photo of Martin ConwayMartin Conway (Fine Gael)
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As of today, the expert group that went in to review the practices in Limerick University Hospital has already made recommendations on changes to patient flow and other areas.

Mr. Liam Woods:

Yes. It has spent some time on-site and has been working with the hospitals group and the community healthcare organisation, CHO. It has documented some proposals in those areas, by way of improving flow, connecting services and looking at overall resources.

Photo of Martin ConwayMartin Conway (Fine Gael)
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What are the exact timelines for the team finishing its work and making its report to the HSE and the publication of the details of the report and its recommendations?

Mr. Liam Woods:

The work will foster a number of pieces of work that will be ongoing. In terms of a report that highlights the particular measures that are relevant, I think there will be an initial view of that within the next couple of weeks. It will also suggest that further detailed work is required in particular areas and that will be ongoing.

Photo of Martin ConwayMartin Conway (Fine Gael)
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Will an interim report be published by the end of this month?

Mr. Liam Woods:

Maybe I should check and revert to the Senator on a particular timescale. I do not think it would be much beyond two weeks.

Photo of Cathal CroweCathal Crowe (Clare, Fianna Fail)
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I welcome the witnesses. Last night, after leaving the Dáil, I took a train home and ended up having to go to the accident and emergency unit of University Hospital Limerick with a family member. I will talk about some of my experiences. The emergency department was extremely busy and there were some trolleys in corridors. The place was not as chaotic as on other days but it was a very pressurised environment. I am concerned that some of the people whom I met in the waiting area had decided to leave the emergency unit and go home because they felt it was not worthwhile waiting. They decided to take their chance at home and come back the following day. What would Mr. Reid say to those who believe UHL does not have the capacity to deal with their immediate needs and they would be better off going home and presenting again in the coming days if their circumstances worsen?

Mr. Paul Reid:

We discussed with Senator Conway some of the initiatives we have which are looking at the whole organisation and flow of emergency departments across the board. We have been under very significant pressures. What I would say to all people who use our service is that they should use the emergency services when they need emergency care, which is exactly what they are for. In some cases, people can use local injury units, which are in all areas, and also some primary care services. However, people also need to go to emergency services. We have been under extreme pressure since January across the board in our emergency departments. We have a significant pressure in terms of presentations by older persons, which have required more multidisciplinary care. In terms of discharges, we were significantly impacted between January and April by discharge processes for older persons into nursing homes and residential care settings because of outbreaks in nursing homes. We have gone through an horrendous period.

As I mentioned to some previous speakers, while the public have moved on from Covid, and I understand that because we all should move on, we still have 477 patients with Covid. This impacts the whole flow as dual pathways are still required in our emergency departments. I would say to everybody who using emergency departments to bear with us. Our staff are under extreme pressure. We fully acknowledge that and the impact on the time it is taking people to get through. I ask that people only use emergency care when they need it.

Photo of Cathal CroweCathal Crowe (Clare, Fianna Fail)
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I left the accident and emergency unit of UHL around 1 o'clock this morning. I am hugely grateful to the staff who are under savage pressure and are very good at their job. I say that with huge sincerity. I am grateful I have not experienced other accident and emergency departments. It is by virtue of where I live that I have not been to other emergency departments. It is struck me last night that the emergency department in UHL is not confined to the area behind its sliding doors. There are trolleys and parts of the department located in other corridors. One part stretches between 60 or 70 yards from the accident and emergency department. This is further evidence that the mid-west region funnels all of its acute needs through one major hospital. The answer lies in having an elective hospital, as my colleague noted a moment ago, and beefing up capacity in Ennis hospital, St. John's Hospital in Limerick and Nenagh General Hospital. We cannot keep funnelling people through UHL, whether that is through its accident and emergency environment or for people with acute needs and even inpatient appointments. Otherwise, the system will eventually cave in, as has already happened several times this year. The hospital is far exceeding its capacity and is incessantly breaking all records.

I will press Senator Conway's point regarding an elective hospital. We have approached this subject many times and the collective answer given by the witnesses, that a plan is being spoken about and there has been some chat or dialogue, is insufficient. It is simply not good enough for the people in the mid-west and Members of the Oireachtas, as representatives of the region, to be told that something is being chatted about when, on the other hand, we hear that elective-only hospitals are planned for Dublin, Cork and Galway. Will somebody own up or has some genius here decided that the mid-west, despite all of the pressures it faces, is not worthy of an elective hospital?

We need to hear it categorically and we need to hear it on record today.

Mr. Paul Reid:

I will address the first part of what the Deputy said about the pressures in the ED, the utilisation of space and so forth. First, and I say this publicly at every opportunity, I fully support management at hospital group level and at local level. We have a good team at both clinical and management levels in UHL and they do a relentlessly challenging job, as do their teams.

Separately, with regard to UHL and the emergency pressures, we have a team in place and it is finalising a report on the overall capacity and utilising the other facilities in St. John's and Ennis to their best capacity. The team will come back with a report and we will be happy to share that with the members.

Regarding the previous discussion we had about the three elective care centres, I merely restated what is the Government's policy. It is three centres and that is exactly what the Department is bringing through in terms of a business case, so I was not trying-----

Photo of Cathal CroweCathal Crowe (Clare, Fianna Fail)
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Yes, but the HSE has advised the Government and advised on where the location should be. There is an expert committee that has advised the Government that there is a need for three, and that they should be in Dublin, Cork and Galway. That is the nub of what I am asking. Given all the pressures UHL and the surrounding counties are under, who has decided that it does not merit an elective-only hospital? For three or four months I have been trying to get the answer to that. That is the so-called expert advice on which the Government is acting and I want to know who within the ranks of the HSE has recommended that.

Mr. Paul Reid:

I am happy if my colleagues want to clarify the process to develop-----

Photo of Cathal CroweCathal Crowe (Clare, Fianna Fail)
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Surely there is somebody here who can raise his or her hand and say he or she is the person who has decided on an expert basis that we do not need it? Who can tell us this? Can Mr. Watt tell us?

Mr. Robert Watt:

The Government has decided.

Photo of Cathal CroweCathal Crowe (Clare, Fianna Fail)
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But who advised? The HSE is bringing memoranda to the Government, and I want to know who gave the expert advice here.

Mr. Robert Watt:

This has been looked at for many years. There was a group in which Dr. Tom Keane was involved, I think. It was mentioned earlier. He and others were involved in this. An analysis was done of current population projections and needs assessments and it was concluded that three hospitals were needed. With regard to the hospital in Cork, that would serve the needs of people in that region, as would the others. It was a recommendation. I do not know exactly-----

Photo of Cathal CroweCathal Crowe (Clare, Fianna Fail)
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Was Mr. Watt's desk the last desk that the advisory memorandum left before it went to the Government?

Mr. Robert Watt:

These decisions predated my time in the Department in this regard. Ultimately, it is the Government that decides. The Government could decide to have three, four, five or any number of hospitals it wishes. It decided that it would be three elective hospitals.

Photo of Cathal CroweCathal Crowe (Clare, Fianna Fail)
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Both Mr. Watt and I know that the Government acts on recommendations from the witnesses. If an expert report says something, that is generally what the Government adopts. There generally is no push back. Can the witnesses please furnish that memorandum in its entirety or redacted? The mid-west and we as its elected representatives need to know what is the logic and what metric has been used to determine one place needs an elective hospital and the mid-west does not. I ask Mr. Watt to send that on to us and who reported that. We need to know that.

I will move on. Often before we meet the witnesses in this committee we get telephone calls from front-line people in the healthcare service. I took a call this morning from one of these individuals when I was travelling up on the train. I will leave it as vague as that. He claimed one of the cruxes of the problem of integrated healthcare and Sláintecare is the lack of information sharing. We have a fascination with staffing and hospital structures, and I have been talking about that for the last few minutes, but he said the information sharing is chronic at times and that sometimes when referrals are made, dates of birth are missing or there is no knowledge of siblings. He also told me, and this was news to me and I was shocked, that each hospital grouping operates its own discrete information system. If a family with a history of public healthcare and going through the public system in Dublin moves from Dublin to the mid-west, there is not necessarily a transfer of files. Could somebody explain if that is the case and, if so, what remedial action is being taken?

There is one example of somebody who came to my office. The person went through a plethora of tests, everything from blood tests and blood pressure tests to angiograms and so forth, and on the day of discharge a doctor said to the person as the doctor was taking up the chart, "I did not realise until today that you also had cancer two years ago". There is no information sharing. Surely that is an easy thing to reconcile. Staff and hospital buildings are difficult matters, but could somebody please answer on information sharing?

Mr. Paul Reid:

I will answer first, but I might ask my colleagues Mr. Canavan and Ms Crehan-Roche to comment as well on what happens on the ground. First, it is a hugely generalised statement to say that there is no information sharing. There is very significant information sharing. What we do not have in our health system is an electronic health record. Many health systems have it. The Government has decided-----

Photo of Cathal CroweCathal Crowe (Clare, Fianna Fail)
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Are we the outliers of Europe in that regard?

Mr. Paul Reid:

Some of the major health providers would have it, although not everybody has it. It was a Government decision to deploy the electronic health record, which is advancing, in Children's Health Ireland, CHI. That is the start of the process, but we do not have the electronic health record and there is no point in me saying we have it. However, there is very significant information sharing ongoing between the acute and community settings. Some examples were expressed earlier, where a 91-year-old is getting his care in a co-ordinated way between the community services and the acute services. Mr. Canavan has given some examples from the acute services as well. However, we do not have an electronic health record, and that is a very significant gap in the delivery of healthcare in Ireland.

What we have done over the past couple of years is utilise the process of doing a vaccination programme to capture accurate information on the entire population to support us in that regard and for better information at an individual level. It is the same with testing and tracing. It is to build up our knowledge and data for individuals in terms of building that capacity in an electronic health record. However, it is a gap, and a very significant one, in our health system.

Photo of Cathal CroweCathal Crowe (Clare, Fianna Fail)
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I thank Mr. Reid. I will conclude by asking the Chairman, the clerk and the team if we can schedule a full session on this issue of gathering information and storing it and sharing it, because it is essential. We can only have an integrated health system when the information is integrated too. Thank you, Chairman.

Mr. Muiris O'Connor:

I fully agree with the Deputy about the importance of information sharing. It is recognised by us. To deliver integrated care, which is the core focus of Sláintecare, we must have integrated data. The Deputy said that hospital groups have information systems. They do not. The individual hospitals have different information systems of various quality, none of which is up to the best practice to which we aspire. As Mr. Reid said, we learned enormously about the lessons of information in the roll-out of the vaccine programme and developed a very comprehensive national approach to the vaccine database. The Minister for Health has secured Government approval to progress a health information Bill, building on the lessons of the vaccine programme, in particular, and supporting the Sláintecare vision of integrated data for integrated care. The legislation will propose the adoption of the personal public service number, PPSN, as the key identifier and will mandate a duty to share information to support the integration of care and the hand-offs that are there.

Photo of Cathal CroweCathal Crowe (Clare, Fianna Fail)
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NCT knows more about Mr. O'Connor's car and my car and their histories than is known about Mr. O'Connor's and my health histories. Is that not damning in itself?

Mr. Muiris O'Connor:

No. We are swimming in information, but it is just not connected enough. We need some standardised summary care records. In other systems we are looking at in the context of developing regional health areas, such as Canada and New Zealand, even in paper the agreement of a standard cover piece of paper with core information about each patient at each hand-off between primary, acute and community care and those types of things can be very important building blocks for the electronic summary care records to which we all aspire. The legislation will be very supportive of the type of information sharing that we recognise is imperative.

Photo of Seán CroweSeán Crowe (Dublin South West, Sinn Fein)
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Thank you for that information. Senator Black is next.

Photo of Frances BlackFrances Black (Independent)
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I thank everybody for coming to the meeting today to give us an understanding of the regional health areas. Regional health areas are extremely welcome. It is very positive. It promises to undo regional health inequalities by creating a central funding model based on population. It is very welcome. Will the provision of services in different RHAs be influenced by available demographic data? For example, an RHA with a younger demographic profile might require more sexual and reproductive healthcare services than an area with an older population. Could the witnesses say a little about that?

Ms Sarah Treleaven:

That is what we term a population health approach to service planning. There is an intention that regional health areas and even the building blocks of regional health areas, CHNs, would have information on the demographics of their populations in order to best plan their services. It is intended that by doing so we will address the health inequalities the Senator mentioned.

We recognise that different areas of the country need different service models or emphasis on particular aspects of service models. We are hoping to empower RHAs to make those decisions based upon the available information they have about the demographics. At the centre, the HSE would set some frameworks or guidance on the assessment of those demographics and RHAs would take that information and plan their services from there within their available budget.

Photo of Frances BlackFrances Black (Independent)
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There is no doubt it is an ambitious plan and I am repeating myself in saying it is one that has potential to do considerable good for service users. However, it will need buy-in from healthcare workers. Mr. Reid mentioned the trade unions. I ask him to outline the consultation the HSE has had with various trade unions.

Mr. Paul Reid:

Trade unions will be key stakeholders in this process and we have been engaging with the staff individually and through their trade union representatives. At this stage we have just worked through some of the hospital group teams, the CHO teams and some of the clinical specialists. Trade unions will be a key part of the engagement both through their input into the design as well as the negotiations on the detailed structures that need to be put in place. As I said earlier, some of them are already in place and have been the subject of negotiations, like the network managers and the community health network teams that are in place throughout the country. There would have been very detailed discussions and dialogue with all the trade unions. They are core stakeholders and we value their input.

Photo of Frances BlackFrances Black (Independent)
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Further to Deputy Kenny's question, the committee has heard from NCHDs. One of the push factors causing them to leave and consider strike action is that they are being treated poorly by their employers. They are struggling to get paid overtime for the hours they work and they report unpleasant experiences with administrators. Will regionalisation produce a better employment relationship for these doctors? How will that play out?

Mr. Paul Reid:

As I said earlier, NCHDs have highlighted the immediate pressures they are under. We are very anxious to work with the NCHDs through their representative body, the IMO, to address any of their concerns. As Mr. Watt said earlier, the Minister is about to set up a working group to engage on those issues. We will very gladly do that and embrace it.

The second part of the Senator's question is very valid. One of the issues relating to the training pathways for NCHDs is they are assigned to different locations on a very short-term basis throughout their internship. We are anxious to look at that so that they have a level of predictability. Obviously, we also need to work with the colleges on that. We will continue to monitor any of the issues raised by NCHDs.

Photo of Frances BlackFrances Black (Independent)
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I would love to get a briefing from the witnesses to get much more detail on the issue. How can the committee support the HSE and the Department in this welcome roll-out?

Mr. Paul Reid:

I support what Mr. Watt said earlier that we should have an engagement with the committee in a more informal environment and maybe off camera to engage on our early thinking and get the committee's input into the design of it. I have said this publicly previously and I mean it in the best way. The role of parliamentarians is key for us in attracting and retaining staff. Today's discussion is very good on what is working, what is happening, what is not working and what we need to address. Public messaging from politicians is critical for us retaining and recruiting staff. The health service is a great place to work. People working there are highly committed to people's lives. Some of the clichés that go around are not true and they impact our efforts to recruit people and get them to stay. I do not mean that in any disparaging away; I mean it in a very true way. What is said publicly here is what people might believe sometimes. I will keep saying it: the health service is a great place to work. We want to continue to retain the best people we have. Politicians have a key role to help us in that.

Photo of Seán KyneSeán Kyne (Fine Gael)
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I welcome Mr. Reid, Mr. Watt and the team. Mr. Reid spoke about financing, including population-based resource allocation. That always concerns me when it comes to smaller regional communities with dispersed populations. They still have important facilities which need upgrading and ongoing staffing. There are concerns about the plans for Clifden district hospital. Ms Crehan-Roche is involved in reassuring people, but still the rumour mill runs. I ask Mr. Reid about population and finance.

Mr. Paul Reid:

Ms Treleaven has also given some input on that. The approach is to design budget allocations based on demographic needs, acknowledging population densities and geography. In the many different careers I have had in telecommunications, local government and the health service, I have seen the investment needed in rural areas. As the previous Senator said, old people have different demands. It is not just our older people who have significant needs. Younger people have significant needs in terms of other services they need. That is the core principle Ms Treleaven just outlined where we will look at the allocation of budgets based on the demographics, population needs and the issues around urban and rural environments. Ireland has very different healthcare system requirements given the population dispersal across rural areas, and we need to look at it differently.

Photo of Seán KyneSeán Kyne (Fine Gael)
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While the population may be low, in the case of Clifden it might be an hour away from a major city like Galway. We also need to take cognisance of that. I welcome the methodology and thinking behind the integration.

Many issues arise with people being sent from private nursing homes to emergency departments. We need a greater focus on GPs, especially out of hours. Could we do more in respect of nursing homes? Obviously, nursing homes have an aged and vulnerable population who require a high level of healthcare. At times they are being sent to emergency departments when they could be kept in the nursing homes.

Mr. Paul Reid:

We are running a very successful initiative in Dublin at the moment with remote scans being taken directly in nursing homes, saving older persons and their families the need to leave the residential care setting to go to emergency departments. Early pilots have proven that to be very beneficial and successful. We see that as a core part of the health service through many different providers and certainly at primary care level.

Ms Anne O'Connor:

The Senator made a very valid point about the reasons people are conveyed from nursing homes to emergency departments. Clearly some people need to be in hospital and that is fine. However, we believe many people could be looked after in a nursing home with the right support. We have the data and we are looking at parts of the country with a higher level of admission from nursing homes into emergency departments to see if we can do more outreaching to nursing homes, for example, through the ambulance service or some of our community teams. We have integrated care teams in most areas now. We are looking to use that to minimise the number of people who go in. If people do not really need to be in hospital, it is very disruptive to them and their lives to be moved at that stage.

Photo of Seán KyneSeán Kyne (Fine Gael)
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There have been a number of successes such as the work on chronic illness and the work that has been done on heart failure. There have successes in various parts of the country with the implementation of Sláintecare. The bigger picture here is the infrastructure. I appreciate it is not all about buildings. Some very important work needs to be done on discharge policy etc. I am concerned the last winter plan for the Saolta hospital group did not include any acute beds.

From the comments of Mr. Woods, it appears it could be the same again for the coming winter. It is a concern because we are told there is no physical space to build acute beds in Galway, which seems hard to believe in some ways. Discharge policies must work in Galway because of the issues with the provision of acute beds. Is that a fair point?

Mr. Tony Canavan:

Yes, it is a fair point. There are capacity limitations in Galway University Hospital, GUH, and with the site itself because it is so congested. It is difficult to develop additional beds on the site. We have plans to develop additional capacity on the site but because of the complexities, it will take time for us to deliver on that. The plans include some additional bed capacity associated with the emergency department and women and children's block, which is moving quite well. We also have plans on the development of a comprehensive cancer centre on the grounds of the hospital as well, which will also include additional bed capacity. We are looking at interim plans to see if we can put some additional beds on the site while those developments are being progressed. It is a very complex site and developing anything on it takes much time.

Photo of Seán KyneSeán Kyne (Fine Gael)
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Mr. Canavan mentions the emergency department, the maternity and paediatric unit and the cancer care facility. They are long-term projects and interim and short-term solutions are vital. Surely there is somewhere we can provide beds. Often there are issues with funding or staffing to make things hard. To tell people in Galway there is no physical space to put a new building, even a temporary or modular building, is hard to fathom. It is a concern.

Mr. Canavan has said the emergency department, and the maternity and paediatric developments are moving quite well but people in Galway would not agree because of the delays in the delivery of the project. The last time Mr. Reid was here, I asked if a planning application would be lodged this year for that. Could Mr. Canavan say a planning application will be lodged for an emergency department this year?

Mr. Tony Canavan:

I cannot say it will be lodged this year. I can say that right now we have completed the strategic assessment review and the preliminary business case has also been completed in respect of the emergency department and the women and children's block. We expect it will go to the HSE board this month and thereafter it will have to go to the Cabinet for a decision to move forward. That development will bring some additional 40 beds. As I said, we are looking interim bed development on the site as well because we are conscious there are a number of hurdles to be crossed in that and other long-term developments on the site. We must have some bed capacity in the mean time.

Mr. Paul Reid:

As Mr. Canavan has said, the executive management team yesterday discussed the strategic assessment review and we are recommending it on to the board for agreement. The process after that is a detailed design business case and that must go to the Department of Public Expenditure and Reform through the Department and the Minister. It is in the hundreds of millions of euro so it will need the approval of the Government to proceed. We want to expedite this in the quickest possible timeframe with the available funding we have in our capital programmes.

I cannot commit right now that we will have the planning application in. There must be pre-planning discussions, and these have been happening at the local level at which these happen. Formal pre-planning must be engaged with before commencing the planning process. We need to get the business case through Government approval. That is the next step.

Photo of Seán KyneSeán Kyne (Fine Gael)
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The strategic business case is going to the HSE board.

Mr. Paul Reid:

It is going to the board on 29 June. It is next Wednesday week.

Photo of Seán KyneSeán Kyne (Fine Gael)
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How long will it take for the board to assess it?

Mr. Paul Reid:

It must go to our audit and risk committee first and then to the board on 29 June. We will meet to have a look at that. The executive team is recommending for approval to the board.

Photo of Seán KyneSeán Kyne (Fine Gael)
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After that, what is the next step?

Mr. Paul Reid:

The next step is a detailed design business case, involving some of the detailed financials. It must be financially assessed under the public service code and it goes through the Minister and the Department to the Department of Public Expenditure and Reform. That is the assessment.

Photo of Seán KyneSeán Kyne (Fine Gael)
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I presume much of that work has been done.

Mr. Paul Reid:

Much of it is in the strategic assessment review but there are some further financials we will have to work through. That is part of the code and we must comply with that.

Ms Breda Crehan-Roche:

The Senator mentioned Clifden and I look forward to meeting him there quite shortly with a number of other local politicians and representatives. We are committed to the nursing unit there and we are reconfiguring 40 beds, as the Senator knows, with ten for respite care, ten for dementia care and 20 long-stay beds. We will meet the Senator there. We will look at integrated care programmes and we have X-ray there. We work closely with colleagues in Saolta and we have step-down beds.

In talking about Galway, at the Merlin Park unit we have 13 short-stay beds and 13 respite beds. There is much integrated work with step-down beds so there are beds in the community to support people. It is about having services near to people. We will meet the Senator shortly and speaking about our plans for older people, including what services can be there. We have joint appointments now between Community Healthcare West and Saolta about consultant posts and there will be visiting and outreach clinics etc. We will speak more and I look forward to meeting the Senator there.

Photo of Bernard DurkanBernard Durkan (Kildare North, Fine Gael)
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I welcome our witnesses and thank them for this morning's presentation. It is something I have spoken about as far back as last November in the wake of what we had seen of Covid-19 at that stage. I spoke particularly of the need to superimpose on the system a way of dealing with the health services generally similar to what we had done with Covid-19.

I have a number of questions I wish to put. I will take written answers but I will require specific written answers in each case. To what extent has a profile been created in respect of each region throughout the country, regardless of location, whether it takes in cities or rural areas? That is important if we are in the business of providing services to suit the region.

To what extent has the Health Service Executive worked on the creation of acceptable working conditions? Over the past couple of years we have had references again and again to unacceptable or unattractive working conditions. How have we addressed that? Have we addressed it satisfactorily or sufficiently? Do we have the answers?

I will speak to waiting lists and times. I realise that we are speaking about proposals to be implemented and put in place in approximately two years. Do we have the capacity to clear our waiting lists in those two years? Before Covid-19 we had a waiting list system and that is why we have a really huge waiting list now. Those lists have got longer. What have we done in the meantime to reduce those waiting lists completely by emergency measures if necessary and remove them altogether inside of those two years? Is that part of the process and how will it manifest?

We have received numerous complaints about mental health services in all our constituencies, with no exceptions. This takes in both residential and emergency services, accommodation and treatment, which is just appalling in some areas. To what extent have we addressed that particular issue, particularly community healthcare organisation, CHO, 7 in my area? The Chairman mentioned we should not be specific to the areas I represent and I do not intend to do so. In parliamentary questions I do not address issues from a local standpoint but in order to deal with matters, we must show progress in all the local areas at the same time. Otherwise, we are putting ourselves at a distance.

People in the regions must know what is going on. To what extent has the structure improved, particularly the linkages between the regions and the HSE? How is the process working now? It was not working for many years.

When is the board of the HSE alerted to the concerns, overcrowding and the other issues that members have brought up at these meetings and people have brought to its attention?

I digress for a second in relation to the need for changes and the waiting times on trolleys. A waiting time on a trolley, no matter where the trolley is located is of no benefit. There is no benefit for the patient because the patient is still waiting. Waiting for what? It is like Waiting for Godot. We need to get ahead of it, be out front of it and to be putting down the markers now. Related to that, I had occasion in the past couple of weeks to intervene in a couple of very similar cases that represented patients waiting on trolleys for one, two, three, four and even five days. At the end of that, the patient had to be removed from the public system and go to a private system where within three or four hours they had a bed and a full-scale diagnosis. Nothing got done in the public system. In fact, the patient had a serious condition. I could mention the areas but I am not going to do that. It could be any area. There are they same replies.

Photo of Seán CroweSeán Crowe (Dublin South West, Sinn Fein)
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The Deputy asked a number of questions. Does he want answers now or a written answer or what?

Photo of Bernard DurkanBernard Durkan (Kildare North, Fine Gael)
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I do not want verbal answers; I want written answers. It is not fair to the person giving the answers to have to do without and it is not fair to me if they are not all answered.

Photo of Seán CroweSeán Crowe (Dublin South West, Sinn Fein)
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There is some indication that they might answer some of the questions. Does the Deputy want some answers?

Photo of Bernard DurkanBernard Durkan (Kildare North, Fine Gael)
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I have four more questions and I will see how it goes.

Photo of Seán CroweSeán Crowe (Dublin South West, Sinn Fein)
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We are running out of time.

Photo of Bernard DurkanBernard Durkan (Kildare North, Fine Gael)
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If we are out time, I might as well finish now.

Photo of Seán CroweSeán Crowe (Dublin South West, Sinn Fein)
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No, the Deputy has about four or five minutes left. He can continue.

Photo of Bernard DurkanBernard Durkan (Kildare North, Fine Gael)
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If the Chair can wait-----

Photo of Seán CroweSeán Crowe (Dublin South West, Sinn Fein)
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I just meant for the answers. The Deputy can go on.

Photo of Bernard DurkanBernard Durkan (Kildare North, Fine Gael)
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I need full written replies to them all. How is the HSE board alerted to conditions in all hospitals, accident and emergency departments and whatever in all parts of the regions? In other words, is the chain of command working in two directions, from the ground up and from the top down, or is it just a wait-and-see situation? As was referenced earlier, what happens when cases go wrong? How often are cases going wrong and what are we learning from them? Are we putting in place measures to ensure that they are minimised? That is a separate question and answer as well. I have one last question. What process is in place to ensure we are doing an adequate job in recruiting GPs for the various areas throughout the country, regardless of which region it is? Again, there are numerous cases where we have difficulty replacing GPs, many of whom are retired, but some have left the service and system as well. Those are all of my questions and I need answers to them all.

Mr. Paul Reid:

With respect, I am happy to do my best to answer what questions I can and my colleagues can answer on the Department, profiling and others. I will try to answer them because written replies to all of those will have the team tied up for a long time.

On acceptable work conditions, we are very anxious to improve and strengthen the work conditions. It is obviously a very difficult environment. We are under pressures, particularly in hospitals, at the moment. We have put in a number of supports for staff throughout Covid around the promotion of staff well-being. I have been involved in communications, as has all the management team, about strengthening processes and supports for people in terms of well-being at work, but also basic facilities such as the canteen, etc., that have been and will continue to be strengthened. Obviously, issues around working time is a key issue.

On waiting times and lists, we have a very significant plan. Mr. Watt and I referenced in the opening statement the around €350 million in the access to care fund, €150 million of which is allocated to the national treatment purchase fund, NTPF, but in respect of the remaining €200 million, we have put in place plans on recurring and non-recurring activity costs to help each of the hospital groups around addressing some of that. Importantly, there are about 37 pathways to change how people get their services and move some of them move into the community to stop numbers coming onto the waiting lists in the manner in which they are. It is a very significant plan that has been published and I am happy to share it.

I might just ask my colleague to comment on the mental health service in a moment.

I just want to reassure the Deputy about our board. We report to the board on a monthly basis. We have what is called a scorecard, which goes onwards to the Minister after every board meeting. That is a report on all aspects of our national service plan and performance against each of the targets in the plan. That includes emergency departments and patient waiting times. The performance delivery of our board is reviewed on a monthly basis by a subcommittee and it is reviewed by our full board. There are very clear linkages between what happens on the ground and us providing assurances to our board, including on patient waiting times.

I will touch on the last couple questions. GP recruitment is a difficult issue. We are working with the Irish College of General Practitioners, ICGP, to strengthen the number of trainees coming through and the number of GP trainee posts over a three, four or five-year period. I think this year we have about an extra 41 posts going through for GPs, which is a start.

I will take a final question on what happens when things go wrong. We have a serious incident management process within the health service. We have various processes, including NIR process as well, that looks at where harm is caused or something went wrong and sets out recommendations. As I said earlier, we have certain ways of progressing both learning from it and addressing some of the issues that emerged. I just wish to reassure the Deputy. I hope we have saved my team a number of written reports on that for the next few weeks. I know I have been brief in my answers but I am trying.

Perhaps my colleague, Ms O’Connor, will speak on mental health services.

Ms Anne O'Connor:

I might actually ask Ms O’Neill because she has the details.

Ms Yvonne O'Neill:

On mental health services, I will link some earlier questions on the population modelling in mental health services. A couple of years ago we took an approach working with our population health colleagues and international deprivation modelling where we actually applied a resource allocation adjusted for deprivation and rurality to the mental health funding, which recognised the types of issues that the Deputy is pointing to. For example, the Deputy’s area of community healthcare organisation, CHO 7, would have had a huge population increase and some very specific deprivation-related increase need that resulted in increased allocation for mental health services in CHO 7. We have done that over a number of years since 2015. Where we receive new funding, we try to orient it towards what we know is imbalance in relation to population-based available services. We try to raise all boats to the same level where we can and account for anomalies. That has resulted in some particular additional funding for CHO 7 services within the available overall allocation that comes to us annually.

Mr. Muiris O'Connor:

I thank the Deputy for his questions. On the issue he started on of profiling, there is enormous work going on around profiling the demographics of each region so that we understand the nature of the care needs. The thing is that the six regions are rather substantial, so there is work going on at community healthcare network, CHN, level, a more localised level, to understand the specific needs of each locality. By the end of this summer we will have very comprehensive profiles of all of the regions, not just in terms of population demographics, but we are also looking at the health and social care staff across each region. In addition, there are colleagues looking at the infrastructure and facilities in each region. They will be completed towards the end of the summer and in quarter 3 we will make them publicly available. I think we probably need a web resource perhaps with a bit of mapping going on. That might be helpful alongside publications. They are essential across the various work streams that are going on to support regional health areas, RHAs. Ms Treleaven explained how important it would be for allocation of finances in a fair way. The Deputy can see from what Ms O’Neill said that we have experience in handling things such as rurality and deprivation. We will borrow from other Departments where they have invested huge expertise in those areas. It is a big part of our work and we look forward to sharing it as we progress. Quarter 3 will definitely have all of these in the public domain.

Photo of Seán CroweSeán Crowe (Dublin South West, Sinn Fein)
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We will try to get answers to some of the other questions.

Photo of Bernard DurkanBernard Durkan (Kildare North, Fine Gael)
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We need an update on the extension and building programme for the entire country. It has a bearing on everything else.

I am not a critic of the health services. As Mr. Reid stated, the way we deal with issues at this level has a bearing on the general picture of what the public can expect. I have always been a supporter of the health services, but they need to be the best. There is no use in having a half-hearted system that only works some of the time and where things go wrong and reflect poorly on the quality of the health services. Many people are trying hard to make this work. We need to ensure, and be assured at all times, that it is working.

Photo of Seán CroweSeán Crowe (Dublin South West, Sinn Fein)
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I welcome Deputy Guirke to his first meeting of the Joint Committee on Health.

Photo of Johnny GuirkeJohnny Guirke (Meath West, Sinn Fein)
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I thank the Chairman for the opportunity to contribute. We met Mr. Reid and others of the HSE's management on Monday. Has any decision been made by the HSE to close the ICU and high-dependency unit, HDU, beds at Our Lady's Hospital, Navan? Has any decision been made on closing the emergency department there? Is Mr. Reid conscious of the concerns of the people of Navan and Meath more widely due to mixed messaging from the Minister and the HSE? According to a briefing note we received on Monday, the final stages of stepping down will commence on 30 June. Is that still going ahead or is it on hold?

Mr. Paul Reid:

I thank the Deputy for his questions. We are working through what we need to address from the concerns that were raised on Monday by Oireachtas Members as well as the concerns raised by the Government. To be clear, what is being done at Navan hospital is not a closing down of any aspect. Rather, it is a realignment of the services and strengthening of many of their elements, particularly those where patient safety issues have been highlighted to us. The Deputy attended the briefing. The chief clinical officer of the HSE, the clinical lead for acute services nationally and the anaesthetists, physicians and surgeons at the local hospital have highlighted to us their concerns about patient safety. As CEO of the HSE, I cannot ignore the risks that have been raised with us. I have to implement mitigations to address them. They are significant risks. For example, there is no local emergency department governance or acute surgical service on site at Navan and it is not an accredited hospital for recruiting individuals with those skills. We have to realign the services so that they provide the best safety and protect people's lives.

Regarding timelines, we are working on what steps need to be taken next. We are working with Our Lady of Lourdes Hospital on what capacity we will need to provide there. I cannot give a definitive timeline for when that will be finished, but these are the actions we are taking now.

We fully respect the role of Oireachtas Members and the Government, and we will address the Government's concerns in the process, but I cannot walk away from the very real clinical risks that have been raised by consultants, clinicians and medical professionals. I cannot compromise on those risks; I have to mitigate them. We will work to a plan to address them. I cannot give a timeframe for when it will all be done, but we expect it to be a number of weeks. In that process, we will address everyone's concerns, including those raised by the Government and Members.

Photo of Johnny GuirkeJohnny Guirke (Meath West, Sinn Fein)
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With respect, if the HSE had been allowed to get away with starting on 30 June, it would not have addressed any of our concerns. Regarding capacity at Drogheda, what will happen in terms of waiting times if a patient does not have a GP referral? It already has thousands of self-admitted patients. Was any consideration given to making Our Lady's Hospital, Navan, a fully functioning model 3 hospital? Would that have been an option? Was any consideration given to investing in the hospital and enhancing its existing services? It was only ten years ago we were discussing building a new regional hospital in Navan. If it was a good place for a regional hospital then, why is it not a good place to upgrade existing services now?

Ms Anne O'Connor:

The Deputy will know from the meeting on Monday that we discussed whether we should have invested more in Navan over the years. Navan hospital has 62 medical beds. Any other model 3 or model 4 hospital has a minimum of 200 or 250 beds. It is not an option to build Navan's number up. While we all accept Meath has become more populated and that certain parts of the county are growing, many specialties do not exist in Navan – nephrology, neurology, infectious diseases and sufficient ICU cover. The Deputy will know from the meeting that all of the emergency department consultant and ICU consultant cover is currently provided by Drogheda. Navan hospital is not accredited by any of the colleges for training, so it is not an option to put trainees there.

It is not sustainable or safe to try to deliver every healthcare service everywhere. Were we to have done that with the cancer control programme years ago, we would not have the cancer outcomes we have today. This change will be difficult.

There has been significant investment in Navan. We have put in place additional theatres and radiology services. We are continuing to invest. The integrated care teams we have been discussing at this meeting are working with Navan hospital. We have put in place 84 beds at Our Lady of Lourdes in recognition of the need coming from Navan. Forty of those beds were to compensate for the growing activity in the Drogheda area and 44 were to compensate for the reduction in admissions to Navan. Something else the Deputy will know from Monday is that, in recognition of the growing demographics, we are putting in place a further ten medical beds in Drogheda. The Deputy heard from the CEO of the RCSI Hospitals Group on Monday that he believed this was sufficient to compensate for any additional admissions through Drogheda's emergency department. We are also putting in place two additional ICU beds and additional ambulance resources, all of which has been agreed and is in train.

Significant and detailed consideration has been given to the demands that will arise as a result of this change. This is in the interests of people's health and lives. On the basis of what I have just set out, we will not be able to sustain that service at Navan in the way described.

Mr. Paul Reid:

I wish to be clear, in that this is not about closure. It is about realignment and enhancing quality patient safety. As Ms O'Connor said, it is about protecting people's lives. She listed some of the investments in Navan. Those were not just made over many years but in recent years. A new laboratory and radiology equipment were put in place in 2019. There was theatre development in 2020 and 2021. There is an expanded recovery room, a new day ward-minor procedure room, a new rehabilitation unit and a new psychiatric day hospital, and the extension of the outpatient department has been under development since 2021. We will continue to invest in Navan hospital. We will realign. To set out the scale, approximately five or six patients will need to be transferred to Our Lady of Lourdes Hospital per day.

Some of the benefits, which have probably not been communicated well in recent days, include advanced surgical care and supports from the Mater hospital, which will see more surgeries and theatre utilisation at Navan by specialists from the Mater. It will be a much-strengthened hospital. I ask the Deputy to examine what has happened with other hospitals. I acknowledge the political pressures on him, but those hospitals ended up being much safer and more enhanced for the communities they served.

Ms Anne O'Connor:

It is important to point out the medical assessment unit, MAU, will be open for medical attendances for 24 hours per day. The local injury unit does not require GP referral. There is a concern about GP referrals to the MAU. That said, I understand a local GP appeared on LMFM saying she believed this was in the interests of the local people. There are many hurdles in this for everyone, but it will ultimately be a much stronger local service with the hospital doing what it was designed to do and the investment targeted at that.

Photo of Johnny GuirkeJohnny Guirke (Meath West, Sinn Fein)
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Mr. Reid spoke about ambulance services. Where I live in the north of the county, someone could be waiting 90 minutes for an ambulance.

If somebody has a heart attack, people there call the ambulance and the fire service because the latter will come in ten to 15 minutes. That is the kind of service we have in the north of the county.

Will the HSE come back to Members before this is implemented with a date on which it will happen? The Minister has said he is not happy and he needs all these assurances. Will he get such assurances? Will the HSE come back to us with dates for when this will happen, if it does?

Mr. Paul Reid:

On the first part regarding the National Ambulance Service, we have enhanced investment in that service at a wider level both in terms of resources and the fleet. That is the strategy that has been brought forward to us and we will continue to invest resources. Specifically on this proposal, the National Ambulance Service and management teams have worked with us to put in place the required enhanced National Ambulance Service, including advanced paramedics, to support the investment for this realignment that will happen.

I will of course continue to engage, as will our teams, with the Oireachtas but I will restate that I cannot compromise. I will not walk away from what I have on my table, and the Department has on its table, which it is working very closely with us on, namely, patient safety risks, patient lives and patient safety. I will not walk away from that. I have to progress the actions to strengthen Navan hospital to address some of those major risks we see. We will come back and continue to engage through the Minister and the process but we cannot walk away, and I will not walk away, from what has to be done in that regard.

Photo of Seán CroweSeán Crowe (Dublin South West, Sinn Fein)
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On improving healthcare in our regions and communities, we all agree we need to divert more people away from hospital care to a community and home setting. A number of committee members were contacted by, for example, Thrombosis Ireland representatives who raised the issue of people on anticoagulants. They said 700 people are using self-test monitors, while almost 250,000 people throughout the State use warfarin. The point they made was that quality of life would be improved and enhanced greatly, and future complications could potentially be avoided, with a minor enough outlay for self-testing in the same manner as people with diabetes. The question they asked was whether there were any plans to increase the availability and use of CoaguChek meters and self-test strips for people who are on this drug.

This also raises another question relating to regionalisation. Who makes a decision on that? Could a region make a decision as regards a new technology or whatever? Will there still be a centralised approach to that? I am asking the question in general but, specifically on this issue, it seems a logical approach. We are all aware of how this form of testing works for people with diabetes. It seems a logical step forward to use these self-monitoring strips and so on.

Mr. Liam Woods:

There was significant growth in respiratory self-monitoring in people's homes and in hospitals using digital solutions during the Covid pandemic. There has been some growth in such monitoring. In the area the Deputy referred to, clinical leads will often bring forward such technologies as potential care improvements. Stroke and blood pressure monitoring, and monitoring in the area of coagulation the Deputy talked about, can come through a national clinical process. It can come through cardiology, stroke leads nationally and local units, where there are clinical leaders. There are already some examples of that happening within the community. As self-monitoring devices improve and are clinically acceptable in what they do, that can roll out further.

Some of that is happening within the primary care chronic condition management approach right now. The effect of it is to allow people maintain lower levels of acuity or increased wellness, reduce the need for hospital beds and better service in the community. That is happening. Can it happen further? Yes, it can. Technology is developing all the time that is doing so.

Photo of Seán CroweSeán Crowe (Dublin South West, Sinn Fein)
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The number of people who are self-testing seems very small. It is 700 people when 250,000 use warfarin. I am just teasing out the logic of it. It would make sense on a preventative basis that the HSE would try to roll that out to that community. Are there any plans to do that?

Mr. Liam Woods:

Our cardiology leads are working in that space. I will send the Chairman something specifically on cardiology. He talked about warfarin and anticoagulant drugs. We can send him a report specifically on that.

Photo of Seán CroweSeán Crowe (Dublin South West, Sinn Fein)
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One of the worries I have, and we touched on it earlier, relates to the pilot programmes being put in place in different areas. We rarely ever hear about the successful ones. Scans in nursing homes were mentioned. Some people are worried about regionalisation, going back to the old heath boards structure, and everyone working in silos apart from each other. That is why I am concerned about where the decisions are made.

A number of programmes and projects are in place. I will mention some of them because it is important we put a little balance into this morning's debate. A number of projects and programmes have been used and tested as regards safety and effectiveness in reorienting acute care away from emergency departments, EDs. I am aware of a couple of them. The community paramedicine project is in operation in the Border region, where community paramedics provide care to ensure unnecessary ambulance journeys to EDs are reduced. Apparently, research there has shown that 85% of all patients served did not have to go to an ED. That is a major section of the patient group.

The pathfinder project is another. It covers Beaumont Hospital in north County Dublin, which sees advanced paramedics, physical therapists and occupational therapists attend older, low acuity 999 callers in their homes to ensure they do not have to be transported to Beaumont accident and emergency. In other cases, I am aware of paramedics calling to older people, where people are informed their mother or father would be better off staying at home. Paramedics do that test. A study of that project found that of 527 callers, 69% were supported to remain home and kept out of the ED.

The last project is the emergency department in the home service. St. Vincent's University Hospital ambulance service allows patients referred to it by a GP or through a 999 call from a nursing home to be assessed by an ED doctor and an occupational therapist at home. According to that project's figures, of 3,137 patients treated over the course of eight months in 2020, 2,909 remained in their homes, saving the hospital a massive 7.9 years of bed days. That saves millions and creates capacity and efficient pathways of care.

What is the HSE view of these programmes? We have heard about some of them this morning. These programmes appear to be successful. What plans are there to roll out those services? We have regionalisation. These are issues coming from different areas, including hospitals and whatever else. How are these programmes rolled out, duplicated and made common practice? One of the very important areas we do not focus enough on are the things we get right.

Mr. Paul Reid:

I welcome the Chairman's comments about trying to bring some balance into it. He is right there are great innovations, pilots and some further roll-outs throughout the country. Some of them have been supported by the Sláintecare integration fund, which we have not spoken about today, where we pilot a number of initiatives and then, based on evaluation of their success, roll them out throughout the country. It is difficult to get public interest through the media in some of these successes but they are there. Of the ones the Deputy referenced, for example, the pathfinder project in place in Beaumont Hospital, there is an equivalent in St. Vincent's University Hospital and Mr. Canavan will start rolling out pathfinder in Galway. They really do work. We are trying to shift our investment and care because it is about hospital avoidance.

How we see that continue to happen is through our increased focus on enhanced community care. A range of initiatives come under the umbrella of such care. Yes, we will have to keep investing in our acute hospital services but we need a parallel stream to invest in community services, many of which the Deputy listed, including the one I mentioned earlier in respect of nursing homes. Scanning equipment in nursing homes is the way to go.

We have to shift our services on an annual basis. We cannot do it all together.

Mr. Liam Woods:

We are expanding pathfinder because the initial pilots have been successful. A similar piece of work has been done in Cork where there is up to 70% non-admission to hospital. There are very successful pilots and we are reviewing and investing where we see they are working. Community intervention teams are also expanding. As part of our unscheduled care planning, which you can think about as protecting the front door of the ED, those sort of programmes are working well and, as part of our proposals for planning further over three years and for next year's estimate, we will go further with some of those. I think they are already rolling out seven more sites within the resources we have this year. We see those as essential to supporting care at or close to home, as Ms Crehan-Roche said.

Mr. Robert Watt:

In relation to what the Chair and Mr. Reid referenced, Ms Treleaven has details on the Sláintecare fund in terms of the number of projects and the mainstreaming of them, which is the big challenge.

Ms Sarah Treleaven:

The Sláintecare integration plan last year facilitated the testing and evaluation of 123 projects, 105 of which were deemed successful. They have been mainstreamed through HSE funding. Another pot of money will similarly encourage integration of innovative projects to the tune of €11 million. Overall, the 123 projects from last year resulted in 15,000 reduced referrals, 18,000 acute bed days avoided and 8,200 patients off waiting lists. There is a report, with which we can furnish the committee, with further details on that.

Photo of Seán CroweSeán Crowe (Dublin South West, Sinn Fein)
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Does a pilot go on forever? What is the timescale of these if something is working? I remember making reference to a hospital I know where people in their late 70s were presenting with cocaine at the weekends. This was a recurring thing. The hospital came up with an initiative whereby they put someone in who was working with the local drug services. It gave people who were clearly in addiction a pathway. It is common sense but had not been done up to then. I am not aware if that was rolled out anywhere else. The frustration that everyone has is we do not hear the positive things happening in the health service but constantly hear the negative. If something works, what is the timescale for pilots like this?

Mr. Liam Woods:

The resources that go in are a recurring requirement where they are working, so they are invested in for the medium term. In terms of roll-out and expansion, the last two to three years have seen quite significant growth in community intervention teams, pathfinder and other initiatives. Community paramedics, which the Chair mentioned, have a lot of capacity based on a review of what has happened in the north east of the country. Sometimes that presents us with regulatory issues. We may need to look at the role of practitioners in the community single-handed and that is happening alongside the potential expansion of community paramedics.

"Pilot" is a dangerous word in our environment. "First instance" or "pioneering initiative" is better because pilots can crash and burn. The Chair may be obliquely referring to that. Where we see it working, we need to amplify it as quickly as we can. Often local leadership, both clinical and managerial, is pushing these and they are promoted and driven in that way. We evaluate and look across when we do our service plan to any area or areas where we can grow and encourage more. The limiting factors are that many of these are therapy and clinical grades of staff and we have to recruit in to them, so that takes a bit of time, and having available resources. We have significant resource to expand this year.

Ms Sarah Treleaven:

The Cathaoirleach highlights a difficulty we have had in the past in terms of having long-term plans for initial pilot projects. With all the projects I referenced and a number that are being discussed by HSE colleagues, they are in test for a year but are not put into that test unless there is a pathway for getting them into the Estimates cycle for the following year if they are deemed successful. It is run for one year, with year 2 Estimates seeking mainstream funding.

Photo of Seán CroweSeán Crowe (Dublin South West, Sinn Fein)
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The key to this is the regionalisation of staff, resources, investment and services. An audiology unit in Tallaght hospital, for instance, covers Wicklow and Kildare. If you are living in Wicklow town and your child needs to get tested, Tallaght is not local, as such. You could be waiting up to two years to get that child tested. The resources needs to follow. It is part of the challenge of regionalisation. We are aware of the challenges in getting staff in particular areas. We touched on that in relation to expert staff in Navan. If we do not have all those pieces, regionalisation will not work. That is the big worry people have. We are changing things because they are not working but are we going to go back to the old health board stuff, which I am old enough to remember? Some people look back on them fondly but most of us remember that they did not work. Is this a poor replica of that?

Mr. Liam Woods:

The developments in service we are seeing are making a permanent difference. Implementing regions to support and encourage that under a single budget and single management will help. Some of the thinking that is national, particularly clinical leadership, can have a big influence across the country quickly and that is important. It is important to maintain that for certain things but to encourage local initiatives. The RHAs will do that. That will be a major benefit of regionalisation.

Photo of David CullinaneDavid Cullinane (Waterford, Sinn Fein)
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We should take up the offer that Mr. Watt made earlier of having a workshop on regionalisation with Mr. Woods, his team and the people who will be involved in that. We can look at drilling down into some of these issues. That would be useful, outside of a committee session in which is more difficult to tease out all of the issues.

I will ask a few questions to Mr. Reid on waiting lists and presentation of them, capture of data and reducing waiting lists. At the moment, the National Treatment Purchase Fund only publishes acute waiting lists. We have to go through parliamentary questions to get access to data on diagnostic waiting lists and CHO waiting lists. Given that we will have an alignment of areas in acute hospitals, can it be looked at that we have better capture of that data rather than having to go through parliamentary questions? Some of Mr. Reid's staff can be critical of us putting in too many parliamentary questions. It would be better if we had access to information. The NTPF data, when it is presented every couple of weeks, is very useful. It shows what is going up and down and what is working and not working. We do not have the same data for diagnostics and community. Can that be looked at?

I got a parliamentary question response yesterday on the validation of acute hospital waiting lists, as opposed to people who are treated or seen. I was not able to get the response on diagnostics or community because it is not captured but we were able to get the information on acute hospital waiting lists. As far as I can see, 80,000 people were removed from the hospital waiting lists last year as a process of validation. So far this year it is just over 30,000, if I am right. I do not oppose that because the system needs to be brought up to date. If there is a validation process that makes it more fit for purpose and we have real data, that is important. However, in the presentation of the data, it is important we can see what is happening, who is being treated and seen and who is removed as a consequence of a validation. We need to watch how we do that. My understanding is letters are issued to patients as to whether or not they are still in need of healthcare. However, sometimes people move addresses, there can be issues or complications where people do not respond to a letter and are then taken off a list. We see it in housing and it becomes a particular challenge, as I am sure the Chair and other members of the committee will be aware. I would not want to see it happen in healthcare unnecessarily that people fall off the list. Can Mr. Reid confirm those figures on the validation process?

Also, can he answer the question as to whether it is something that can be improved upon in terms of the presentation of the National Treatment Purchase Fund figures, both in terms of community diagnostics and validation versus patients seen, because the more information we have the better for all of us?

Mr. Robert Watt:

I agree that there is a great deal of data. Much of it is made available through the reports from the NTPF and we should look at that. It is in everybody's interests that the data we have on this significant matter of public interest is put out there. The Deputy should not have to be asking parliamentary questions of us. It is time-consuming for the Deputies and for us. This is not a complaint, because Deputies have the right to ask whatever they wish, but we got 15,000 parliamentary questions last year. It is tying up a great deal of resources of staff who could be doing legislation, policy work and all the other things, which they want to do and which add more value. Absolutely, we can look back at the Deputy's requests. If that information is available now, what we should do is agree to put it up every week or every second week - whatever is practical - so that the Deputy could access the data. That is something we can commit to doing. I will talk to colleagues.

Mr. Reid may wish to answer some of the specific questions. The numbers the Deputy quotes seem to be correct but Mr. Reid can confirm them.

Photo of David CullinaneDavid Cullinane (Waterford, Sinn Fein)
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Just on that - if they are correct - when we say validation am I right in saying that if it is a figure of 110,000, that is 110,000 people who came off waiting lists, not because they were seen by a consultant or not because they were treated, but simply because there could have been duplication, they no longer require care or they were seen elsewhere in that they might have been referred to two or three specialists? Whatever the reason, am I right in my understanding of what that means?

Mr. Robert Watt:

Yes, that is correct.

Mr. Paul Reid:

On Mr. Watt's commitment to publish as much as we possibly can, we are getting at the hospital level to a better place. We have what we call a high-performance visual platform, which, in essence, is a system and database that allows us to drill down at a better level - at a hospital level, at a consultant level and at a specialist level - around what is waiting, what is active and what was done last week. There are a smaller number of hospitals for which we have to finalise the data to be able to put that up but we are getting to a much better place, even of the current data we have, to get better information on it. Obviously, we want to publicly share that.

Within the current waiting lists, even as they are produced by the NTPF, there are some people who have received an appointment for the next six weeks. In essence, they are not waiting. They are on a list and they have an appointment. There are some people who are attending a second appointment as part of their consultancy and they are in the service. There are some people who are not available. Even when one gets the big figure of approximately 800,000, when one drills down there are approximately 90,000 who are in those three categories. There is the active waiting list and then one looks after that.

On the Deputies third question around community service waiting lists, that is a real issue for us, first of all, in capturing it because we do not have any level of equivalence on our community side of systems. My understanding - Ms O'Connor could help qualify it - is even in what we have there is a legislative requirement for the NTPF to be able to publish community lists. That is something that is needed in legislation.

Photo of David CullinaneDavid Cullinane (Waterford, Sinn Fein)
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What if I bring forward an amendment Bill to include community and diagnostics?

Mr. Paul Reid:

Even currently, what we have is not easily trackable or traceable.

Photo of David CullinaneDavid Cullinane (Waterford, Sinn Fein)
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We get the figures. It is not that we do not get them. I understand that there is a better system of capturing data for acute hospitals. I agree with Mr. Reid that how it is categorised could be a bit better as well, by the way, even from the HSE's perspective, to show when services are working better as opposed to that overall figure that people can see. It is in everyone's interest that the data is presented in the best format possible.

There is data on community waiting lists. We get them every month, but we have to go looking for them. It is the same with diagnostics. All I am saying is that whatever the data is, as imperfect as it might be, they should at least publish it.

Ms Anne O'Connor:

We all wanted this. In terms of the reporting that we ourselves have in place, it would be good to be able to capture it. Initially, we had thought it would necessitate a change to the statutory instrument but I believe that is not the case. There is a more substantial change required for the NTPF to be able to include community data but none of us would have an issue with that. It would be good to standardise it.

Photo of Róisín ShortallRóisín Shortall (Dublin North West, Social Democrats)
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To get back briefly to the population health approach, I want to clarify for Mr. Muiris O'Connor that what I am looking for as soon as he can provide it is details of the weightings of population that are being used for developing that profile. Mr. O'Connor stated that there would be more detail available later in the year but if he could get me those headings, I would appreciate it.

On the question of elective hospitals, the Sláintecare committee learned from the experience in National Health Service, NHS, Scotland and that is why we made that recommendation. What had happened in Scotland was that NHS Scotland had bought a private hospital and used it as an elective hospital and then went on to build a second one. I am wondering has any consideration been given to purchasing an existing private hospital.

Mr. Paul Reid:

Is that procuring a private hospital for the public system?

Photo of Róisín ShortallRóisín Shortall (Dublin North West, Social Democrats)
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Just buying a private hospital, yes.

Mr. Paul Reid:

Not from a HSE perspective. From a Government perspective, I cannot answer. It would be a big policy issue to buy a private hospital.

Photo of Róisín ShortallRóisín Shortall (Dublin North West, Social Democrats)
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It is not necessarily a policy issue. It is a faster way of procuring than going through the rigmarole.

Mr. Paul Reid:

From a procurement perspective, we procure services from private hospitals.

Photo of Róisín ShortallRóisín Shortall (Dublin North West, Social Democrats)
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I am talking about buying the building.

Mr. Paul Reid:

There is certainly a rationale as to why one would see it would be beneficial but, obviously, that would be a Government decision on policy. Certainly, during Covid-----

Photo of Róisín ShortallRóisín Shortall (Dublin North West, Social Democrats)
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I thought that would be considered as a speedy way of bringing an elective hospital on board.

Mr. Paul Reid:

No doubt it comes with a significant price.

Photo of Róisín ShortallRóisín Shortall (Dublin North West, Social Democrats)
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Building them comes with a significant price too and, as we know, a long delay.

Mr. Reid stated earlier that the committee should be giving people confidence that this will happen and encouraging staff to stay. I would agree with that but more than anything, the Government needs to give confidence to healthcare workers that it is serious about reform. There are still big question marks about that. Part of giving confidence is that there is a sense of urgency about recruitment. It is all very well having reform programmes set down on paper but it will not happen unless we have the staff available to us and staying in this country. That is why it is hard to understand that there has been such an inordinate delay in the consultant contract discussions. We talked about this previously and Mr. Watt stated that there was not an intention to appoint a replacement chair. I could not understand what that was about. It is six months since there was a chair in place. What exactly is happening about the consultant contract negotiations and when are they expected to get back up and running?

Mr. Robert Watt:

The expectation is that next week formal discussions will take place. We have a chair appointed now. There have been numerous engagements with representative bodies of an informal nature to discuss some of the issues and to understand that there is a basis for a more formal engagement, and we are hoping that this will start next week. As I mentioned earlier, we are hoping to do this quickly but, as ever, it requires us to reach an agreement and the parties have different views on many questions. We are hoping to do this before the summer and to finalise it before the summer because it has gone on too long.

Photo of Róisín ShortallRóisín Shortall (Dublin North West, Social Democrats)
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It is an important time. There has been a loss of six months. The six months' delay has been regrettable. The health service will not work unless we have enough doctors and other staff in it. I cannot understand why there was not an urgency about that. What kind of timescale would the Department be working to with the new chair?

Mr. Robert Watt:

We hope to finish this up before the summer break. The intention is to have a short intensive engagement where, hopefully, we can reach agreement on the key issues. As ever with negotiations, we are hopeful and optimistic and we all want to reach an agreement. The Government wants to reach an agreement - the Minister has said that clearly - but we need to have the substantive engagement. Hopefully, those substantive talks will start next week and we can conclude quickly. That is the Government's wish. We shall see.

Photo of Róisín ShortallRóisín Shortall (Dublin North West, Social Democrats)
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Connected to that is obviously the threatened strike action.

Photo of Seán CroweSeán Crowe (Dublin South West, Sinn Fein)
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Mr. Reid is looking to contribute.

Mr. Paul Reid:

Briefly, to reassure the Deputy on the urgency on recruitment, including of consultants, as I stated on the previous occasion, up until last month we have increased the workforce in the health service by over 12.5%, which is the biggest increase since the formation of the health service.

Over the past two years, almost 15,000 people have been recruited in net terms.

Photo of Róisín ShortallRóisín Shortall (Dublin North West, Social Democrats)
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Okay. It is hospital consultants I am asking about.

Mr. Paul Reid:

Specifically, on hospital consultants, we have recruited 471 hospital consultants in net terms. Last year there was a 160% increase in hospital consultant net recruitment on the previous year, which has never happened in the history of the health service.

Photo of Róisín ShortallRóisín Shortall (Dublin North West, Social Democrats)
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In the context of the reform programme of Sláintecare and having the Sláintecare contract and dealing with private care in public hospitals, etc., all of which is part of a piece, if the basic Sláintecare contract is not in place none of the rest will follow.

Related to that is the threat of strike action and the decision to support strike action by the junior hospital doctors. Mr. Reid seems to be making excuses about why people are going away. There is an important piece of research that was done by Dr. Niamh Humphries on the exact reasons we cannot hold on to hospital doctors. It is very informative. I understand the Minister heard a presentation on it recently. I do not know whether Mr. Reid has, but it is important that it would inform action in relation to the threatened strike.

Photo of Seán CroweSeán Crowe (Dublin South West, Sinn Fein)
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I need to bring the meeting to an end. We are over time.

Mr. Muiris O'Connor:

On Deputy Shortall's starting question around the population-based allocation and the weightings, we would not have determined the weightings. The profiles are an important part of getting there - looking at the utilisation rates by age and health status and looking at international formulae. We will see what we can share. In Q3, as part of that development of the implementation plan, there will be proposals around population weightings that will be most suitable and justifications around that. We can share that as part of the deliberation with the committee.

Photo of Róisín ShortallRóisín Shortall (Dublin North West, Social Democrats)
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I thank Mr. O'Connor.

Photo of Seán CroweSeán Crowe (Dublin South West, Sinn Fein)
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I mentioned the audiology unit in Tallaght Hospital. There are 2,500 children involved. Mr. Reid might come back with a note on it. I do not know what the problem is but the average waiting time is 66 weeks. There are some children waiting two years. It would be remiss of me if I did not ask that. I would appreciate a written note at some stage.

I thank all the witnesses for their comprehensive discussion with the committee here today. The meeting now stands adjourned. We meet again in public session on Wednesday, 22 June at 9.30 a.m.

The joint committee adjourned at 12.32 p.m. until 9.30 a.m. on Wednesday, 22 June 2022.