Bernard Durkan (Kildare North, Fine Gael)
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We have the usual statutory warning in relation to privilege. I do not need to read it out as everybody knows what it is anyway. We cannot mention or identify people, persons or places outside the arena, and if people are joining the meeting from outside the precincts of Leinster House, they have no privilege.

The purpose of this meeting is to discuss the implementation of Sláintecare. To enable the committee to consider this matter I am pleased to welcome Mr. Leo Kearns, chair of the regional health areas advisory group. All those present in the committee room are asked to exercise personal responsibility to protect themselves and others from the risk of Covid-19. Incidentally, no matter how well one looks after oneself, it is still spreading and very much alive.

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 any of their statements are potentially defamatory in relation to an identifiable person or entity, they will be directed to discontinue their remarks. It is imperative they comply with any such direction.

Members are reminded of the long-standing parliamentary practice to the effect that they should not comment on, criticise or make charges against persons outside the Houses or an official either by name or in such a way as to make him or her identifiable. I remind members of the constitutional requirement that they must be physically present within the confines of the Leinster House complex to participate in public meetings. I will not permit a member to participate where they are not adhering to this constitutional requirement. Therefore, any member who attempts to participate from outside the precincts will be asked to leave the meeting. In this regard, I ask members partaking via MS Teams that, prior to making their contributions, they confirm they are on the grounds of the Leinster House complex.

I invite Mr. Kearns to make his opening remarks.

Mr. Leo Kearns:

I thank the Vice Chair and the committee for the invitation to attend. In late December 2021, the Minister for Health established the regional health areas advisory group and appointed me as independent chair of this group. The membership of the group includes people of great experience from right across the health and social care system. It is important to note the role of the group is to provide advice. The responsibility to draft the plan and to implement regional health areas, RHAs, rests with the HSE and the Department of Health. An implementation team has been established under the joint leadership of the Secretary General of the Department of Health and the CEO of the HSE.

I will give a little bit of background, which I am aware members are very familiar with. The six new RHAs are in line with recommendations made in the Sláintecare report published by the Oireachtas Committee on the Future of Healthcare in 2017 that regional bodies should be responsible for the planning and delivery of integrated health and social care services. Integrated care is where services, funding and governance are co-ordinated around the needs of the patient, encompassing both acute and community care. RHAs will ensure the geographical alignment of hospital and community healthcare services at a regional level based on defined populations and their local needs. This is key to delivering on the Sláintecare vision of an integrated health and social care service. As well as enabling the integration of community and acute care, RHAs aim to empower local decision-making and support population-based service planning. This will ultimately strengthen our health service and lead to improved patient experience as well as access to healthcare closer to home. Since its formation, the advisory group has met on a number of occasions and I will outline some of the key pieces of advice provided.

Ensuring clarity of purpose is one aspect. The core vision driving RHA implementation is to improve care to patients by enabling a joined-up, integrated approach to service planning and delivery and to empower those who deliver that care. There is still a significant risk RHAs are being viewed primarily as an organisational, back-office type exercise. If this perception remains, then this reform programme will be undermined.

I will speak a little about governance and accountability. A key issue at the heart of the RHA implementation is the belief that the current centralised and hierarchical governance approach to the health service needs to change fundamentally and radically. It is not possible to define a clear role for an RHA without also doing the same for HSE centre and for the Department of Health, and this includes how all these entities relate to each other. The guiding principle that should underpin this work is that of subsidiarity, namely, there should be a guarantee of independence and authority for the RHAs commensurate with the responsibility they are being given, with absolute clarity as to how an accountability framework will work, and the same should apply to HSE centre in relation to the Department of Health. As a natural consequence of that principle, the plan to implement RHAs must also include an aligned change plan for HSE centre and for the Department of Health. In determining the levels of authority that should be delegated, the bias should be towards providing maximum devolved authority sufficient to allow the RHA to exercise effective decision-making to deliver on its responsibilities while working within relevant national frameworks. The only authorities that should be retained at national level are those that are necessary to be retained at national level, and where they are retained, there should be an explicitly stated rationale as to why this is the case. I should state also that there are authorities that should stay at national level. I will speak about that later.

The next aspect is leadership and organisation. Each RHA will be a very large and complex entity within the national health service. It will serve a significant population with a budget of multiple billions, have tens of thousands of staff, and be responsible for the planning and oversight of integrated service provision incorporating prevention, primary care, community, specialist and acute care. It will be responsible for all aspects of care, including mental health, children and older persons' care, and will have to plan and deliver these services across multiple national and local service providers, including voluntary and private providers, and develop integrated service provision with other sectors such as local authorities. Thus, an RHA will be a very significant organisation by any standards. In this context, it is essential the core leadership team for each RHA be appointed as soon as possible to take ownership of the implementation from the perspective of the RHA. A reasonable aim could be to have the recruitment of RHA CEOs commence early in 2023 with a view to the appointment of the core leadership team by the middle to the end of 2023.

Given their scale, there is a risk that RHAs themselves could become centralised, top-down organisations, and simply introduce another bureaucratic layer to the health service. Therefore, the principle of maximum devolved authority also needs to be translated into the organisational arrangements within the RHA. This must ensure appropriate levels of authority for decision-making at the level of the patient pathway and enabling local and regional structures to enable relationships and trust-building across boundaries in acute, community, and other areas. We wish to emphasise this point, as the core rationale for RHAs is to enable integrated pathways of care to patients and clients. Thus, any RHA that does not organise itself in a way that devolves relevant and necessary responsibility, authority, and accountability as close to the patient pathway as possible, will not be fit for purpose. In order to provide clarity and avoid varying or conflicting understandings on this matter, it is important to establish at an early stage the level of authority devolved to RHAs for finance, HR, ICT, estates and so on., and then some basic models as to how this will be operationalised, bearing in mind the principle of subsidiarity mentioned earlier. This will, of course have implications for service planning, budget allocations and care group funding, and will have to provide for transition periods and nuances such as care provided across RHA boundaries, or where services are provided nationally and drawn down regionally. It will have implications for the role of the HSE centre and the Department of Health in relation to finance, HR, ICT and so on, which will have to change from current practices. I should emphasise as well the importance of ICT and data as a critical enabler of integrated care.

The national clinical programmes have been a success for the health service in recent years. In the context of the RHAs and the reformed role for the HSE centre, these frameworks and models will assume a much more fundamental responsibility within the HSE centre, and the development, enhancement, and expansion of these should continue. There are many excellent examples of such frameworks, for example, the national cancer programme, the integrated care programme for older persons, chronic disease management and so on, which demonstrate many of the characteristics of an effective national framework.

I want to mention workforce planning and human resources. At the heart of the motivation to implement RHAs is the concept that this will enable services to be designed and delivered in an integrated way to meet the needs of people at local level. Right across the health service, people will buy into this as a concept worth committing to. However, without staff, this vision will never be realised and people understand this also. It is important to acknowledge that this exercise is taking place at a time when we are experiencing a workforce crisis at many levels. Therefore, it is necessary to establish a credible, sustained, cross-system approach to a multilayered workforce strategy. Failure to make parallel progress on this will fatally undermine efforts to implement RHAs, as it will indicate to people that the implementation of RHAs is not serious about the delivery of better care. There must also be an acknowledgement that for many and varied reasons there is a deficit of trust and a strong sense that people working in the health system do not feel valued. We need to improve the culture in our health service in order that we rebuild trust among staff at all levels. Doing so will help to create the sense that people are valued. Inherent to this culture change is ensuring that staff are included in all changes that will impact upon them in order that they have confidence in the direction of travel. This is key to successful change and not addressing this poses a risk to successful RHA implementation.

I will mention a little bit about engagement. The implementation of RHAs is not simply an organisational or administrative change within the HSE, it requires systemic change, and involves multiple parties. These various entities must be fully engaged in the design and implementation of RHAs. Simply presenting them with a fait accompli will not work. Therefore, thought must be given as to how these organisations and entities will be meaningfully involved, and not just communicated with, from the beginning and throughout the lifetime of this implementation in order that they are part of leading the change.

Implementing RHAs is an extremely challenging and large-scale change. It is not credible that change of this magnitude can be managed without a significant investment in an implementation support infrastructure. While the leadership and drive for the implementation must come from within the system, they must be supported by thought leadership, research, specialist expertise and change and programme management from outside as required. Significant project support and specialist expertise is required at Department of Health, HSE centre and RHA level and must be co-ordinated across all three. It is difficult to see much real progress being made on implementation unless senior leaders in the HSE and the Department of Health are freed up from some of their business-as-usual responsibilities to devote significant thought and time to this.

While work is ongoing to draft the implementation plan, there is also a need to draft a critical path plan based on the key milestones so that it is easier to visualise and understand the critical and main steps in the pathway to implementation. The critical path plan should be shared and communicated widely. Transparency will be vital in building confidence, trust and support. Progress towards implementation should then be evaluated against this critical path plan.

The implementation of the RHAs is essential if we are to set ourselves up to deliver joined-up care to our patients and clients. This is not a simple task and will require significant sustained investment and outstanding leadership at all levels, but particularly at national level to make it happen. We must stop depending on short-term, reactive solutions to crisis situations, and must commit to making the fundamental reforms that are necessary to allow us to develop sustainable solutions to the very real problems we have in our health system. I extend my thanks to the RHA advisory group members for their enthusiastic engagement and I again thank the committee for its invitation today.

Bernard Durkan (Kildare North, Fine Gael)
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I thank Mr. Kearns. All of the issues outlined are very important. He mentioned that some people in the health service do not feel valued. That is something we have spoken about here before. It is important that those on whom we depend to deliver services are recognised for that. Where improvement is needed, we must speak on that as well. Co-ordination is hugely important, because if everybody is not pulling their weight we will not go anywhere. It requires trust as well. We must trust one another - those of us who are in public life and those who are administrators and official leaders in their own areas. In particular, we must value those who have made great sacrifices in recent years to deliver an increasingly vital service in difficult circumstances. We must acknowledge that.

Seán Kyne (Fine Gael)
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I welcome Mr. Kearns to the committee meeting and thank him for his presentation here this morning. Cutting to what it means in reality, he referred to the recruitment campaign for RHA CEOs, and said it was a reasonable aim that it would commence in 2023. In effect, in the west, for example, we have a CEO for Saolta and a chief officer for community healthcare. Is he talking about somebody who would be over both of those, who would liaise, engage - I will not say manage - but work with both of those organisations to make sure there is better integration of services and care?

Mr. Leo Kearns:

Effectively, yes. We are going to have community services, acute services and specialist services. The intention is to have a leadership team across all of that for the population in the region. At the moment, as the Senator is aware, there is a budget for community care, acute services and mental health. GPs provide a service in the community. Essentially, we are providing the care in a fragmented way. Some of the real problems that we have are because it being done like that. The key reason for the RHAs is that we must look across all the services being provided for the full population. The leadership team sits across all of that. The point I made is very important, namely, that we cannot just introduce another layer into the health service. If the joined-up approach does not work at local level, then putting in the RHAs is not going to make any difference. Essentially, that is exactly what needs to happen.

Seán Kyne (Fine Gael)
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I thank Mr. Kearns. That makes absolute sense because it is clear that we have pressures on the acute system and we must ensure that the community system works - that there is capacity and staff within it. I do not expect Mr. Kearns be across this, but I will give an example. There is a debate at the moment regarding Clifden District Hospital, which is more than an hour from Galway city.

There is a lack of referrals to the hospital from University Hospital Galway even though UHG is one of the busiest hospitals in the country. In UHG, one in eight patients were on trolleys this time last year. We have been told that referrals have dried up because there is no physiotherapist in Clifden and that demand for respite has stopped. Doctors have been told that they cannot refer. Even though these doctors have local knowledge and work in the community, they cannot refer patients to the district hospital and referrals must be made by UHG. These are real problems as staffing and recruitment are having an impact on the delivery of service. In addition, community healthcare units tell us that they cannot get staff despite bespoke campaigns.

As far as I can see, the units have not searched internationally yet that is being done by the Saolta Hospital Group. There is a need for more engagement and a joint analysis of the problems in order to find solutions. I have given a perfect example for why these two elements need to be connected. We can talk how we like about Sláintecare and plans but there are real examples in some of the more remote areas located away from the hospitals where there is, in this case, a district hospital. Indeed, there is a public nursing home in An Cheathrú Rua facing similar staff issues. The nursing home has beds but no staff to provide a service and care which is situation that keeps pressure on UHG.

Mr. Leo Kearns:

I cannot comment on the details. What the Senator has described is where we are. It is the same patient who travels across the entire service so today he or she is at home, tomorrow he or she is with a GP, the day after he or she needs to get into an emergency department and later that patient needs to get home but we have set the service up in complete silos so there is no way that it can work.

Front-line staff work incredibly hard and make huge sacrifices but they are faced with an impossible task so the system must be changed. The RHAs must establish a joined-up approach and create a plan that addresses all of the issues but does not leave pockets that are disconnected. It is like trying to play a game of football and the manager is on the side of the pitch but somebody else is managing the two corner backs so they are playing a different game, which means the system cannot work. This is why we must be passionate about the RHAs because it can be quite a dry topic as it is about governance and so on. Fundamentally, the way we have set up the health service ensures that it cannot function because we have split the service into all of these different buckets and that is before we even mention the people who do not work for the HSE such as GPs and others. Earlier the Senator gave a perfect example for why we need RHAs and he outlined the problem that they must address.

Seán Kyne (Fine Gael)
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On autonomy, the aim is that the CEO, for example, of an RHA would work in collaboration with the CEO of a regional group and the community healthcare group. Will the CEO be able to say, "Hold on, I do not agree with what you are doing there and this is the approach that I believe should be taken" or is it a case of engaging amicably and finding a solution? Is there a need sometimes to say, "Hold on, I do not like what is happening and we need whatever"? How does Mr. Kearns see that operating without creating more antagonism? I agree that it is the right approach and it is necessary but I am concerned that there is collaboration versus direction.

Mr. Leo Kearns:

This is why we are putting such a huge focus on what we call the control model. How does it work? We said that one of the key things, in addition to appointing the leadership teams for the RHAs, is that there is significant work to be done on the organisational structures within the areas and that has to go down to patient level. A key part of that is all the authority that RHAs need to fulfil their responsibilities has to sit at the RHA level. However, the RHAs then need to understand that they must devolve some responsibility and authority further down because, with the best will in the world, whoever leads the RHA is not on the ground in Clifden District Hospital.

A big challenge for RHAs is how to create that sense of ownership and empowerment right down at patient level, which means that one must allow some decisions to be made on the front line, within the community and so on. The big part of that is one needs to have that clarified upfront. So when one designs the RHA, one must say these are the decisions that need to be made at the regional level and these are the decisions that are made at a local level. When a decision is made, it is not like someone can go off and just make whatever decision he or she likes. He or she must be accountable for the decisions made. He or she cannot create a situation where someone says he or she is managing the hospital yet cannot make a decision, which should be his or her decision to make, because he or she has to get approval from two or three levels above. That would be authority in name only and is a terrible place to be. We are saying that a big piece of work to be done by the RHA is figuring out the organisational design within the area, which is just as important as how the RHA relates to the centre, for instance. We do not want to create a sense that in the RHAs there is some kind of command and control centralised function. That just does not work in a complex system. It cannot work. There must be collaboration, good planning, clarity on who is responsible for what, and if someone is made responsible for "X" then he or she needs to have all of the authority that one needs to deliver "X". As we now know, most of these authorities now sit at the centre rather than with the hospital CO even as we speak. That is a critical element in all of this.

Seán Kyne (Fine Gael)
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Mr. Kearns mentioned GPs, for example. There are capacity issues for GPs. The capacity issues have an impact on the ability of GPs to provide out-of-hours services within, for example, the Westdoc framework. The Westdoc framework does not cover the full county because there is no agreement or buy-in. City-based GPs, for example, may not wish to travel to areas located in the countryside which, in turn, puts pressure on local GPs and GP services. How does Mr. Kearns see that being integrated as part of an RHA?

Mr. Leo Kearns:

That is a critical part. First, there are the issues of capacity and workforce, which are issues that I might come back to. Dr. Ronan Fawcett is a GP in Kilkenny and he is a member of our group. He is very strong on the need to build local structures and to support them between GPs and acute and community services, which is hit and miss at the moment. There is a sense that GPs are somehow separate from the health service when, in fact, they are integral to the health service if one understands the health service not to be just the HSE or just an organisation. One of the problems that we have is that there is a perception that the health service is just the HSE when, in fact, a huge proportion of the services are provided by non-HSE.

Bernard Durkan (Kildare North, Fine Gael)
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We must move on as the ten-minute time slot has been exceeded.

Róisín Shortall (Dublin North West, Social Democrats)
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I thank Mr. Kearns for his presentation. I am sure that the Vice Chair, as the only other member of this committee who was a member of the Committee on the Future of Healthcare, will recall that this issue was the most dominant issue for that committee over the 11 months that it existed. It was the issue of most concern not only to members of the committee but also to patient groups, staff groups, etc. I refer to the disconnection between the two elements of the acute services and community services. There was a real determination on the part of all of the members of that committee to address the matter because one cannot achieve integrated care unless one does so.

There are three key elements in the recommendations about RHAs that were made by the committee. First, there was the integration piece and how barriers between the sectors should be removed.

Key to that was a call for a single budget and a single management team within each RHA. The second element was that resources would be based on the local population and the weighted population, given the socio-economic profile, age, rurality and factors like that, and that we would move towards a kind of population-based resource allocation, so that there would not be a variation in services across the country. The third element was legal accountability for the spending of the budgets and the provision of services and that that legal accountability would apply to both administrative and clinical management. Are those three elements still intact and is there buy-in to ensure those three elements actually happen?

Mr. Leo Kearns:

First, what I would say about that is that they are central to it. So far, we have been talking about the integration of care, but that care has to be planned for on the basis of the population. Therefore, the RHAs need to understand their population and they need to deliver their services on the basis of the population need. That issue around accountability is fundamental.

In the advice we give, we are clear about this point and there is a commitment to that. I can see at a political level, within the Department and within the HSE, there is clarity that the budget has to move and that that is not just an administrative move. There has to be clarity that the RHA is accountable for its budget, that it has ownership of that budget and that it can make decisions within national frameworks. For instance, it would have to work with international framework on public procurement and within national frameworks around clinical programmes, such as the National Cancer Control Programme and so on. They have to have the ownership of that. In terms of the control model we are asking the HSE and the Department to design, our group will not be designing this but is simply stating the requirements that their model has to present. One of these is that there must be clarity about the responsibility, authority and accountability within the RHA, which incorporates all of that. I would say that there is a commitment to that as well as a growing understanding that it will mean radical change and that is not simply a matter of some kind of administrative move. Yet, we still need to see the control model, or the operational model, that will give rise to that.

Róisín Shortall (Dublin North West, Social Democrats)
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Fundamental to the dysfunction that exists in the health service at the moment is the fact that there is a block of funding, the lion’s share of which goes to the hospitals. This is not necessarily based on anything and it can be for traditional reasons, wherever a Minister happens to be or whatever. The lesser share, then, goes to community.

Fundamental to this plan, if it is going to work, is that there must be a single budget. That budget must go to what will achieve the best health outcomes and that will entail moving existing budgets. I would hope it would be a matter of the hospitals and the community continuing to be funded separately. There will need to be a single budget and those decisions on the best places to spend that budget must be taken centrally, rather than on political grounds or because the hospital group has had so much in the past and it wants to continue with that. Is that principle accepted in both the Department and in the HSE?

Mr. Leo Kearns:

I think it is but we need to get beyond the principle to how it gets operationalised and how we make it real. There is no doubt about it, but one cannot do integrated care, population-based care planning or care delivery if one is not looking at a budget across all of that. In fact, a prime reason we have such a dysfunctional system is that we have all these multiple budget lines where the budget goes off one way but never goes horizontally across.

That principle is clear, as is the fact that this cannot be done in Dublin, but it has to be done within the region, with the people who should know their population best. They should have the facilities and the skill sets to be able to understand their population and how they allocate their budgets. I think there is highly likely to be quite a bit of the duplication going on at the moment because of the way the budgets are organised. I have no doubt that one of the main reasons behind the blockages that we are seeing in various parts of the system are to do with this lack of joined-up planning, budgeting, clinical services and so on. What we still need to see is how we move from where we are to that. That is the destination and there can be no deviation from that. That is a principle we must stick with. From everything I hear, people understand that is where we have to go and this is why we emphasised the scale of this. There is quite a bit of work to be done to understand how one makes that real.

Róisín Shortall (Dublin North West, Social Democrats)
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To clarify in relation to the hospitals, in the west, the hospitals in the Saolta group, for example, would be in the local RHA, but that situation would not apply in other parts of the country. The hospital groupsper sewill no longer exist under this proposal. Is that not right?

Mr. Leo Kearns:

That is right.

Róisín Shortall (Dublin North West, Social Democrats)
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The relevant local hospitals will be reporting into the RHA. At the hospital level, what is the attitude there, given the historical way in which hospitals have operated, when they have had the ear of the Minister, or whatever? Is there a recognition that we need to move to that single budget so that, for example, there are not 600 delayed discharges from hospitals for want of funding for home care or step-down facilities, and that that rational decision making would then be taken?

Mr. Leo Kearns:

I would be reasonably confident that there would be because at the local level they are living this every day of the week. They are seeing the older person and the trolleys in the corridor with older people on them for 24 hours. They are frustrated by the fact that there are people who have been medically discharged but who are still in a bed in the hospital because they cannot line it up.

Róisín Shortall (Dublin North West, Social Democrats)
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Is it Mr. Kearns’s sense that people are up for this?

Mr. Leo Kearns:

I think people are up for it, but they need to believe that this is going to happen. They need to believe that they are going to be involved in designing it and they need to know that we are not going to deviate from this again, because one of the issues we have is-----

Róisín Shortall (Dublin North West, Social Democrats)
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Okay, that is fine. I have one other question. The Chair will recall that we had Professor Tom Keane before the Oireachtas committee to share his experience with the cancer programme and to give us advice on how we may go forward. I recall him saying that essential to this reform was ensuring that there was legal accountability at clinical and administrative level for decisions taken, for the spending of budgets and for the provision of services. In the early stages of this, there seemed to be a significant reticence on the part of the Department and the HSE to legislate for that accountability. What is the current thinking on that and what is the advice the Department of Health has been providing in that respect?

Mr. Leo Kearns:

The advice we have been providing is that they cannot establish the RHAs without a clear control model that clarifies their responsibility, the authority they have, which should be a comprehensive authority, and how they are going to be held to account. That has to be achieved and there can be no dilution of that. They have to come up with a design of how that will happen. If that requires legislative change, then that should follow. Establishing boards does not necessarily solve the problem, because the problem is about accountability and authority. There can be no moving back from that. The advice we give is that this is central to this and if the control model they come up with does not address it, then it will not be fit for purpose. However, we believe the principle of subsidiarity is accepted and I would expect that the design of the model they come with, on which we would then give advice, will address that legal issue.

Róisín Shortall (Dublin North West, Social Democrats)
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Have the Department and the HSE bought into that?

Mr. Leo Kearns:

I am reasonably confident that we are there. The detail is still needed but in principle, people understand that.

David Cullinane (Waterford, Sinn Fein)
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I welcome Mr. Kearns. His opening statement is music to our ears. Everything he said has been said by us for some time. At our first session on RHAs, many of the arguments made by Mr. Kearns in his opening statement were made by us to the head of the Department and the head of the HSE at the time.

I will discuss some of the points made by Mr. Kearns in his opening statement and juxtapose them with what the Cabinet signed off on for regional health authorities. I will then tease out what flexibilities might be there. In his opening statement, Mr. Kearns said a key issue at the heart of the RHA implementation is a belief that the current centralised and hierarchical governance approach to the health service needs to be fundamentally and radically changed. Does belief in this principle exist at the top of the HSE?

Mr. Leo Kearns:

There is no doubt that it is challenging because it is saying that the model we have and what the HSE centre does have to radically change. There is a key role for the HSE centre. That is necessary and strategic. I have no doubt that is what the HSE centre hears from ground level because it has been running a number of workshops over the past while and is feeding that back in. We still need to see the detail coming back regarding what this actually means in terms of what the HSE centre has to change and what is devolved to the regions.

David Cullinane (Waterford, Sinn Fein)
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I think Mr. Kearns is saying it is complex. My question concerned whether, at senior management level, the HSE is really committed to these changes. In his opening statement, Mr. Kearns said that there should be a guarantee of independence and authority for the RHAs commensurate with the responsibility they are being given. I agree with that. He went on to say we need absolute clarity as to how an accountability framework would work. I agree with that. He said there should be a bias towards providing maximum devolved authority sufficient to allow the RHAs to exercise effective decision making to deliver on their responsibilities. I agree with that also. Crucially, he talked about RHAs having a budget of multiple billions of euro and tens of thousands of staff responsible for planning and oversight of integrated service provision. He said the RHAs should have maximum devolved responsibility in all of these areas and that the bias should be towards effective decision making.

If you look at what was signed off on by Cabinet, this is where there may be some conflict with what Mr. Kearns is saying. It stated that the HSE centre provides all corporate functions, that is, RHAs are divisions within the HSE centre. The HSE centre provides central procurement, central finance control, central HR functions and ICT support to facilitate the use of shared facilities. It goes on to state that the RHAs are divisions of the HSE and cannot enter into contracts in their own right. They are not legal entities nor are they the employer. I can see a conflict between what I would want and Mr. Kearns's opening statement and what was in the business case signed off on by Cabinet. It also stated that no legal change is required. That is what was signed off on by Cabinet. If there is movement from the Government and the HSE, that is really welcome but when I read the business model signed off on by the Cabinet and then Mr. Kearns's opening statement, I see a conflict. Perhaps it is a healthy one but I see a conflict.

Mr. Leo Kearns:

It is like that old saying that everyone has a plan until they meet reality. In fairness to the Minister, he established the advisory group because he wanted objective advice and input. We are looking at the implementation of the RHAs from the perspective of people with a lot of experience in the health service at all levels and the community and patient advocate groups. We are saying that if the RHAs are to work, these are the principles that should underpin them. That raises issues-----

David Cullinane (Waterford, Sinn Fein)
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I must put it to Mr. Kearns that if we are talking about devolved authority and responsibility, accountable autonomy and making sure these RHAs have their budgets and the authority on how to spend it, their not being a legal entity and not being the employer constitutes a problem.

Mr. Leo Kearns:

In some of the advice we have given, we have said there needs to be a legal base for this. This cannot simply be an administrative-type structure. We recognise this is not necessarily what is in the business case signed off on by Cabinet but we are giving advice based on what we believe is necessary.

David Cullinane (Waterford, Sinn Fein)
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That is welcomed but does it mean a memo would have to be brought to Cabinet by the Minister if there was a change, which I imagine there would be because it would require new legislation and to be signed off by Cabinet?

Mr. Leo Kearns:

We are providing advice. The HSE and the Department have responsibility for drafting the implementation plan. If in that drafting, in order to deliver on what is necessary, they need further legislation, it would be their responsibility to come forward with that.

David Cullinane (Waterford, Sinn Fein)
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Regarding corporate function and the memo signed off on by Cabinet, can Mr. Kearns square this with what is in his opening statement? I agree we need a HSE centre to provide governance, clear guidance and consistency. I think we all accept that. We need a lead HSE centre. However, when it states that the HSE centre provides all corporate functions, including all central procurement, central finance control, central HR functions and ICT support, the fear is that if this was implemented, everything would stay the same at the top and we would just reconfigure underneath. Nothing would change - no board, no legal entity and no legal powers. It would not be the employer. It would be rearranging the deck chairs and yet all the main corporate functions would stay at the centre when we know it takes far too long to get capital projects done and to recruit staff and we need much greater flexibility. What is in that business case again suggests that we need a shift in that attitude. Does Mr. Kearns agree with that? What is his opinion?

Mr. Leo Kearns:

My opinion and the advice that has been given are exactly what I described in the opening statement. We put a bit more detail behind it but that is it. If that is not the outcome of this, as we said in the statement, this is fatally undermined. We are giving that kind of advice and saying it involves the HSE and the Department. I believe they are committed to this. It may be that there is a growing understanding of all of these issues but it simply will not work if we just move chairs on the deck. You could make an argument for saying that some of those services are shared services - in other words, they are providing a shared service. That is a different thing from a control function. Even with a shared service, if the shared service cannot deliver the service, it effectively becomes a control function because they are so busy doing all this stuff, they are not responding to what I need here.

David Cullinane (Waterford, Sinn Fein)
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I think we are all on the same page. I think Mr. Kearns will find members of the committee agree with everything he is saying. We need people to listen. There needs to be a shift in the mindset in the HSE. I think the Department wants change but there is some resistance from the HSE. I am not saying that some of that is not justified because it wants to provide that central guidance. That is not in question for me. I just think there is a bit more than that and there needs to be push back. I am happy with what I am hearing from Mr. Kearns.

He makes the point in his opening statement that, if this goes wrong, we could then end up with a whole new bureaucratic layer-----

Mr. Leo Kearns:

Yes.

David Cullinane (Waterford, Sinn Fein)
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-----which is the last thing we need. Thousands of organisations are funded by the HSE. We have a complex healthcare system, with voluntary hospitals but also all the section 38 and 39 organisations. The business case here, signed off on by the Cabinet, states the HSE centre will approve all service level agreements, SLAs, with voluntary organisations. I am not sure how this is going to work if RHAs are to have the autonomy they need. How in God's name is this going to work in practice?

Mr. Leo Kearns:

We have said that the SLAs in place now must all be reconsidered in the context of RHAs. Again, we need-----

David Cullinane (Waterford, Sinn Fein)
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That is not what it says here in the business case.

Mr. Leo Kearns:

I know.

David Cullinane (Waterford, Sinn Fein)
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It seems to me, therefore, if we look at the business case, that everything it said and all the concerns we raised have been proven right by the expert group looking at this subject and giving advice. As Mr. Kearns is aware, three models were presented to the Cabinet. Model 1 was no change, while model 3 was much more devolved authority. I think it was somewhere in the middle, at 2.5, and it seems this is where it is at.

Mr. Leo Kearns:

Yes.

David Cullinane (Waterford, Sinn Fein)
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This model has now been essentially binned, or needs to be binned. This is the message coming from this session, as far as I can see.

Mr. Leo Kearns:

I could not comment on that, to be honest with the Deputy.

David Cullinane (Waterford, Sinn Fein)
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Everything Mr. Kearns has said has suggested this is what needs to be done.

Mr. Leo Kearns:

Yes, and I suppose I am in the happy position of being able to give advice. The advice we are giving resonated with people on the front line. It resonates here-----

David Cullinane (Waterford, Sinn Fein)
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I fully agree.

Mr. Leo Kearns:

It definitely resonates with many people in the HSE. In fairness to the HSE centre, as well, it is, and I will not say victims in this scenario, but it has what it sees as its responsibility today. It must keep that going. We must recognise, however, that we must now be in a transformational phase and this is moving into a different space.

David Cullinane (Waterford, Sinn Fein)
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I thank Mr. Kearns and I hope he succeeds.

Gino Kenny (Dublin Mid West, People Before Profit Alliance)
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I thank Mr. Kearns. There is a perception among the public that the HSE is overly bureaucratic and has too many managers and not enough delivery. Does Mr. Kearns believe this perception is true?

Mr. Leo Kearns:

This is the perception, including that there are too many managers. We must be careful about this as well, however. Most clinical teams need non-clinical people to make them function. If we are looking at, for instance, organising SLAs with multiple organisations, then it is necessary to have people with experience in that area. Healthcare management is tough and it is a difficult gig. Setting up the healthcare system the way we did means pretty much everybody in it has an impossible job. We can see that the system is firefighting and engaging in crisis management all the time. We have not made it a good place for people to work. This is why we mentioned the whole workforce and culture issue in our advice. We must address this situation in the round. Whether someone's role is to be an accountant, the porter at the front door of the hospital, the practice nurse in a GP practice, the GP, the consultant, the junior doctor or whatever, in a complex system there is a need for all these people in all these roles, including the manager of a hospital and the manager of a community healthcare organisation, CHO, etc. While what the Deputy said might be the perception, therefore, I do not think it brings us forward that much really.

Gino Kenny (Dublin Mid West, People Before Profit Alliance)
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Mr. Kearns understands, though, how this perception prevails.

Mr. Leo Kearns:

Yes, I know.

Gino Kenny (Dublin Mid West, People Before Profit Alliance)
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When people try to access healthcare and it is simply not there, it is the most frustrating thing.

Mr. Leo Kearns:

The Deputy is absolutely right. When people get into care, they find it is very good, generally speaking. People have a great experience. The problem is with access. People's trust then erodes. Many people are worried about having to go into an accident and emergency department and whether they may have to wait for 24 hours on a chair or what might be going to happen to them. For the staff watching this, it is incredibly difficult. One of the big issues we have, particularly after Covid-19, is that the stress of working in healthcare is so significant. The past two and a half years have just amplified this aspect, but it existed before the pandemic as well. We have set up the system in such a fragmented and poorly governed way, but the people working in healthcare are trying to do their best.

This is the case at every level. I can see it within the Department, the HSE centre and right out onto the front line. People have, I will not say burned out, but there is a significant burnout element to this context. This is why we must put such a great focus on this aspect. This situation is not sustainable. It is not that this change is a nice thing to do, it is that we cannot go on like this. It is probably also important for me to say that the cross-party support Sláintecare brought in is critical to this endeavour. Having political support - joined-up political support - for this process is absolutely necessary. It will give people confidence that if there is this kind of support and coherence with the Department, the HSE and the front line, then there is some hope this situation is going to improve. This is important.

Gino Kenny (Dublin Mid West, People Before Profit Alliance)
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I agree. Regarding the past two and a half years, it has been beyond challenging regarding the pandemic and other factors.

Mr. Leo Kearns:

Yes.

Gino Kenny (Dublin Mid West, People Before Profit Alliance)
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Many people working in the health service are put to the pin of their collar concerning everything going on. Turning to Mr. Kearns's statement, his critique of our health service is a breath of fresh air. This is how it can be corrected. Mr. Kearns uses words like "a joined-up, integrated approach to service planning and delivery and ... [empowerment of] those who deliver that care". Is this not happening now? If not, then you would get very concerned.

Mr. Leo Kearns:

To be honest, I do not think it is possible for it to happen now. When we think about the way the system is set up, we have all the budgets separated out. We have GPs operating separately and not necessarily with access to diagnostics. I know the situation has improved and that more diagnostics are available, but I would not like to be a GP without immediate access to diagnostics. I refer to the risks this creates for GPs and patients. This is why Sláintecare is fundamental. The way we have organised our health service is like we are playing a game of football and, first, we have not even marked out the pitch. Then, every single player on the page is reporting to somebody different. They are not reporting to the manager. They do not even know who that is. To continue the analogy, we then expect them to go out and play. By the way, as well, we should have 15 players on the pitch, but we only have ten and we expect them to play a game. When we understand, therefore, just how impossible this is, this fact must be the drive for saying this current situation is utterly unsustainable and must change.

Gino Kenny (Dublin Mid West, People Before Profit Alliance)
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I hate using the "D" word but it sounds like, and the picture painted by Mr. Kearns suggests, there is absolute dysfunction at the heart of our health service in respect of how it is managed. Mr. Kearns drew the parallel with football.

Mr. Leo Kearns:

The problem is not so much with how it is managed, but just with the way the system has been set up. That has led to this. I have huge sympathy for people trying to do their best to manage in this context. Let us again imagine a football manager on the side of the pitch, doing his or her best to put some shape on things. Meanwhile, everybody is reporting in a different way.

Gino Kenny (Dublin Mid West, People Before Profit Alliance)
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Regarding the RHAs, does Mr. Kearns believe that if they were constituted right now, this kind of dysfunction and these issues would be addressed? I refer to the parallel drawn with the situation on a football pitch.

Mr. Leo Kearns:

The RHAs will have to address this situation. I refer to bringing things local. Ultimately, joined-up care only means something if it happens to individual patients. It must be done at the system level. At the end of the day, however, when people go to their GP, there must be a connection between that visit, the diagnostics, the hospital and the community and so on. This does not happen unless it is planned for it to happen. The only people who can plan for this particular thing to happen are the people who are doing it.

The RHAs in themselves do not solve it but create the means and approach that will. That is why we need to get on the path now. At the HSE centre, the staff just cannot spend time on what they should be spending time on, namely the strategic framework, the overall programmatic approach and accountability. They are sucked down. Everybody is operating two or three layers below where he or she should be, meaning we can be critical, but it is impossible for the staff. It has also had an impact on the Department in the past and, therefore, we have to be-----

Gino Kenny (Dublin Mid West, People Before Profit Alliance)
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It sounds like it will take considerable time to correct.

Mr. Leo Kearns:

I would love to be able to say it will be done tomorrow. We have been building this for the past 20 years nearly and it will take time. If people genuinely feel something significant and serious is going to happen, they should note there is considerable support from front-line staff, hospital managers and so on. Some of it will be difficult enough but there is considerable support and, therefore, there will be a lot of acceleration.

Gino Kenny (Dublin Mid West, People Before Profit Alliance)
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Where will the six RHAs be placed geographically?

Mr. Leo Kearns:

Does the Deputy mean the boundaries?

Gino Kenny (Dublin Mid West, People Before Profit Alliance)
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Yes.

Mr. Leo Kearns:

There is a map available.

Gino Kenny (Dublin Mid West, People Before Profit Alliance)
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When I was growing up, the Eastern Health Board was the model of healthcare. It has evolved since. Some are quite nostalgic about the health boards. How different would such a model be from the one Mr. Kearns referred to in his statement?

Mr. Leo Kearns:

The fundamental difference is that while the health boards had autonomy, it led to considerable variability in the quality of care and outcomes. It depended on where people lived and their health board, and also on political issues. It is critical to have national standards. The HSE centre has a critical role in this regard. We have to say that we will not have multiple ways of delivering cancer care but a national model that deals with prevention and treatment and can decide certain facilities are just not fit for delivering certain types of care. While we are saying local ownership and joined-up care are critical, we believe one must work within national standards.

The other point is that there has to be strong accountability so that if an RHA is responsible and makes the decisions it needs to make, it has to be held to account for that.

Colm Burke (Cork North Central, Fine Gael)
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I thank Mr. Kearns for the presentation. I refer to the issue of structure. Am I correct that capital projects will still have to be signed off at central level? What will be the view on that?

Mr. Leo Kearns:

All I can give is the view of the advisory group, and we are just providing advice. Our view is that while national frameworks around capital expenditure are needed, the decisions on capital should sit with the RHAs, provided they are working within the national frameworks. There may be national capital projects and capital expenditure, so there will be a mix of national and local. If the RHA CEO needs to spend €20,000 on something, he or she needs to have the authority to do so without having to go through some other decision-making process.

Colm Burke (Cork North Central, Fine Gael)
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The big problem in the southern region is that it has been slow in getting funding for any project. As a result, people must travel to Dublin to gain access to many services. In Dublin, there are many more independent hospitals. They have been able to get access to funding whereas we have not had the same opportunities in Cork. A simple example is that while planning permission has been secured for a new paediatric unit in Cork, we are now being told it will be another four to five years before funding is even considered. To what extent will each RHA have independence in prioritising capital projects? What funding will they be provided with for such projects?

Mr. Leo Kearns:

This is where some of the detail needs to be worked out. There will always be a capital envelope, so there has to be prioritisation. However, in the annual or multi-annual service planning and capital planning, one would like to see a much stronger role for the RHAs in determining the plan and setting out the priorities. Generally, we will be constrained in respect of healthcare resources and priorities will have to be set. RHAs will have to put forward their cases. Within that, however, they should be able to make decisions.

Colm Burke (Cork North Central, Fine Gael)
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That is what is in place at the moment. The South/Southwest Hospital Group has put forward its proposals on the new elective hospital, paediatric unit and ophthalmology unit, but we still find getting funding involves an extremely slow process.

Is Mr. Kearns saying there will be a separate finance structure for each of the RHAs? Salaries are all paid from a centralised service at the moment. Will that change? Will six groups pay out salaries?

Mr. Leo Kearns:

I mentioned shared services earlier. There will definitely still be shared services. There is no value in creating six payroll-type services, as long as shared services do not become a block. There is nothing wrong with a shared service; it can be quite positive. I would expect an RHA to have financial capability, however. Since the organisations are significant, it is unthinkable that they would not have a strong finance function. They have to do all their financial management strategising and align their strategy with the clinical services. However, I imagine that a service such as payroll is certainly one that could be shared.

Colm Burke (Cork North Central, Fine Gael)
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Let me deal with management. Since December 2014, the HSE’s number of whole-time equivalents has increased from 103,000 to 135,000 or 136,000, which means 150,000 or 160,000 people overall. There has been a huge increase in the number of administrative staff across the board. Does Mr. Kearns feel we will end up with another round of administrative staff increases? How do we deal with that? I accept that there must be administrative staff because the services could not be provided without them. While many are quite negative about our health service, we should remember that there are more than 3.5 million outpatient appointments every year. Someone has to administer these and follow up. A total of 65,000 or 66,000 attend an outpatient clinic per week. This is a huge number. Will there be duplication of the administrative role?

My colleague raised the issue of funding. Approximately 2,500 organisations get funding from the HSE, which adds up to €5.6 billion per annum. How are they all incorporated into six different structures? In Cork, Cope Foundation, which gets funding from the HSE, provides residential care for well over 1,000 people and also provides considerable support.

That necessary service is not necessarily provided in other areas by a voluntary organisation and may be provided by the HSE. How can we ensure the same level of service in each area?

Mr. Leo Kearns:

The Deputy is right. An enormous amount of activity goes on every day of the week and great credit is due to the health service. At the same time, there are very significant emergency department waiting times and overall waiting lists. There is a systemic issue here. It is not a question of putting more people into this; we need to change how things are being done. We could add more people in and not necessarily-----

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

Mr. Leo Kearns:

The Deputy also mentioned the deployment of staff. The centre should reduce in size.

Colm Burke (Cork North Central, Fine Gael)
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We thought that would happen with the HSE when we created one structure and moved away from the health board structure. In fact, the number of people in administration grew substantially meaning that we had the opposite result. Will we have the same thing here when we go back to six different structures?

Mr. Leo Kearns:

This is why there must be a workforce strategy on the implementation of the RHAs. It cannot be divorced from it. It was definitely possible and it was predicted that the centre would grow in the way that it has because of how it was set up. The workforce strategy going with this is really important and we need to see what that is.

The Deputy also mentioned the staff in section 38 and section 39 organisations. It is a valid point that we need to stop thinking about the health service as an organisation and think about it as a system. Those staff are critical to multiple care pathways. We need to have agreements with those organisations. There might be a national organisation with local service delivery. Therefore, there could be SLAs with the national organisation but at a local level they need to have flexible and agile relationships with those service delivery entities because they are all part of the care pathway. Part of our advice is that we need to rethink how the SLAs are designed in terms of the RHAs to get-----

Colm Burke (Cork North Central, Fine Gael)
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When the health service needed to deal with Covid, it provided services very well. We need to do what Mr. Kearns is saying and bring everyone with us because that is exactly what happened with Covid. Management, medical people, nursing staff, care assistants and everybody else worked extremely hard to deliver. We can deliver a very efficient service, but we need to ensure the leadership is provided. I am not clear on this one whether we can bring about the change and, at the same time, convince the people who are working on the front line that it is a team effort to deliver a better healthcare service.

Mr. Leo Kearns:

The Deputy is absolutely right. Covid was an example of everybody being focused with a shared purpose. That went way beyond the call of duty and great credit is due to them. Difficult and challenging as it was, that was one issue. What we are talking about here is much more complex. The Deputy is absolutely right when he talks about leadership. When making big change like this, it comes down to leadership. Leadership is essentially to what degree do people at the front line and at every level within the HSE and the Department believe in leadership and the direction in which we are moving. That is a challenge. We definitely need to see leadership within the RHAs and we need leadership in the centre and in the Department. Having that leadership is what makes the change happen. People start to believe that this will happen and it is the right way to go.

Bernard Durkan (Kildare North, Fine Gael)
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Mr. Kearns worries me with some of the things that he says because they are true. Time is something that comes in to focus. The problem is that there is not time. For instance, emergencies occur all the time. I want to bring in the rest of the speakers on my list as quickly as possible. We need to implement the proposed changes as if they were part of the system already. In other words, we need to use a template that incorporates on the one hand Sláintecare. The bits that have to be kept that fit into that fit into it. However, they can fit into it now. It is like making a jigsaw. The pieces fit into place and it is not necessary to wait until everything is ready. They can be fitted into place one at a time or whenever.

Having listened to the points made by the members and by Mr. Kearns, I am worried that there appears to be a certain amount of vagueness about who tells whom what happens next and from whom it should come. The HSE and the Department have responsibilities, but there needs to be a co-ordinated approach because if we do not have that co-ordinated approach, we will be talking about a five-year plan, a ten-year plan or a 20-year plan, which we cannot afford. That would be time wasted.

Frances Black (Independent)
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I thank Mr. Kearns for the work he is doing. I agree with his opening statement which is a breath of fresh air. It is vital that significant time and resourcing are given for the RHAs to be successfully implemented. I ask Mr. Kearns to forgive me if these questions have been asked; I arrived late to the meeting.

We all know the extreme pressure that was placed on healthcare workers during the pandemic. In his opening statement, Mr. Kearns pointed out that many healthcare workers do not feel valued and cared for. Obviously understaffing will ultimately risk the successful implementation of RHAs. What would Mr. Kearns's advice to the Department be to achieve a fully staffed workforce to deliver integrated health and social care services?

Mr. Leo Kearns:

The Senator certainly does not ask easy questions. She is correct that we need to give it time to implement. However, the Vice Chairman mentioned the urgency and this is why we mentioned the critical path. We need to see a critical path plan with key milestones. The issue of workforce is probably the one that we should be most concerned about. We are in a very difficult position. Covid has exacerbated it but the problems existed prior to that. I believe the RHAs will make a big difference. Generally speaking, people feel that at a local level and with their team there is considerable support and that people are working well together.

We are under enormous pressure to recruit and retain staff across the board. We are in a global market. There is a shortage of healthcare workers worldwide. This is one of the big issues for every healthcare service in the world. In the past, we have not taken a really strategic joined-up approach to this; we have been doing it in a very fragmented way.

The advice the group has given on this is that it is very important that, in parallel with the implementation of the RHAs, there needs to be a cross-system, multilayered workforce strategy that deals with this in a number of different ways. At one level it would deal with the issues in a way that would give people the impression that they are valued. The likes of junior doctors, for instance, may have difficulties or working time directive issues, roster issues, issues with emergency tax and so on. There are a lot of what I would call on-the-ground hygiene factors which are really important to the people there. Those issues have to be addressed. The Minister has established a working group, a task force, with relevant people from right across the health service, including non-consultant hospital doctors, NCHDs, to try to address some of those issues in respect of doctors.

There is also the overall planning and the numbers. How many do we need and where do we need them? How many are we bringing through university, nursing schools and recruitment? There is the matter of training places and the number of clinical placements. There is a whole piece of work that needs to be done on planning. There is a very significant project being led by the Department of Health in that regard.

There are also areas like the configuration of services. Can we project forward? If we are to move services into the community, what does that mean for our staffing, and are we training enough people for that? Our challenge is that we are so far off where we should be that it will take time to get us to where we need to be. The thing not to underestimate is the degree to which people who work in healthcare love working in healthcare and do so because they have a vocation. That includes people in the Department. It is not just people on the front line. Generally speaking, people who are interested in healthcare and who want to work in it at policy level or on the front line do so because they really care about it. I think, therefore, that they are absolutely open to responding. They will respond to well thought through, proper strategies that are joined up in order that we do not have one hand working against the other. Unfortunately, this will not be turned around overnight. If, however, there is a sense among staff that this is being taken incredibly seriously and there is a real effort to address it at all those levels, I think we can make progress.

Frances Black (Independent)
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I totally agree with Mr. Kearns. For a great many people who work in this area, it is a vocation and they are passionate about what they do. Does Mr. Kearns think that this should be the first step? It is a huge piece of work, which he has just explained very clearly. Does he think that it should be a priority? What is the first step? I can only imagine what it must be like for people in the Department hearing about these huge changes. I imagine it is quite overwhelming to look at how we will manage all this. If Mr. Kearns were to break it down step by step, what would be the first step? That is what I am trying to ask him.

Mr. Leo Kearns:

Is that in respect of just the workforce or overall?

Frances Black (Independent)
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Everything.

Mr. Leo Kearns:

There are maybe three major areas. I will outline them broadly. One of the first things we have to do is be clear about and say what the roles of the HSE, the RHAs and the Department will be. We have to develop the organisational model for the RHAs in order to address some of the issues about being really clear about this which Deputy Cullinane brought up earlier. We have to appoint the leadership teams in the RHAs. If there are no leadership teams within the RHAs, they effectively do not exist, so let us do that really quickly. Now there is an entity that can start developing that.

We also need to design models as to how workforce, IT, finance, estates and so on will be dealt with in the context of the RHAs. Those are the practical things that will give clarity to people such that they will be able to see how this can begin to work. The overall clinical programmes are critical because, ultimately, these are services we are providing. How do we enhance the national clinical programmes we have at the moment and the integrated programmes and make them more effective and more connected to the front line?

Then we have to admit that this will not happen on a wing and a prayer. There has to be significant engagement with all the people I have mentioned. As I said, there are multiple organisations involved. There has been some engagement, but there needs to be a way in which all those organisations can contribute and design this new service.

Then we have to invest in the support for the implementation. One of the challenges we have is that the people leading on this are also dealing with all the crises we have. That is a difficulty. It is incredibly challenging for them and they need support.

It is just a matter of getting right some of the basics such as putting the right leadership in place, the right support for the implementation and, then, being really clear about what we are implementing.

Frances Black (Independent)
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Mr. Kearns is right. There are so many crises going on that it can be a bit difficult for people even to look at this. Have I time for one more question, Vice Chair?

Bernard Durkan (Kildare North, Fine Gael)
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A quick one.

Frances Black (Independent)
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It is about mental health. Given that more than 40% of Irish adults have a mental health disorder, there is no doubt but that demand for adequate mental health services is to be predicted for each RHA. The population-based approach seems absolutely rational, but is the advisory group giving any thought to a demographic-based approach? Some parts of Dublin, for example, straddle three different RHAs, and there is a correlation between the disadvantaged parts of Dublin and poorer mental health. The needs in different parts of each RHA will vary, given that correlation and the fact that some parts of Dublin straddle three different RHAs. Does that make sense to Mr. Kearns?

Mr. Leo Kearns:

Yes, absolutely. The Senator is 100% right. That is what population base should be addressing. The way in which one might address something like chronic disease in the Inishowen peninsula will be different from how one might address it in north Dublin because those two areas have different demographics, different populations and so on. That is exactly why we must have this kind of approach.

Bernard Durkan (Kildare North, Fine Gael)
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I remind members that I intend to finish as soon as possible. I do not believe in dragging things on just for the sake of dragging them on. We have a couple of other speakers left. We are waiting for Deputy Cathal Crowe, Senator Hoey and Deputy Hourigan. In the meantime, I call Deputy Cullinane. Are you up for speaking, Deputy Cullinane, in the short time available to you?

David Cullinane (Waterford, Sinn Fein)
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I wish to come back in on a couple of issues. It was impossible to get everything in in one round. I thank Mr. Kearns for his responses to the first set of questions. If I may focus on capital planning, there is a review of the public spending code or a review of capital from the perspective of the Department of Public Expenditure and Reform ongoing, I think. There is a need for reform in that area. Will Mr. Kearns give me his insight into how he sees the HSE estates working in a devolved situation? Is he a believer in and a supporter of multi-annual funding for health? When I talk to senior officials in the Department of Health, they say that having maybe a three-year cycle of multi-annual funding for both current and capital would be really helpful and would allow the healthcare system to plan more effectively. We have a similar debate in housing, where we have a four-stage process whereby plans have to be presented over and over again, working through multiple layers of accountability. One might say that that is necessary at one level, but it is too much at another level in that things do not get done. Will Mr. Kearns give me his insight into the types of changes he is advocating? This is an important area.

My view of the regional health areas is, as Deputy Shortall mentioned, that we now need to see a bias towards primary care and, especially, community care.

Once we give the RHAs a budget, I hope there will be a single tier of management that will manage the entire budget and, to use an expression, the head-butting of what is needed should be done within the RHAs within an envelope of money over a number of years. The RHAs will then have to prioritise where the spending should be. Rather than submitting endless business cases, which hospitals do - I do not know how many of those cases go to the Department but never see the light of day - and all the time spent on that, we should start to get them to focus on what is needed and to prioritise where the spend should be in order to get the best bang for our buck for patients. Mr. Kearns will appreciate the point I am making. I ask for his insight into how he sees that developing.

Mr. Leo Kearns:

What the Deputy has described is exactly how it should be. In fairness to the HSE centre that is getting multiple business cases, how is it to know what should be prioritised? We have created this scenario whereby everything funnels up to the top. Not only does it disempower the local but it swamps the top, which means people cannot focus on the things they need to. The people who are closest to the service should be prioritising and asking where should they best use their resources. It is difficult to know until we get into that, but our demand and capacity, particularly around acute and emergency services, have been so out of kilter that it will take time to understand those flows and get them properly set up. I could not agree more with what the Deputy said.

Multi-annual budgets would clearly be very beneficial. In a system as complex as healthcare, to operate on the basis of an annual budget is very challenging. I know that is challenging from a governmental perspective but it is something that has to be-----

David Cullinane (Waterford, Sinn Fein)
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I will put it to Mr. Kearns that we fell into that by accident in budget 2021 when, he might recall, there was an announcement of 1,147 additional acute inpatient beds. In the last year's budget and the budget for the year before that, there were big numbers for additional staff, most of which were not realised. It was never going to be done in one year-----

Mr. Leo Kearns:

Never.

David Cullinane (Waterford, Sinn Fein)
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-----but it ended up having to be carried over a number of years. That was, in essence, a form of multi-annual budgeting. It was not designed to be that; it was by accident. Multi-annual budgeting makes sense.

Mr. Leo Kearns:

Definitely.

David Cullinane (Waterford, Sinn Fein)
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I will ask Mr. Kearns about another issue, that of IT infrastructure, which, as he mentioned, is also important. We understand that the health information Bill will come before the committee in a few weeks. That is very important. I am a great believer in individual health identifiers and centralised referral systems. That now needs to be managed regionally, when we have the RHAs in place, to make best use of the capacity we have across the system. I am a great believer in all of that as well.

There is an ongoing debate about what we do with the overall system change. Do we go for a single integrated system or do we have interoperability between the different systems, which would cost less money and may be quicker to do? I probably lean towards the latter, but I am trying to get a sense of how Mr. Kearns sees that working. What is his view? How important is it? Where does his priority lie in that space?

Mr. Leo Kearns:

A lot of work relating to IT is going on. It is not something the advisory group specifically discussed but, first, the information Bill is incredibly important. That will be highly advantageous. Second, on the single integrated system, while in theory it sounds great that we would have a single integrated system across the country, in practice, that is incredibly difficult. IT-----

David Cullinane (Waterford, Sinn Fein)
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Is Mr. Kearns saying it will become a single point of failure? Is that the danger?

Mr. Leo Kearns:

It becomes a single point of failure, but some of those issues can probably be addressed by modern ways of doing things. That may not be as big an issue. The bigger issue is the multiplicity of systems we currently have. There are thousands of systems. There are also GP systems that are outside those. If we put all our focus into a single integrated system, which the UK tried to do, that may not be the best bang for our buck in the medium term.

David Cullinane (Waterford, Sinn Fein)
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Interoperability would be-----

Mr. Leo Kearns:

It is interoperability. That is supported by the health information Bill and so on. Interoperability would probably be quicker. For instance, the national integrated medical imaging system is a great example of having quite a specialised system for radiology and imaging that multiple parties use. That is a very good example of where we have speciality-----

David Cullinane (Waterford, Sinn Fein)
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I have two more questions. I will make one overall point on the RHAs. The expression "levelling up" is much misused at present but having RHAs and giving them autonomy could have that levelling up-----

Mr. Leo Kearns:

Impact.

David Cullinane (Waterford, Sinn Fein)
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-----impact in making sure that those regional disparities that exist are dealt with. We know about the problems in the mid-west, for example, and so on. That will be a big part of how successful or not these RHAs are.

How does Mr. Kearns see the role of the National Treatment Purchase Fund, NTPF? How will it interact with RHAs? There is a view, and it is one I share, that there needs to be much more transparency about NTPF waiting lists. At present, those lists do not cover community and diagnostic waiting lists. We also need a much sharper validation process for the waiting lists. I accept all of that. The functions of the NTPF could be changed, however, to allow it be a commissioner of services. In fact, it might be the body that could oversee a national, integrated hospital waiting list management system. That may not be the case. However, a system like that needs to be put in place. Has Mr. Kearns given any consideration to how he sees the NTPF working in a reformed HSE?

Mr. Leo Kearns:

We have not. It is probably a matter in respect of which I would not be able to give a significant view. In a way, our role is not to design, it is to set out the-----

David Cullinane (Waterford, Sinn Fein)
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Advice.

Mr. Leo Kearns:

-----advice on it. There are services that would benefit from having visibility at a national level. Even when we look at any kind of demand-capacity flow, there will always be situations where we have the capacity but may not have the demand, and where we have the demand we do not have the capacity. Being able to manage that across regions, and then at a national level to have a way of seeing that nationally, could be very positive but I would have to come back to the Deputy on more-----

David Cullinane (Waterford, Sinn Fein)
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I will make a final point. Mr. Kearns made the same point in his opening statement and in a private session we had with him and others in the HSE and the Department on RHAs. I mentioned workforce planning as being critical to success. That will be the single biggest challenge in healthcare over the next number of years. We need to be much more ambitious in setting targets for training but also dealing with a whole myriad of recruitment and retention issues. What advice on workforce planning has Mr. Kearns given to the Government?

Mr. Leo Kearns:

We mentioned that earlier. I completely agree that this is probably the biggest issue we have because if we do not have people, we do not have a healthcare system, regardless of what else we have. We have a serious crisis. In the advice we gave, we said there needs to be a multilayered, cross-system and pretty fundamental workforce strategy that deals with all those issues in a joined-up way. We know we have issues at ground level. These are basic things that are not happening, such as people not getting their rosters or emergency tax issues and so on. We have a lack of clarity around career planning and training, and a connection between education and health that is aligned to the configuration of services. Where are we going with our services? What is that telling us about the numbers? Do we then translate that into actuality? The Department and the HSE have definitely taken on board how critical and profound an issue this is. It is going to-----

David Cullinane (Waterford, Sinn Fein)
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I will make one final point. I will be so bold as to ask Mr. Kearns whether he has applied for the job of head of the HSE.

Mr. Leo Kearns:

I was not expecting that question.

Bernard Durkan (Kildare North, Fine Gael)
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We will conclude shortly. I will mention one or two points that came up. We hear what Mr. Kearns is saying regarding time.

Time is not on our side. It is time to put the template into operation and fit the pieces on the board into place. Football terms were used in relation to it a few moments ago, but I would use road traffic. One often comes across a sign which says "Traffic Merging". The two lanes of traffic are supposed to converge without causing disruption or crashes. That is how it is designed. It is particularly applicable to the health services now that those on the main thoroughfare andin situ recognise the changes taking place. It has to be dealt with.

There are two areas we need to talk about urgently. There is CAMHS, which is seriously undernourished at present. There needs to be a serious evaluation of where it is going and what it is doing. It has been ushered out into a side lane that we have not spotted yet. It is not working the way it should or to the advantage of patients, children, anybody or itself, which is sad.

The other area concerns emergencies. The definition of an emergency is an emergency. If an emergency cannot be handled, from whatever side it comes or however it appears, at an early date, then it ceases to be an emergency and falls into a backlog. To go back to traffic, the further one goes back down the line of a backlog, the more frustrating it gets. Regarding emergency medical cards, there is a classic situation where patients receiving radium treatment who have other life-threatening illnesses want medical cards on an emergency basis. The hospital sends in the application and it is looked at by another medical expert, who deems it ineligible. They cannot get the medical card. The unfortunate patient is looking for reassurance. They do not want to hang on to it forever. Only one person in the family may need it but it is hugely reassuring for them to be able to say they are covered in that area and do not have to worry about it. They have enough worries already. I refer to emergency medical cards and reimbursement. The sad part is if you or I ring the people concerned who are busy working at whatever the are working at, we will not get a reply.

There is a sadder situation emerging. There is a strict regime where parliamentary questions are concerned. It used to be a sacking offence if an honest reply was not received to a parliamentary question. That seems to have gone by the board. In the Department of Health, it used to be that the answer to a parliamentary question should be received in ten working days, which is fine. We would accept that. Now it is as soon as possible, which means never. It is code for never. It is an affront to Members of Parliament to get such an offhand answer. If you pursue it by way of wishing to speak to somebody, you go around in circles.

If that happens to people used to dealing with administration systems across all Departments, how will the poor, unfortunate people waiting for reimbursement, an emergency medical card or CAMHS feel? How will they think about the system? They think about it based on how it affects them, and it is not helpful. It is bad for the morale of the system and of the patient and it adds to the suffering of the patient. There is no need for it. All that is required is that the person in that position enlists support if they cannot deal with the backlog or overhang. Let us do it. We cannot afford this situation whereby we need to apply to get on a waiting list. I have often said we are the nation of waiting lists. Everything has to be on a waiting list. It does not have to be so. Once the issue is dealt with, it is no longer on a waiting list and no longer somebody's problem. It is solved insofar as we can manage.

We have exhausted our supply of members. Does anyone else wish to comment quickly? No. I thank Mr. Kearns for his time, frankness, obvious knowledge of the system and accuracy of reply. We look forward to a dramatic result from the briefing today. I have no doubt Mr. Kearns will go back to wherever he directs his thoughts and explain to all and sundry that they are on to it. Thank you very much.

Mr. Leo Kearns:

Thank you Chair.