Oireachtas Joint and Select Committees
Wednesday, 16 November 2022
Joint Oireachtas Committee on Health
HSE Winter Plan 2022-2023: HSE
Seán Crowe (Dublin South West, Sinn Fein)
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The purpose of this meeting is to consider the HSE's winter plan for 2022-2023. To enable the committee to consider this matter further, I am pleased to welcome from the Health Service Executive Mr. Stephen Mulvany, chief executive officer; Mr. Damien McCallion, chief operations officer; Dr. Mike O'Connor, national clinical adviser, acute operations; Ms Mary Day, national director, acute operations; and Ms Yvonne O'Neill, national director, community operations.
Those present in the committee room are asked to exercise personal responsibility to protect themselves and others from the risk of contracting Covid-19.
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 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 also 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 also 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 campus.
I invite Mr. Mulvany to make his opening remarks.
Mr. Stephen Mulvany:
I thank the Chairman and members of the committee for the invitation to attend today's meeting. I am joined by my colleagues, Mr. Damien McCallion, chief operations officer; Ms Mary Day, national Director, acute operations; Ms Yvonne O’Neill, national director, community operations; and Dr. Mike O Connor, national clinical lead, acute operations.
Significant investment has been received for the winter plans and national service plans, NSPs, over the past three years. This investment has enabled the Health Service Executive to respond to the immediate demands of the Covid-19 pandemic, and to enhance health and social care services.
The winter plan for 2022-2023 includes national and local initiatives which have been developed in an integrated manner to target hospital admission avoidance, facilitate patient flow through hospitals and discharge back to home and community. The plan details leadership, governance and accountability structures at both national and local levels which are providing monitoring and reporting to support effective timely implementation over the winter period. The plan aims to prepare services and mitigate the additional risks posed by winter pressures.
There are a number of key challenges contributing to increased pressures at an earlier point in the winter period which is resulting in a high level of unscheduled care activity with a significant sustained increase particularly in attendances and admissions for those patients aged over 75 years.
There are particular demands for our primary and community care services in responding to and supporting the health needs of those seeking international protection. These increasing demands are compounded by a shortage of healthcare workers both nationally and internationally to address and deliver the staffing capacity required for core and new service developments. Issues are being faced in maintaining and opening additional bed capacity related to infection prevention and control requirements, recruitment and staff retention challenges.
While currently Covid-19 hospitalised cases are stable at 317 patients, including 11 patients in intensive care units, ICUs, there remains the potential for a high incidence of seasonal illnesses this winter. The numbers of Covid-19 patients still present a significant demand on acute hospitals in terms of bed capacity and increased length of stay.
The Health Protection and Surveillance Centre, HPSC, has advised of increasing notifications and hospitalisations of influenza and respiratory syncytial virus, RSV, cases at an earlier point in the winter period than previous pre-pandemic winters. The incidence rates of such seasonal illness are likely to increase with the colder weather during the winter period. The HSE anticipates these seasonal illnesses, Covid-19, influenza and RSV, coupled with other challenges, will result in high pressures in the demand and delivery of health and social services this winter.
In the week ending 5 November, there were 117 influenza cases and 439 RSV cases notified. As of 6 November 2022, 1.2 million patients have attended our emergency departments, EDs, in the year to date. This equates to an additional 77,000 patients, which is an increase of approximately 7% compared with the same period in 2019. For patients older than 75 years, the total number of ED attendances for the year to date is almost 161,000. This represents an increase of approximately 14% on the same period in 2019. ED admissions have also increased, with approximately 305,000 patients admitted from our emergency departments in the year to date. This represents an increase of slightly more than 3% compared with the same period in 2019. However, for patients aged over 75 years, ED admissions in the year to date are 10% higher than the same period in 2019.
In line with previous years and in response to these demands, the Winter Plan 2022-23 national initiatives have focused on delivering additional capacity, improving pathways of care and rolling out the vaccination programme for flu and Covid-19. Funding has been allocated for the delivery of additional capacity in both acute and community services. Within our emergency departments, staffing capacity is being increased through the recruitment of additional nursing staff in line with phase 2 of the safe staffing and skill mix framework. All hospital sites and associated community healthcare organisations will implement an integrated process for patients with a hospital stay of more than 14 days to improve integrated communication, patient flow and discharge to home or community. Alternative patient pathways are being implemented during the winter period to support admission avoidance, patient flow and discharge. Examples include €6.8 million allocated to the National Ambulance Service for winter initiatives, including deploying rapid handover teams; funding of €500,000 to provide 1,340 nights of palliative care nursing; €16 million allocated for transitional care beds to support the discharge of patients from acute hospitals; €4 million allocated to the provision of short-stay respite services, providing important supports for both patients and their caregivers; €4 million allocated to complex care packages to facilitate discharge and maintain patients with highly complex care needs at home; €5.1 million to provide 18 residential packages to people with a disability; €3 million allocated to mental health placements to assist discharge from acute hospitals; €4.5 million allocated to provide aids and appliances; €10 million allocated to GP supports, including GP access to diagnostics and out-of-hours supports, which are ongoing; €2 million for the expansion of community intervention teams, with a particular focus on the mid-west and north west; and enhanced community care pathways and supports to target those at risk of hospital admission this year including the provision of ring-fenced community bed capacity and home supports for older people.
In addition to the outlined national initiatives, since April 2022, individual integrated bespoke winter plans were developed for acute hospital sites and associated community healthcare organisations. A total of 447 whole-time equivalent posts and funding of more than €54.8 million is associated with these local plans. In total, a funding requirement of more than €169 million has been approved to implement these measures in 2022-2023, including the recruitment of 608 whole-time equivalent posts across a range of services.
The chief operations officer is responsible for the Winter Plan 2022-23. A performance unit monitors and reports on an agreed suite of targeted key performance indicators, KPIs, and winter plan implementation. To ensure oversight at a local level, each area has local integrated implementation teams that are jointly chaired by hospital groups’ chief executive officers and community healthcare organisations’ chief officers.
I acknowledge and thank all healthcare staff for all their efforts during the past two and a half years as we have combated both Covid-19 and the cyberattack. I include in that acknowledgement our private hospital and private nursing home colleagues, our primary care colleagues, including GPs and pharmacists, and, importantly, our section 39 and section 38 voluntary partners.
Seán Crowe (Dublin South West, Sinn Fein)
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Before I open up to questions, it would be remiss of me not to wish committee member, Deputy Lahart, well and a speedy recovery from his recent health challenge. I will move straight into questions and invite Deputy Burke to begin.
Colm Burke (Cork North Central, Fine Gael)
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I thank all the witnesses for coming before the committee and for setting out a comprehensive plan to deal with challenges facing all our hospitals in the coming months. There are problems which, if they were resolved, it would deal with some of the issues arising in hospitals. For instance, I have come across hospitals where consultants cannot hold clinics because nursing staff are not available. Consultants are prepared to hold the clinics, even if nurses are not available but care assistants are available to assist at those clinics.
I received a reply to a parliamentary question about the number of consultants looking for category C contracts. A category C contract means a consultant can work outside the HSE hospital in a private hospital. One of the reasons consultants tell me they are applying for category C contracts is that they cannot get access to theatres in HSE hospitals.
My third question relates to the number of hospitals where there is a challenge in theatres. In some hospitals, no patient is allowed to enter theatre after 4 p.m. I fully understand that some staff want to leave at 5 o'clock because they have children to collect etc., but surely the hospital can restructure so that staff start at 8 a.m. and finish at 5 p.m. and perhaps other staff start at 12 noon and finish at 8 p.m. in order that theatres could continue.
They are three issues that arise that could help to deal with the challenges in hospitals. I was speaking to one consultant who only has a half day per week in theatre and tries to do three operations in the afternoon. Many weeks, one of the three operations is cancelled because the staff are unable to get the patient into theatre by 4 p.m. That means the person waiting for the operation is occupying a bed, the operation does not go ahead, and the person has to be discharged and come back on another date to go through the whole procedure again. What are we doing to deal with the existing logjams?
Colm Burke (Cork North Central, Fine Gael)
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Will Mr. Mulvany make enquiries about that issue? I am told there is resistance to allowing the clinics to be held because nurses are not available.
Mr. Stephen Mulvany:
Absolutely. If the Deputy shares details of the particular hospital or consultant who raised that with him, we will be happy to check it out. My colleagues can also comment on it in a moment.
On category C consultant contracts, as the Deputy will be aware, the policy is to move towards a public-only contract and we would much prefer to work with our consultant colleagues and others to get them access to theatre than lose their skills to the private sector. We do not see that as a solution.
Colm Burke (Cork North Central, Fine Gael)
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Does Mr. Mulvany accept that someone having only a half day per week in an operating theatre is not adequate from a consultant's point of view? Consultants now have no choices because they cannot get access to a theatre any other day of the week.
Colm Burke (Cork North Central, Fine Gael)
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I accept that, but they have no choice in this.
Colm Burke (Cork North Central, Fine Gael)
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Consultants do not have a choice if they cannot get access to a theatre.
Mr. Stephen Mulvany:
As I said, it depends on individual sites but I am not so sure that kind of a wide-scale application of category C contracts is the solution to those problems. Again, my colleagues may want to comment.
Regarding the theatre closing at 4 p.m., that comes down to the complexity of the operation and the individual patient. There are certainly many operations that can and do take place after 4 p.m. We accept the general principle of flexibility around that where it is appropriate.
Colm Burke (Cork North Central, Fine Gael)
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Can we have discussions with hospitals where this problem arises to find a solution?
Ms Mary Day:
On the theatres, without knowing the individual cases, I can say we are looking at a theatre optimisation programme and theatre productivity.
There is a programme of work that will, I hope, be commencing next year looking at theatre sessions and a whole programme of process and improvement around that. It will look at the whole theatre optimisation programme. That, I hope, should look at addressing access to theatre.
Colm Burke (Cork North Central, Fine Gael)
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Looking at is one thing; we have a problem where theatres are not taking people after 4 p.m. Operations are being cancelled, people are occupying beds and then being discharged and brought back in another day. It is taking up huge administration time and everyone's time. We should look at this immediately and not be trying to devise a plan that comes into place in March next year. We are facing into a crisis. This is a scenario that is happening in hospitals across the country. Now is the time to deal with this challenge.
Ms Mary Day:
The South/Southwest Hospital Group has done a pilot programme on theatre optimisation and has looked at this particular issue. The learning from that will be implemented and shared across the hospital system. The other area is the extended working day. Without commenting on the actual hospital - having details of the hospital would be helpful - we are also looking at an extended working day, with nurses and anaesthetists working later into the evening to facilitate surgery later into the evening.
Colm Burke (Cork North Central, Fine Gael)
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I am not looking for people's eight-hour day to be extended to 12 hours. If you are in theatre, it is a demanding job. Errors can arise in a long day if people are working for too long. Surely we can restructure the time people start and finish. That may suit some people.
Colm Burke (Cork North Central, Fine Gael)
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Can this issue be prioritised, as regards throughput through the hospitals, rather than cancellations occurring?
Colm Burke (Cork North Central, Fine Gael)
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Can we get a report back on what progress is made on that issue?
Colm Burke (Cork North Central, Fine Gael)
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I was recently speaking to a nurse who moved to London and the big change she saw working in London was that, no matter what day she worked in a hospital, there was a set ratio of senior nurses to junior nurses. She had worked in a unit where there were 20 nurses. One day, there would be two senior nurses and 18 junior nurses or nurses qualified within the last two years. The next day, she would come in and there would be eight senior nurses and 12 junior nurses. The problem when there were only two senior nurses was that there was a big logjam in the system. There does not seem to be a planned approach to having the same ratio across the service from one end of the week to the next.
Colm Burke (Cork North Central, Fine Gael)
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What about for accident and emergency departments?
Colm Burke (Cork North Central, Fine Gael)
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This should be in place already. If there is a situation where there are 18 junior nurses on with two senior nurses in an accident and emergency department, in fairness to the nurses, they do not have the same expertise and therefore decision making is a slower process. This should be in place now, particularly going into the winter plan, so that there is better turnover and a faster decision-making process.
Dr. Mike O'Connor:
We need to acknowledge first and foremost the extraordinary effort of our healthcare colleagues, in particular nurses, who have been at the front line, particularly over the last few years of Covid-19. If one looks at the whole-time equivalent, WTE, in the health service, it is 135,000 WTEs. The biggest growth has been in nursing. Everything should happen now, but from a recruitment point of view, things need to come in at a pace so far as we can recruit. From the clinical perspective, the situation that Deputy Burke described would not be the norm.
Colm Burke (Cork North Central, Fine Gael)
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It is happening.
Colm Burke (Cork North Central, Fine Gael)
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It is happening.
Dr. Mike O'Connor:
It would not be the norm from the point of view of the skill mix, be it healthcare assistants or junior nurses, that is planned out over 24/7 delivery of services. I appreciate the story the Deputy may have heard, but that would be from an individual nurse; that would not be the norm.
Colm Burke (Cork North Central, Fine Gael)
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Over-75s were referred to in the opening statement. This is biggest complaint we get from families. It is not unusual for me to get a phone call from someone where their elderly parent has been in an accident and emergency department for more than 36 hours. We must have something put in place to deal with the issue of elderly people. The uncertainly of staying in an accident and emergency department for more than 12 hours is frightening from their point of view. What is going to be done about that in the coming months?
Dr. Mike O'Connor:
I could not agree more. In the last year to date, more than 16,000 people over the age of 75 have spent over 24 hours in our emergency departments. It is a specific focus of the winter plan, which our chief operations officer, just called out. It has a specific focus on these areas, particularly for those over 75 because they do not tolerate those delays; in fact, it causes illness and morbidity and prolongs their length of stay. These bespoke winter plans are for each individual site. We have asked them to particularly look at what material differences would be made by focusing on what staff they would require. Often, it is therapy staff or more medical staff who are trained for geriatric medicine. Often in these bespoke plans, it is specific areas in the emergency department that these patients will get to quicker. If they are able to go home, interlinking with community services, they will go home, or if they go up to a ward, they will go up to a ward faster. It is underpinned in the winter plan, if one reads through it. It is a key area of focus, namely, staffing, how we deal with these patients, how we operationally manage them and how we flag them up in the hospital. This must not happen. We must reduce this number.
David Cullinane (Waterford, Sinn Fein)
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I want to be associated with the Chair's offer of condolences to the family of the late Vicky Phelan. I also want to commend all of the staff working in our hospitals and in community care and primary care. It is a big challenge at the moment. From talking to those who work in healthcare, they are rising to that challenge but it is a difficult job.
There are many challenges in our healthcare system. There has been a high volume of patients attending emergency departments and there are reasons for that. The waiting times are unacceptable, as the Minister acknowledged. However, there are some good news stories and examples of hospitals that seem to be performing better than others. I raise University Hospital Waterford not because it is in my constituency, but because it is a fact. The figures for October - it has been consistent for some time - show that it has a very high volume. I think per capitait was the highest volume in the State. It had the lowest waiting times in emergency departments and was able to reduce inpatient and outpatient waiting lists. If I am right, there has not been a patient on a hospital trolley in University Hospital Waterford since the middle of 2020. University Hospital Waterford is able to perform at that level and achieve that success, yet we have the crisis in Cork, Limerick and other hospitals in Dublin and elsewhere. I think Mr. McCallion visited University Hospital Waterford recently. Will he give his sense of what is happening in Waterford that is not happening elsewhere, that could be replicated?
Mr. Damien McCallion:
I acknowledge the work of the team in University Hospital Waterford in relation to, as the Deputy said, its positive performance. There are a number of hospitals around the country which are achieving good outcomes on inpatient, day case and emergency care. We are trying to apply the learning from sites where things are working well to other sites, including factors such as local operations, patient flow and the capacity of the system, not just beds, but also community capacity in terms of beds and home care. University Hospital Waterford still has challenges but they are managed through. We have an improvement team, which Dr. O'Connor may want to speak on. The team takes the positive learning from those sites and applies it to some of the other sites that are under pressure. Different hospitals face different challenges regarding capacity, community services, staffing challenges and so on. We work with each site - that is the purpose of the local plans - to ensure it reflects what is needed in its community and for its population. One of the lessons from University Hospital Waterford is that it is a positive experience for patients. I have walked around the hospital and you can see it in what is happening there. We want to take that learning from Waterford-----
David Cullinane (Waterford, Sinn Fein)
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Of course I appreciate different hospitals have different challenges, and I will get to one of those hospitals in a second. However, we have a much better patient-focused service operating out of one hospital with very high levels of efficient pre-admission and post-admission patient flow, good management of the emergency department and good integration with community services so patients can be discharged quicker. We have the same capacity challenges in Waterford that other hospitals have. I do not want to labour the point, but if Waterford is doing something right, and there are other hospitals in Drogheda and elsewhere which have really got to grips with the trolley crisis as well, we have to make sure that those learnings are applied across all of our hospitals. It begs the question as to how effective the patient experience, the patient management and the management of other hospitals are, if we can have one hospital perform at that level while others do not. It does beg questions as to whether or not we have good practice across all of our hospitals.
Mr. Stephen Mulvany:
In fairness to the Deputy, and to support what Mr. McCallion said, I want to say that we recognise Waterford is a very good performer as are some other hospitals, particularly in the RCSI hospital group. We have called that out recently to our healthcare managers. There will be different challenges on some sites, but we accept there is no strong evidence that Waterford is particularly better advantaged compared to other hospitals. We are working to share those learnings. We are working to see why other sites cannot do the same thing.
David Cullinane (Waterford, Sinn Fein)
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I think that is important.
Mr. Stephen Mulvany:
All we can expect of sites is that they do the best they can with the resources they have. Waterford seems to be doing that. Not every site can get to the same place as Waterford perhaps, but we all need to be convinced that everything that can be done is being done to get them to do the best they can.
David Cullinane (Waterford, Sinn Fein)
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I have a lot of questions. I want to move on to waiting lists. Can Mr. Mulvany tell me how many people are on health waiting lists right across the health service at the moment? I am not just talking about acute services. I am looking for the total number of people on all health waiting lists as we sit here today.
David Cullinane (Waterford, Sinn Fein)
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That is the figure we always get. I want to make this point, because it is important. We should not have to put in parliamentary questions to get that total figure. When we are talking about a winter plan to deal with the challenges patients have, I would expect the HSE to know how many people are on waiting lists across all layers of the health service. It should be a big ticket number that is obvious. As we know, we have acute hospitals, both inpatient and outpatient. We have community waiting lists, CHOs, dietetics, audiology and all of that. We have dental waiting lists. We have mental health and child and adolescent mental health services, CAMHS. We have children's disability network teams. I think there are about 210,000 people on diagnostic waiting lists and we have home care. Yet no matter how many times I ask this question, I cannot get a figure from the HSE on how many people are on all health waiting lists.
David Cullinane (Waterford, Sinn Fein)
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As he sits here today, does Mr. Mulvany have any idea what the total figure is?
David Cullinane (Waterford, Sinn Fein)
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Before this meetings is finished, can somebody come back with the total number of people on all health waiting lists? In my view, it is approximately 1.2 million but it could be more. It is a huge figure and surely the interim head of the HSE and senior officials here should know what the total figure is. We should not have to put in parliamentary questions in all of these areas to try to piece it together, when we are asking what the total figure is and we cannot get it. Does anybody in the room know what the total figure is?
David Cullinane (Waterford, Sinn Fein)
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The total figure is never published.
Mr. Stephen Mulvany:
If I could answer the Deputy's question, the key thing is what we are trying to do about those individual waiting lists. We can talk about that, if the Deputy wishes. We are improving those waiting lists, not in line with the targets we have set. However, since the peak in Covid, a lot of those waiting lists have fallen substantially, between 40% and 80% in different cases. We are focused. We are investing and seeking to improve the process. It is not about the numbers on the waiting lists, but the time they are waiting.
David Cullinane (Waterford, Sinn Fein)
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Let me just finish. If the figures are published on a monthly basis then it is not beyond Mr. Mulvany, before this meeting finishes today, to tell this committee how many people are on all health waiting lists across all community, primary and acute hospital waiting lists. What is that total figure across all waiting lists? If I am being told these figures are published every month, I have to go digging to get that figure. I want that figure before the meeting is finished.
David Cullinane (Waterford, Sinn Fein)
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Before the meeting is finished today-----
David Cullinane (Waterford, Sinn Fein)
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I cannot understand when we are told the figures are published that somebody cannot give us the figure before the meeting is finished. Where are those figures published?
David Cullinane (Waterford, Sinn Fein)
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I have the acute figures. They are published by the National Treatment Purchase Fund, NTPF. I am talking about all the others.
Mr. Damien McCallion:
We also publish those regularly. On the community side, as part of our performance report, clearly there is a whole range of different services. We can obviously get someone to aggregate those to show the total across CAMHS, disability and so on.
David Cullinane (Waterford, Sinn Fein)
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I just want a total figure.
David Cullinane (Waterford, Sinn Fein)
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It is not too much to ask for, and I am including home care in that. Every time I get a response I find there is some category missing. I am asking a very simple question. What is the total number of people on all health waiting lists? I want the witnesses to come back to me with a figure. It cannot be beyond them to provide that.
To come back to the issue of capacity, I talked about a good performing hospital but there are ones that are not performing well and Limerick is one of them. It was before this committee a number of weeks ago, and said it need at least 150 additional acute beds. I got a response to a parliamentary question last week from the HSE and the Minister stating that since 2020 1,228 beds were funded. Is that right? There were 1,156 as part of the 2021 budget announced in October 2020, and then 72 as part of the national service plan in 2022. That is a figure of 1,228. How many of those beds, funded today, have still not been delivered?
David Cullinane (Waterford, Sinn Fein)
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I am asking specifically about that. I got this response only last week. This goes to the heart of efficiency within the HSE, and getting things done. In last year's national service plan, 72 beds were included. It states here that none of those 72 beds has been delivered to date, and the number of remaining beds to be delivered is 72. Not one of those 72 beds that was announced in last year's service plan will be delivered this year. How is that the case when we are being told by a hospital in Limerick that it needs 150 beds? The response further states that a full review of the remaining beds against profile is currently under way in the context of ongoing and planned capital works and current recruitment challenges. Every single time we ask about something that is funded and not delivered we hear about recruitment, which again shows workforce planning is a problem. It goes on to states that there are no additional acute inpatient beds planned as part of the winter plan for 2022-2023. We have hospitals telling us that beds are a problem. It states here 304 beds, but the witness said it is a bit less than that now in the space of a week. That surprises me, but there you go. Maybe we can be sent the accurate figure. We know there are hundreds of beds funded since 2020 but not delivered, and we have hospitals crying out for beds. How in God's name is that happening?
David Cullinane (Waterford, Sinn Fein)
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With respect to Mr. Mulvany, I am asking about the ones that have not been delivered.
David Cullinane (Waterford, Sinn Fein)
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No. That is the national service plan for this year, exactly. In the 2022 service plan 72 beds were funded. We are now into November, not one of those beds has been delivered. It is here in black and white.
David Cullinane (Waterford, Sinn Fein)
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My problem, if I can make this point, Chair, is that we have the Minister making these big announcements, which are great, that we are going to have all of this additional capacity. We have hospitals which tell us they are waiting for capacity. We have 1,200 beds that are funded. We have hundreds of beds not delivered, and we are being told it is because we cannot get the staff and there are all of these challenges. Once we fund the beds we should be able to deliver them at a time when we have a real crisis in our hospitals. I have one final question on capacity, because again this goes to the heart of the winter plan. The Minister announced 51 emergency department consultants. How many of those are in place right now? How many have been employed in the last number of weeks?
Mr. Damien McCallion:
There are a couple of points on beds. There are two challenges in terms of hitting the additional target over the 1,200. One is construction issues in terms of the factors in that sector and staffing. We have a detailed breakdown of the remaining beds and the expected opening dates and we can provide that if it is helpful, in terms of the sites that are there.
David Cullinane (Waterford, Sinn Fein)
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Yes.
Mr. Damien McCallion:
The second issue speaks to the challenges with bed capacity. We would love to be putting more beds in with the winter plan. However, physically with the construction and the timescale around that the issue is that we have utilised a lot of the existing space that was able to be reconfigured.
David Cullinane (Waterford, Sinn Fein)
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I was not talking about the winter plan. I am talking about last year's national service plan, and budget 2021.
David Cullinane (Waterford, Sinn Fein)
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Let me be clear about what I was asking about, which was beds that are funded. I am not asking about additional beds because they are not there.
Mr. Damien McCallion:
On the balance, we can tell the Deputy where those sites and the delays are, and when their target opening dates are.
Some of them will be in early 2023. On the point about the lack of capacity, there is a bigger challenge there in terms of generating bed capacity around the country. We are looking at this problem in the short, medium and long term. The short term is the winter plan. The medium term is over the next three years. This involves all the elements that Mr. Mulvany referred to in his opening statement around primary care and other investments and, lastly, working with the Department on bed capacity in terms of where we go in the future.
David Cullinane (Waterford, Sinn Fein)
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What about the 51 consultant posts?
David Cullinane (Waterford, Sinn Fein)
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Are they locum?
David Cullinane (Waterford, Sinn Fein)
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I know, but are they filled on a permanent basis?
David Cullinane (Waterford, Sinn Fein)
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They are locum at the moment.
Mr. Damien McCallion:
One of the key things in the winter plan was around trying to look at safer staffing, for both nurses and medical staff. We will not be able to fill some of the medical consultants and supporting doctors positions permanently in that timescale. It can take up to a year. People are international. We are trying to tap in to that and get people home. The key message is that if there is a permanent post, it is potentially more attractive to a locum to come back. That is what we are hoping. We knew we would not fill all those posts this winter. This was not just for the winter. It was trying to strengthen the medical numbers for the future. Hopefully, that will be what happens.
David Cullinane (Waterford, Sinn Fein)
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The document does not state that. The actual plan states 51 consultant posts. This is part of the problem. We announce that we are going to have 51 additional emergency department consultants and then we are told that more than half of these will not be appointed until next year. This is the problem every year. These winter plans come, promises are made and big numbers are put out. In reality, only a fraction of what is actually promised gets delivered.
Mr. Stephen Mulvany:
I agree with the point but, in fairness, the plan is clear that it is about a longer term piece. It is not just the current winter. One cannot just plan for the winter just before it starts. We have been planning for this winter since the previous winter plan and the service plan. Elements of what is in this winter plan will come on stream next year. The plan is clear on that.
Róisín Shortall (Dublin North West, Social Democrats)
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I would like to welcome the witnesses and thank them for their presentations. The most striking aspect of the health service is the fact that in every service one looks at, there are log jams. The result is that large numbers of people are denied access to basic healthcare. This has been the case for several years and in most cases there is no indication things are getting any better. I want to start off by talking about the emergency departments in our hospitals and comments that are made on a regular basis by Dr. Fergal Hickey. He talks about the need for additional beds. When we look at the service plan, figures are provided in relation to acute beds and I want to start with those. I refer to the target funded from the national service plan and the winter plans 2020-2021 and 2021-2022. Out of 1,228 beds only 907 of those have been delivered. That leaves a remaining 321. What is the schedule for delivering those 321 overdue beds?
Róisín Shortall (Dublin North West, Social Democrats)
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Sorry, is that 995?
Róisín Shortall (Dublin North West, Social Democrats)
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I am quoting from the figures in the winter plan. For acute beds, there was to be 1,228 but only 907 have been delivered. That is a shortfall of 321.
Róisín Shortall (Dublin North West, Social Democrats)
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Is Ms Day saying that there will be no additional beds provided in 2022?
Róisín Shortall (Dublin North West, Social Democrats)
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I am getting back to the target that was set the year before last and the year before that. The HSE has only managed to deliver 907, according to its own figures. There are 321 outstanding and Ms Day is saying that it will be at least 2024 before those beds are delivered.
Róisín Shortall (Dublin North West, Social Democrats)
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Ms Day just said that in 2023, there will be 184 beds delivered.
Róisín Shortall (Dublin North West, Social Democrats)
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What are the timelines? When will all of those beds that were promised a couple of years ago be delivered?
Róisín Shortall (Dublin North West, Social Democrats)
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Yes.
Róisín Shortall (Dublin North West, Social Democrats)
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If the 1,228 beds were promised a couple of years ago, is there any credibility in the figures that Ms Day is using if it is going to take a total of four years, minimum, to deliver those beds?
Róisín Shortall (Dublin North West, Social Democrats)
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Yes, I am quoting from the witnesses' figures, namely, the 1,228 bed that were planned.
Róisín Shortall (Dublin North West, Social Democrats)
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It does not look like that and I am not talking about the last ten years. I am talking about the situation now and what the Irish Association for Emergency Medicine is saying. It is all very well to say there are 51 additional consultants but if there are not any extra beds, there will continue to be a log jam.
Róisín Shortall (Dublin North West, Social Democrats)
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Sorry, I am talking about beds. Will the witnesses present us with that schedule?
Róisín Shortall (Dublin North West, Social Democrats)
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I want to continue this point. Is it not the case that there are long delays in delivering the promised beds and that there are no new additional beds provided for in this winter plan?
Mr. Damien McCallion:
There were definitely some delays but those are being seen through in terms of construction into early next year. Some of the projects in latter end of that delivery are significant in scale. In the Mater Hospital, for example, there is a big block being developed and it is being fitted out. Some of the bigger projects take time from a construction perspective. We can provide the detailed schedule in relation to the balance.
Róisín Shortall (Dublin North West, Social Democrats)
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Okay. According to the plan, there are no new beds provided for in this year's winter plan. That has been confirmed by a response from the HSE and the witnesses. There are no additional acute inpatient beds planned as part of the winter plan.
Róisín Shortall (Dublin North West, Social Democrats)
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These are targets that were set as far back as 2020.
Róisín Shortall (Dublin North West, Social Democrats)
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The bottom line is the HSE has not delivered on the beds it committed to and it is not providing for any additional beds in this winter plan. I am going to move on.
I want to raise the question of staffing. We have talked about the 51 consultants. What is the number of additional nurses for emergency departments in the winter plan? I can not find any figure within the plan for additional nurses.
Róisín Shortall (Dublin North West, Social Democrats)
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Sixty two additional nurses going into emergency departments this winter.
Mr. Damien McCallion:
Correct. Yes there is €3.75 million set aside for that. In addition to that, locally, sites have identified their pressure points and there may be additional resources going in to support emergency departments in hospitals. There are 400 staff going in. That is the local part of the plan that the CEO is referring to.
Róisín Shortall (Dublin North West, Social Democrats)
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How many additional nurses will be made available in emergency departments this year in the winter plan?
Róisín Shortall (Dublin North West, Social Democrats)
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I cannot see any figure in the winter plan for additional nurses.
Róisín Shortall (Dublin North West, Social Democrats)
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What is the number on that?
Róisín Shortall (Dublin North West, Social Democrats)
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RTÉ was reporting the HSE said in a press statement that 101 additional nursing staff would be provided.
Róisín Shortall (Dublin North West, Social Democrats)
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Four hundred and forty-seven.
Róisín Shortall (Dublin North West, Social Democrats)
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What number of staff members is in that subset?
Róisín Shortall (Dublin North West, Social Democrats)
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Given the major problems in EDs, it would be helpful to know what additional nurses the HSE is going to provide this winter.
I want to move on to another aspect of acute beds and that is delayed discharges. I have figures from September across all hospitals. At that stage, and I suspect the figure is probably worse now, there were 621 delayed discharges in our acute hospitals. We can talk forever about the promised additional beds, but if there are 621 beds inappropriately occupied, that is a major problem. What is the HSE doing to reduce that number?
Mr. Stephen Mulvany:
We are increasing the amount of home care capacity so that we can discharge people to home care. We are also increasing the amount of transitional care beds and have put €16 million extra into this so people can move on quickly after hospital before they get to their long-term care bed, and obviously we are funding the nursing home fair deal scheme.
Róisín Shortall (Dublin North West, Social Democrats)
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Anybody in the HSE could make those claims any year, because there is nothing different.
Róisín Shortall (Dublin North West, Social Democrats)
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Has the HSE a specific plan to reduce that number of delayed discharges from 621 to a lower figure?
Róisín Shortall (Dublin North West, Social Democrats)
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Apart from the generalities, has the HSE a specific plan to reduce that number of 621 delayed discharges?
Róisín Shortall (Dublin North West, Social Democrats)
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Okay. Hospitals cannot do an awful lot about lack of funding or lack of staff for home care. What is the HSE centre as an organisation doing about that?
Mr. Damien McCallion:
As Mr. Mulvany said, we are supporting them through a range of measures such as providing transitional care, additional capacity in terms of community beds, and additional staff in some of those areas for home care where that is feasible. It will not be feasible in every area. That is the reason each site is asked to work between the hospital and the community-----
Róisín Shortall (Dublin North West, Social Democrats)
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Does the HSE have an overall plan for reducing that number?
Róisín Shortall (Dublin North West, Social Democrats)
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Sure, but it is the solutions I am looking for.
Róisín Shortall (Dublin North West, Social Democrats)
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How many additional community beds will be available this winter?
Róisín Shortall (Dublin North West, Social Democrats)
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How many additional community beds are provided for in the winter plan?
Mr. Damien McCallion:
We have not broken it out but, in total, across both aspects, there are 361 public intermediate care beds through various funding streams, including the national service plan and the winter plan, and more than 650 private intermediary care beds. Then there is separate funding provided to support sites. We referred to Waterford, and this is one of the areas where officials have worked well with the private sector in utilising those beds to assist discharge of patients.
Róisín Shortall (Dublin North West, Social Democrats)
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When are all those beds expected to be delivered? What is the target date?
Róisín Shortall (Dublin North West, Social Democrats)
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I want to come back in about staffing later but I will leave it there for the moment.
Gino Kenny (Dublin Mid West, People Before Profit Alliance)
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I thank all our guests for coming and for their statements today. I will start off with a comment the Irish Medical Organisation made very recently. It said the winter plan had increasingly become a media exercise rather than a meaningful intervention. What do the witnesses say to that?
Mr. Stephen Mulvany:
I do not agree. When we launched the winter plan, we had a very low-key technical briefing for the press. There was no big launch. We see the winter plan as an important but ongoing contribution to trying to mitigate the problems. We know the congestion in the emergency departments is a symptom of the wider system and that is why we are focused both on investing in and improving what happens before people have to go to hospital, what happens in hospital, and what happens afterwards. We would not accept the statement that it is a media exercise. We are planning on keeping people apprised of the winter plan, its progress, the challenges being faced, and what staff and the HSE are doing about them. We do not accept it is purely a media exercise. It is focused on trying to mitigate very significant pressures of which we are very much aware.
Gino Kenny (Dublin Mid West, People Before Profit Alliance)
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Obviously, the witnesses would reject the sentiment that it is basically a rehash of funding and interventions of previous plans?
Dr. Mike O'Connor:
The winter plan members have here is part of the overall winter plan, but there are also what we mentioned earlier, such as what specific impacts individual sites can make in a number of key areas. That relates to the over 24 hours piece, the over 75-year-old piece, and the patients who have long lengths of stay. Rather than blanket measures, we have asked hospitals and CHOs to think specifically about what measures they need. The plan this year is more nuanced than previous years. As well as the overarching plan, there are 29 individual plans to look at how each hospital can optimise flow, which sounds like a nebulous thing but actually is a very important thing, in addition to which are actual specific KPIs. Therefore, it is different than the previous winter plans.
Mr. Damien McCallion:
We would not disagree with the Irish Association of Emergency Medicine in that we need to look at the long term. The winter plan is about supporting additional capacity in the system and, as Dr. O'Connor and Mr. Mulvany have said, the flow in the system for that period. We are not saying the plan is something that will resolve this in the longer term and it needs to be done in parallel. I do not think there is any point of disagreement on the need to invest in the system and better utilise the capacity that is there, but that is a longer term piece of work. The winter is really just about recognising we get this peak and trying to ensure we minimise the impact on patients as best we can.
Gino Kenny (Dublin Mid West, People Before Profit Alliance)
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How many of the 608 new posts have been filled? I understand there are huge challenges with the recruitment of medical professionals, not only in Ireland but across the world. How many of those posts have been filled thus far?
Mr. Damien McCallion:
What I would say regarding those numbers is that the plan was approved only a number of weeks ago so we have not started to collate that information yet. Officials at the sites were aware vacancies were coming and were trying to recruit staff, so we will be collating that information on a monthly basis through the winter. Some were targeted in the first half of the winter, in quarter four this year, and others are planned to be in place by quarter one for the January period, when we also know we hit additional peaks. It will vary but we will be pulling that information together over the next while with the sites. In excess of 400 of those are local to all the sites and some of the balance of those are central.
Gino Kenny (Dublin Mid West, People Before Profit Alliance)
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Has there been much interest in the posts?
Mr. Damien McCallion:
It varies. We talked about the emergency department consultant posts and the fact we have had good interest from a locum perspective for the winter. This is positive, because if we just looked to fill a locum post on its own and did not have a permanent post for someone, it would not be an attractive enough career move for someone to come back for. There will be challenges with some of the other posts such as certain nursing posts and some of the therapy posts. The sites were asked to try to make sure they had a good chance of filling these posts as part of the winter submission, and Dr. O'Connor may want to talk to that. We are positive overall. You will never get all of those posts filled, just to be clear. There are going to be challenges, which the Deputy referred to, but we asked the officials at the sites to try to recruit for posts they felt they had the best chance of filling this winter, either in quarter four or quarter one.
Dr. Mike O'Connor:
That doability piece, so to speak, was very important when we were getting each site to look at where their points of hurt were or what would make a difference. In some cases, some of the sites moved people from existing posts to other posts that came through on the winter plan, particularly around the whole area of patient flow, and then would recruit backwards. As Mr. McCallion noted, the plan was published a number of weeks ago but the preparation for it has been going since April and May and included a deep-dive into individual sites.
Gino Kenny (Dublin Mid West, People Before Profit Alliance)
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As I said from the outset there are huge challenges in recruitment. Are there any incentives for nurses and doctors who are being recruited internally and externally to mitigate any costs of coming to Ireland such as rental costs?
That is a huge issue. Some people that have just qualified will say, "I will take my chances elsewhere. I am not going to work in the Irish public system because it is just not worth my while". Are there incentives? Other jurisdictions do it. The main thing about new recruits in the Irish health system is to keep people here, rather than emigrating. Although it is a challenge, it can be done. Certain things have to be done and put in place to keep people here.
Mr. Stephen Mulvany:
Retention and recruiting our own is the first port of call. We have and are offering every nursing graduate and health and social care profession graduate this year a permanent post in the HSE. On international recruitment, we have brought in approximately 1,400 nurses this year and we offer a relocation package. In other international recruitment, including doctors, we also offer relocation packages, which have a variety of elements including flights and support around accommodation in the initial weeks. We are also seeking to offer and secure retention of as many new graduates this year as we can. We need to grow the pipeline so that there are more graduates being trained, to whom we can then offer posts. On staffing, we are trying to make sure that we are doing something about safety issues around staffing levels and skills mix - one aspect of why we may have retention problems. It is about retention, first, and recruitment efforts at home and abroad; then there is the longer term issue of growing the number of placements for a bigger pipeline of graduates, which takes a long time.
Gino Kenny (Dublin Mid West, People Before Profit Alliance)
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Accommodation issues are the practical things people will think about when they are coming to Ireland. Are there any situations where that can be addressed in relation to accommodation for medical professionals?
Mr. Stephen Mulvany:
It is a policy matter. We have not gotten into the generalised provision of accommodation on an ongoing basis beyond the relocation packages we offer when bringing people home from abroad. The questions of accommodation allowances and Dublin allowances have been raised; it is not something we are actively considering.
Gino Kenny (Dublin Mid West, People Before Profit Alliance)
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Would the HSE consider it?
Gino Kenny (Dublin Mid West, People Before Profit Alliance)
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On the accident and emergency departments, there are enormous challenges regarding the staffing environment. For those of us who have tried to access accident and emergency departments, it would be an understatement to say the experience has been quite dramatic. I have personal experience from a number of family members that have gone through the accident and emergency department; the experience they had was absolutely unacceptable. I understand that the people working in these departments are under serious pressure and face challenging situations, but people being left on trolleys for two or three days is not acceptable.
Gino Kenny (Dublin Mid West, People Before Profit Alliance)
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It continuously happens. If it was any other profession, those with responsibility for accident and emergency departments or health services would be sacked. There are no two ways around it. Some 27,000 patients who went to access accident and emergency departments across the State left without being treated in the first three months of this year. That is not acceptable. I would like to hear the HSE's comments on that; that people go to emergency departments and are left on a trolley for two or three days or have to leave because they cannot be seen.
Mr. Stephen Mulvany:
Both of those situations are unacceptable; we acknowledge that. It is not what we or the staff in those emergency departments or any staff in the health service want. We are concerned about people who leave without treatment and people whose admissions are delayed, particularly those over 75. We are clear that it is not a problem that can be fixed largely inside the emergency departments; it is a symptom of the wider system. That is why we are looking to do as much as we can before people have to consider going to hospital, so that there are admission avoidance opportunities. We are investing in the community regarding chronic disease and older persons' care so that, as much as possible, we can delay people having to go to emergency departments or give them a different route to being admitted which is quicker, if they have to be admitted, than going through an emergency department, particularly for over-75s and vulnerable adults. We are also focused on trying to improve capacity in hospitals and the use of that capacity. Investment is part of the solution, as is making sure that at all stages staff are supported to make the processes as efficient as possible. In other words, so that we are moving people towards discharge; that is important.
Gino Kenny (Dublin Mid West, People Before Profit Alliance)
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Why does it continually happen? It happens every single year.
Mr. Stephen Mulvany:
It does. It is an intractable problem; it is a problem across many jurisdictions, not a problem unique to Ireland. I am not just saying that because it suits me. That does not mean that we are not trying to improve; we are. The longer term solutions are about the size and shape of the health service and having more investment in hospitals and particularly strengthening our community care services. That is what Sláintecare is about. The job today is to improve it as much as we can with what we have available and help staff to do that; they absolutely want to do so.
Martin Conway (Fine Gael)
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I thank the witnesses for attending. This morning at 8 a.m., and as we sit here discussing health matters, there were 87 people on trolleys in University Hospital Limerick according to the INMO trolley count. What does HSE say to those people?
Mr. Stephen Mulvany:
We would say that we wish there were not 87 people on trolleys in Limerick; we would wish that people would be able to move through the emergency department at reasonable pace and get admitted, where they need to be. We are working with the local hospital group and the hospital to try to assist them to make sure that, insofar as possible, delays in emergency departments - a symptom of wider problems inside and outside the hospital - are mitigated. I might ask my colleague Dr. O'Connor, who has been-----
Martin Conway (Fine Gael)
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Since Mr. Mulvany became interim CEO of the HSE, has he visited University Hospital Limerick?
Martin Conway (Fine Gael)
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He has not been in University Hospital Limerick. When does he plan to go down there?
Martin Conway (Fine Gael)
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Would he consider, in his new role as CEO, a visit to the hospital with the consistently-highest trolley numbers as a top priority?
Martin Conway (Fine Gael)
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Would Mr. Mulvany not consider that the worst hospital in the country is where he should have been first?
Seán Crowe (Dublin South West, Sinn Fein)
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Senator Conway, let Mr. Mulvany answer the question, please.
Mr. Stephen Mulvany:
In the first weeks in the job and every week, I have visited services, including disability, older persons and acute hospital services. I have not got to Limerick yet but I will. There is not necessarily a magic bullet in the form of a visit from me, but I will be going to visit University Hospital Limerick in due course.
Martin Conway (Fine Gael)
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Will Mr. Mulvany let us know when and what his feedback from the visit is? I am not being provocative; this is very serious. Some 87 people, many of them from my area and citizens of this country, are on trolleys. People on the ground are doing their best. The CEO is doing their best, but this is a HSE problem. It requires a full HSE response. I would like an update from the HSE on what tangible progress has been made since the expert review team went to the hospital. What are the tangible improvements in place now?
Ms Mary Day:
I have been in University Hospital Limerick twice since I came into the role on September 1. I will ask my colleague Dr. O'Connor to talk about the intervention team. There is a lot of work going into University Hospital Limerick, including local work, to improve the problem.
There are a lot of hardworking staff in Limerick, as the Senator will be aware. We have an opportunity to give credit for the work. The intervention team's work is about improving flow, targeting the length of stay and improving the 24-hour delays.
In respect of bed capacity, in the past four weeks a sod has been turned on the second block of 96 beds. Some 95 beds were delivered in 2020 and the second block of 96 beds will be delivered in the next two years. It is positive to see that additional capacity.
Martin Conway (Fine Gael)
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We all welcome that, but it will be 2024 before those beds are in the system. How are the HSE negotiations with private operators in the mid-west progressing in the context of the winter plan? Have they concluded and has the HSE purchased bed space in private hospitals as part of the winter plan in addition to what is there already?
Ms Mary Day:
There is local discussion about working with private bed capacity. For all hospitals, we look to private hospitals to provide additional bed capacity. I have a meeting next week with the CEO on pursuing additional private capacity. I will ask Dr. O'Connor to speak about the interventions as he has been very involved in it.
Dr. Mike O'Connor:
As the Senator will be aware, the HSE support team, which is a collaboration between community, acute operations and the performance monitoring and improvement unit, went into University Hospital Limerick in July and met highly motivated staff dealing with an extremely high volume of work. It probably has the highest attendance of any hospital in the country. In addition, it has the highest attendance of patients over 75 of any hospital, and it is unique in that it does not have a model 3 hospital in its group nor does it have large private capacity in the region it can decant to, so it has a unique set of challenges. We found the leadership team to be focused on areas it needs to improve. The hospital remains challenged but we focused on how we can optimally improve integration between the hospital and the community and how we can look at efficiencies within the hospital. A new area for the over-75s only has opened in the emergency department, which is probably the first in the country. We also focused on the long-stay patients who are in hospital for more than 14 days. That process continued for approximately four weeks and the engagement continues. There are some issues relating to how the medical on-call rota is constructed, which is a technical piece and we have ongoing engagement about that. These internal processes and external integration pieces take time.
In response to the Senator's original question about the 87 people who are on trolleys, I apologise on behalf of the HSE. It is a terrible thing. There are a unique set of challenges in Limerick, we are working through them, and the group has a clear idea of-----
Martin Conway (Fine Gael)
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Finally, because I am conscious of time, as the Chair and Deputy Cullinane mentioned, University Limerick Hospitals Group was before the committee and we had a positive engagement with its representatives a few weeks ago. They were clear that an elective hospital is needed in Limerick and yet the Department does not seem to prioritise it. What is the HSE's view on the need for an elective hospital in Limerick? Is it needed and would the HSE support it?
Martin Conway (Fine Gael)
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With respect, I hear that answer regularly, but at the end of the day, the witnesses are the HSE. They inform the Department that informs the Minister. It is policy but the HSE has a view and I would like to hear it.
Dr. Mike O'Connor:
I was at the committee meeting with UL Hospitals Group and the Senator asked the same question, so I will give the same answer. Capacity is required in the mid-west and that could be a mixture that includes acute capacity. As the Senator will be aware, the staff in Limerick are focused. They have delivered a block of 96 beds and are following with a second and third block. It is clear as crystal to everyone, and the CEO is doing a fantastic job in putting the message across, that community capacity is also required. We know there are patients in our hospitals who would benefit from step-down rehabilitation. That is probably the solution.
As a technical piece, if we step back and ask whether elective capacity is required, the answer is yes, but we can generate it by adding acute capacity and giving the community capacity.
Seán Crowe (Dublin South West, Sinn Fein)
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I have a few questions. I will focus on the National Ambulance Service initiatives, including deployment of rapid handover teams. Will the HSE expand on what is involved in that? My concern arises from the fact that, at one stage two weeks ago, there were 11 ambulances outside Tallaght hospital. Ten were Dublin Fire Brigade ambulances. I know this because a number of constituents contacted me who were trying to enter the accident and emergency department. Deputy Kenny spoke about the conditions in the accident and emergency and so on. One patient had pains in his chest and a suspected heart attack. He was released that night and ended up calling another ambulance the next morning which brought him back again. He spent three days on a chair, not on a trolley. He has had cancer in both kidneys and a fractured lower vertebra. He was on a chair going through that. A woman beside him ended up lying on the floor that night. They both have VHI private insurance. Some of the challenges the families spoke about related to communication. When a loved one is in hospital, no one can go in with them under the current Covid-19 regulations, so no one is with them. When people are seriously ill in hospital, we are relying on them, if they are well enough, to answer the phone. I give that as one example.
The same weekend a family from Wicklow whose mother had fractured her hip waited three or four hours for an ambulance. A woman contacted me this week whose mother had a heart attack and subsequently died. She waited four hours, lying on the floor of their apartment. I am giving examples, but there are probably many and people listening at home probably have similar personal stories. I will not get into those individual cases.
Rapid turnover is important because the longer those ambulances are sitting outside Tallaght or any other hospital - a number was also outside St. Vincent's hospital the same weekend - the longer the response time will be. Will the witnesses expand on what is needed? Are more staff needed? Will they let people at home know?
Mr. Stephen Mulvany:
The Chair is correct. The delay in the handover of ambulances outside EDs is a problem. It means those ambulances cannot pick people up from the side of the road who might need to be picked up. That is a significant issue. While the target time for a handover is 30 minutes, the actual average time in the country now is approximately one hour. That is a problem.
In some jurisdictions internationally, including across the water, the handover time is multiples of that but that is not a reason to be complacent. The problem is largely a symptom of the pressure in the ED. The ambulance service is seeking to mitigate the problem. They have a number of protocols. Some patients are well enough to be handed over to the triage part of the ED and are able to sit in the waiting area. I acknowledge the awful stories the Chair relayed.
In some cases, an ambulance crew that is already at the hospital waiting for handover can co-operate and look after another patient to free up an ambulance to go back on the road and be able to pick up callers. We allocate ambulances dynamically, so we try to mitigate the impact of having ambulances backed up outside the ED. Again it is a system problem. The staff of the ED want to get the patients in and through as soon as possible. That is not always practical and we need to encourage insofar as possible a whole-hospital, whole-health service approach, because if we cannot get people into the community, it is hard to move them through the hospital and hard to admit them. The very back of the back door is the ambulance, which can in some cases, unfortunately, become almost part of the emergency department. While those patients are safe and being cared for by paramedics and advanced paramedics, as the Chair stated, they need to be on the road picking up the next patient. It is about seeing it as an entire risk system, so the rapid handover team tries to assist with that. Do colleagues want to make any other comments on that?
Dr. Mike O'Connor:
I commend the National Ambulance Service and Dublin Fire Brigade on their professional and highly trained nature. They are a pleasure to work with in the HSE. I absolutely double down on the concerns about those handover delays. Mr. Robert Morton who is the head of ambulance service reckons that at any one time there is 137 WTEs lost by having patients waiting at the front of hospitals. It is the most visible effect of people being in the wrong place at various stages in our hospitals and one can drive by a hospital and know there is congestion inside the emergency department by how many ambulances are outside. We convened a group between the National Ambulance Service and HSE acute operations in August. We will do a learning piece in early December about what we can learn from rapid improvement cycles to improve this quite dramatically. The CEO mentioned two of them which was cohorting, when one ambulance crew takes a second patient to free up an ambulance and the fit to sit campaign where patients do not necessarily have to go into a cubicle. There is a body of work being done on this mainly because it is a problem and, second, because the problem is growing, with the handover delays growing as we have gone through 2022.
Mr. Stephen Mulvany:
In fairness to Tallaght University Hospital its average for October was a 49-minute handover which again was outside the target but the national average was approximately 59 minutes so the hospital is doing what it can to try to get patients off the ambulance and through the emergency department.
Seán Crowe (Dublin South West, Sinn Fein)
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The response from the hospital at the time was that it was down to a lack of beds. It has a plan for a 72-bed unit which is currently going through the system and will help resolve the situation.
Can I focus again on the headline of unscheduled care activity and the figures in relation to 75-year-olds and older? There is an increase of 14.1% on the same period in 2019. Emergency department admissions of 75-year-olds and older again up 10.1% on the same period in 2019. What is happening there? Is this due to the post Covid-19 situation with older people are getting more infections? For those aged 75 and older it normally means a longer stay in hospital. That is posing a challenge for the system. Pathways were spearheaded by Beaumont Hospital. We all accept the number of hours it is saving and it has saved people from having to go through the emergency department and so on. It seems to be a no-brainer that something like that would be replicated right across not only Dublin but across the State. Could the witnesses explain those figures and what is happening there as they are stark and are big numbers?
Mr. Stephen Mulvany:
We are very focused on the over-75 population. First, there is a demographic effect and while overall we have a younger population compared to the rest of Europe, our population is ageing more rapidly. The over-75 cohort is growing at around 4% to 5% per year which is much faster than the general population is growing. Covid-19 has also definitely had an impact. The clinical view coming back is that people may have delayed their health-seeking behaviour during Covid-19 and that elderly patients, and others, are often arriving sicker. They are much more likely to be admitted and their lengths of stay, which are typically longer anyway, are longer since Covid-19. A lot of our efforts are focused on trying to provide early intervention, that is, front door teams in our hospitals so that if older people arrive in hospital, we try to move them through the process as quickly as possible to minimise their waits because we know that is not good for patients. We are also investing in the community side in our integrated care programmes for older people, so that we can again intervene before they go to hospital and give alternatives to hospital admission, and certainly alternatives to hospital admissions via the emergency departments as much as possible. On the discharge side, we are trying to discharge people home for assessment because in hospital they are at their worst and we want to try to assess them at home and keep as many people at home as possible.
A big focus of the overall plan has to be and is on the over-75 vulnerable population. Dr. O'Connor will comment further.
Dr. Mike O'Connor:
The Chair's point about why the attendance numbers have gone up is well made. The demographics speak for themselves with 629,000 people aged over 65 years in 2016 and a mere five years later there are 742,000. That is to be celebrated. If one looks at the over-80s, there were 147,000 in the census 2016 and five years later, there are 176,000 aged over 80 years. Again, that is something to be celebrated and most of them are healthy. There is that demographic piece and the Chair has very astutely mentioned what has happened post Covid-19. We are now beginning to see the effects of lockdowns on people who were pre-frail and have moved from this pre-frail stage into frailty a little quicker than they ordinarily would. That explains the increase in the over-75s.
From the point of view of our emergency departments, as they were designed originally and whether they fulfil the needs of the older, frailer patients, I do not think they do and we need to have the redesigned piece the CEO mentioned about frailty at the front door. University Hospital Limerick is leading out on a specific area for over-75s.
We cannot change the demography and we cannot turn back the clock on the Covid-19 frailty. We have to adapt our services so they are friendly and, in addition to that, specific to the needs of the older person as they come through.
Seán Crowe (Dublin South West, Sinn Fein)
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The big concern is that we are not into the proper flu season yet but with the challenges emergency departments are going through at the moment, it looks like it will be a very difficult winter.
David Cullinane (Waterford, Sinn Fein)
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I come back to the issue of emergency medicine consultants. Mr. Mulvany said earlier when I put questions to him on that issue that the 51 consultants was never designed to be for this year. That is not what it states in the plan. On page 17 of the plan for winter 2022-2023 it states that analysis by site has been completed and the number of additional emergency department consultants required to enhance the delivery of safe and timely care to patients in emergency departments is 51 whole-time equivalents. That tells me that an analysis was done and here is what we need to ensure that patients have access to a safe and timely service. It goes on to state that due to recruitment limitations, these posts will be filled initially with locum consultants - I think the figure of 21 was given earlier. Mr. Mulvany said that the remaining, or certainly a portion of those, will not be delivered for this winter. It goes on to state that an additional 20 whole-time equivalent registrars will also be required to support the emergency department consultant posts. It is reasonable for us to put it to Mr. Mulvany that we have a winter plan again where figures are put into it to suggest we will have all of this additional capacity when, in fact, it is a multi-annual plan. If it is a multi-annual plan, state that it is. However, it does not state that in the plan.
What concerns me more is that if an analysis has been done by site, which I assume is each emergency department, that states that we need an additional 51 emergency consultants but that we are not going to have 51 additional consultants, then we are not equipped to deal with what is happening in the emergency departments this year given Mr. Mulvany's admission that about half of those consultant posts will not be filled or in place this year.
David Cullinane (Waterford, Sinn Fein)
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Where does it state that? I do not see it anywhere. It states "for this year". The Minister said that this year we will recruit 51 additional consultants for emergency departments and what it states here, if I can put it to Mr. Mulvany again, is that this was done as part of an analysis to ensure we have a safe and timely service. We will not have those 51 posts on site for this winter. It certainly does not state it here that it will be next year. If they are not in post, then we will not have timely and safe care this year because we simply cannot recruit those consultants quickly enough.
Mr. Stephen Mulvany:
The plan was approved in recent months. The recruitment process for the consultants has started. Perhaps we could look at the language and make it clearer. It has always been clear to everyone in the system that we cannot recruit 51 permanent consultants inside of six months. In fact, it would be a challenge to do it inside of 12 months. The analysis is the analysis. The 51 posts have been approved along with 20 registrars. We managed to get 20 in as locums, which actually is quite an achievement. That is substantial. The balance will be recruited as soon as they can be.
David Cullinane (Waterford, Sinn Fein)
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I could not agree more with Mr. Mulvany because I said last year, in last year's budget, that the time to plan for this winter was in last year's budget as it takes time to put beds in place and to recruit staff.
That begs the following question. Why were those 51 consultant posts not funded last year to enable us to get to a point where this winter those posts would be in place? I ask because it is stated in black and white that an analysis by site was done which shows that we need 51 whole-time equivalents to deliver a safe and timely service. My point is as follows and it is one that I have made before. Each winter plan is produced as the winter begins, promises are made and big numbers are put in the plan but, in reality, they cannot be delivered and should have been done the previous year.
Mr. Stephen Mulvany:
We agree with the principle and the plan sets it out. We would see this as an incremental approach over a number of years through both service plans and the winter plan itself. Any capacity whether it is bed capacity or recruiting someone like a consultant takes time. That is always understood and, therefore, one does as much as one can as early as possible.
David Cullinane (Waterford, Sinn Fein)
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I agree but these winter plans are a rehashing of previous commitments and give the impression that a lot of things will be done when, in fact, they cannot be done. I know that some of the plan can be done and lots of it will be done. I agree that it takes time to hire consultants and put beds in place, which is why when I see big figures and promises for both in a winter plan my confidence in the overall plan is undermined.
David Cullinane (Waterford, Sinn Fein)
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The winter plan is the Minister's plan.
David Cullinane (Waterford, Sinn Fein)
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The 51 consultants will not be in place this year, as identified by the HSE's research that shows we need them to provide a safe service. It is an undisputed fact.
David Cullinane (Waterford, Sinn Fein)
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I want to discuss the consequences in terms of the human side.
Ms Mary Day:
As many as 20 of the locums are in place and are progressing and 13 are in the recruitment process, which bring the number to 33 consultants. In terms of the remainder, there are 18, and in a couple of places there were no applicants, and a number of posts must be re-advertised. A total fo 33 consultants will be in place because the recruitment process is shortlisting and there are applicants for it.
Mr. Stephen Mulvany:
Safety is not a binary thing. We are putting them in place so we can have a better service, a safer service and an improved service. In terms of their absence, it is not as simple as saying that if the HSE does not have them by this year then the service is unsafe.
David Cullinane (Waterford, Sinn Fein)
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I want to have all of the consultants in place.
David Cullinane (Waterford, Sinn Fein)
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As the HSE does, and I want them as quickly as possible.
David Cullinane (Waterford, Sinn Fein)
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I want to quote some figures. Emergency department waiting times for an admission on average in July, for all patients, was 12.8 hours; and for those over 75 years it was 15.3 hours. In August, the wait was 12.5 hours for all patients and 14.8 for those over 75 years. In September, the wait was 12.7 hours and for those over 75 years it was 14.8 hours. As many as 35,000 people waited over 24 hours in an emergency department for admission to a bed. These are figures that I cannot contemplate and I cannot even understand how any of this happened. In July, a patient aged over 75 years in Galway University Hospital waited 9.4 days. How in God's name could any patient be left waiting for 9.4 days never mind a patient aged over 75 years? In August, a patient aged over 75 years waited 8.9 hours, and seven patients waited over 4.5 days across Cork University Hospital, University Hospital Limerick and University Hospital Kerry. Explain to me how somebody can wait 9.4 days for admission to a bed in a hospital. Surely to God there is a better way of managing a patient like that.
David Cullinane (Waterford, Sinn Fein)
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I cite a response to a parliamentary question on the maximum wait times, which I would have received from the HSE. Take a look at the matter and come back to us with the reasons, in particular the reason somebody waited 9.4 days for admission to a bed in Galway University Hospital. It takes my breath away to think that that could be the case. Please come back to me on that.
Dr. Mike O'Connor:
A wait of over 12 hours is unacceptable. On the specific issue, we have become attuned to realising when we hear someone has waited 9.4 days that there is probably a unique set of circumstances, which might be things like isolation beds and-or telemetry and monitoring. We can look into the matter. Waiting more than 12 hours is unacceptable.
David Cullinane (Waterford, Sinn Fein)
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People wait over 24 hours in many cases in some hospitals such as those in Cork, Limerick, Galway, etc.
David Cullinane (Waterford, Sinn Fein)
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That is just not acceptable. I wish to ask a final question on an unrelated issue. There was a report in The Irish Timestoday that the HSE has very serious concerns about amending the Patient Safety (Notifiable Patient Safety Incidents) Bill. We know that the Minister has given a commitment that an amendment will come back on Report Stage to deal specifically with the CervicalCheck issue and there is an expectation that this will not be done by the end of the year. Can the CEO confirm that there is a concern within the HSE about ensuring that discordant slides related to screening is one of those notifiable incidents? We had a very lengthy exchange on Committee Stage with the Minister for Health. I accepted the complexities of the issue. I know that it is a complex issue but the Minister said that he was going to come back with an amendment that would reflect that. In the CEO's view will that happen notwithstanding whatever concerns exist? Can he explain what the concerns are? Is he confident that such an amendment will come to enable us to get this Bill through both Houses of the Oireachtas before year end?
Mr. Stephen Mulvany:
I will deal with the questions in a straightforward manner. Policy and legislation, particularly the legislation that we are talking about, is a matter for the Minister, the Government and the Oireachtas. They are advised primarily on those matters by the Chief Medical Officer. That is not the HSE's role. To be clear, the HSE is fully supportive of full and frank open disclosure where patient safety incidents occur, that is, where unanticipated of unintended outcomes of healthcare provided has arisen so there is no query. Equally, in terms of cervical screening, we have spent a lot of time and are rolling out a patient-requested review so that women can review their slides with the support of a screening service. Again, that is something that the HSE fully supports. There are concerns in the clinical community around what may be labelled as an incident and a notified incident. In fairness to the Minister, a meeting has been scheduled where our chief clinical officer who will represent those concerns, and a couple of our board members, will meet the Minister in the next couple of weeks in order that we can relay those concerns. That is probably as much as I can say for now.
Seán Crowe (Dublin South West, Sinn Fein)
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The debate has gone outside discussing the winter plan. Deputy Shortall is next.
Róisín Shortall (Dublin North West, Social Democrats)
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The HSE has put a certain amount of emphasis, in the winter plan, on avoiding attendances at EDs and avoiding admissions. That is only right as it is another logjam. I mean a lot of people end up in EDs who should have an alternative pathway. The difficulty is that in many cases there are no alternative pathways. That seems to be a key issue in respect of the logjams. The advice being given to people is to seek assistance or advice locally, go to one's GP or go to other facilities but those facilities do not actually exist. At the moment GP surgeries are experiencing major pressures and, as everyone knows, there is a shortage of GPs. In addition there are huge issues with out-of-hours services. Let us say somebody has a six month old child who has a very high temperature and it is 11 o’clock at night. What should they do? Are there options available to them other than going to an ED?
Róisín Shortall (Dublin North West, Social Democrats)
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Am I correct to say that most of them are not open out-of-hours?
Róisín Shortall (Dublin North West, Social Democrats)
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What options are available out-of-hours and in the evening for the scenario I have outlined?
Dr. Mike O'Connor:
Most of the local injuries units are open out-of-hours. In fact, most of them run a seven-day service, which would be classified as out-of-hours. Most of them do not operate a service after 8 p.m. Those units are one option and that is really for minor fractures, dislocations and sprains.
Róisín Shortall (Dublin North West, Social Democrats)
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Is the service available up to 8 o’clock?
Róisín Shortall (Dublin North West, Social Democrats)
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I am talking about emergencies that arise out-of-hours.
Dr. Mike O'Connor:
There is a second option. We should be cognisant of our general practitioner colleagues. On an annual basis there are 29 million GP consultations. There are 1.3 million emergency department attendances so general practitioners do a lot of the emergency lifting. The out-of-hours work done by GPs in consultation is 1.1 million, which is a number just shy of the ED attendances.
Róisín Shortall (Dublin North West, Social Democrats)
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They are the global figures.
Róisín Shortall (Dublin North West, Social Democrats)
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What is a parent with a very sick child supposed to do at 11 o’clock at night?
Róisín Shortall (Dublin North West, Social Democrats)
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No.
Róisín Shortall (Dublin North West, Social Democrats)
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What are such parents' options when it comes to accessing services?
Dr. Mike O'Connor:
Out-of-hours GP services are the first option most people access, judging by the 1.1 million attendances in that regard. The second option is to attend an ED. There are other options, including the website. The HSE has a very well-----
Róisín Shortall (Dublin North West, Social Democrats)
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Okay.
Róisín Shortall (Dublin North West, Social Democrats)
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The reality is that the alternatives to EDs out of hours are wholly inadequate. Does Dr. O'Connor accept that?
Róisín Shortall (Dublin North West, Social Democrats)
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This just stands to reason. If the HSE does not want people who are sick or concerned about sick children or elderly relatives to go to EDs, it has to provide an alternative. At the moment, out-of-hours services are really only skeleton services. There are several minor injuries clinics and primary care centres around the country, some very well equipped, but I put it to the witnesses that these are not advertised or promoted because there are no staff in them. One obvious solution would be to recruit GPs who would be more than happy to work part-time, on salary and out of hours. Why does the HSE not do that? We know that it would suit many GPs, particularly female GPs and those with young children, very well to work those kinds of shifts or unsocial hours. To me, it is blindingly obvious that the HSE should be recruiting salaried GPs to staff those centres in order that there are alternatives to EDs. Has the HSE considered that? If not, why?
Mr. Stephen Mulvany:
On the question of salaried GPs, GP out-of-hours services are open 24-7. We can show the numbers going through them. The reason some of the services are staffed and open according to summer hours is not only staffing but also the fact that not everyone arrives in the middle of the night. There is a well-known pattern as to when people attend EDs.
Róisín Shortall (Dublin North West, Social Democrats)
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Of course, there is real difficulty getting access to same-day appointments with GPs. I feel like that is-----
Róisín Shortall (Dublin North West, Social Democrats)
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I do not know what that means. In trying to get people not to attend EDs, why does the HSE not provide a realistic alternative service?
Ms Yvonne O'Neill:
Currently, of the 1.1 million attendances at general practices, only 14% get a referral to an ED, so we know that the is the model that is working. To answer the question, the difficulty about just enhancing the capacity of general practice, in hours and out of hours, is that the delimiter is the staffing, as the Deputy herself has described it. We want to develop those models-----
Róisín Shortall (Dublin North West, Social Democrats)
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Have the witnesses any idea what the limits are on employing GPs out of hours on a part-time basis?
Róisín Shortall (Dublin North West, Social Democrats)
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It is a skeleton service and based on the existing, out-of-date contract.
Róisín Shortall (Dublin North West, Social Democrats)
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Why are we talking about out-of-hours companies?
Róisín Shortall (Dublin North West, Social Democrats)
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Why is the HSE, as the health authority, not employing GPs to provide out-of-hours services?
Mr. Damien McCallion:
I will make two brief points. In the context of the Deputy's point about salaried GPs, and as she will know, discussions are ongoing on the new GP contract. That includes the ongoing expansion of the number of people who will be eligible for free care. There are scenarios in which GPs are employed to cover in certain centres.
In respect of the local injury units, LIUs, and to go back to the Deputy's original question, we have opened one new LIU in Mullingar. There is a review ongoing to look at whether there are other places where we could support that. We are also looking at staffing those units and extending their hours through the winter. Funding is available to expand their hours in order to try to make them consistent. We promote those units actively through various social media channels, local radio and so on through the winter. There is funding set aside for that. One of the challenges-----
Róisín Shortall (Dublin North West, Social Democrats)
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Okay.
Róisín Shortall (Dublin North West, Social Democrats)
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Then the HSE has to get national agreement on things. Why does the HSE not just try to recruit GPs to staff out-of-hours services part-time? That way, people would have an alternative to going to their local EDs. It is very regrettable that this has not been pursued seriously. In 2018, the then Minister announced that there would be salaried GPs. There has been zero progress on that. It is a proposal coming from the Irish College of General Practitioners again now as a way of addressing this. Again, this seems blindingly obvious, and it is regrettable that that has not been done.
Róisín Shortall (Dublin North West, Social Democrats)
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I would appreciate it if that were pursued seriously.
Róisín Shortall (Dublin North West, Social Democrats)
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The whole purpose of that, however, is just to fulfil an element of the contract, not to actually provide a realistic service, and that contract is very much out of date.
Róisín Shortall (Dublin North West, Social Democrats)
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There is something to be said for the HSE deciding that it will recruit staff to cover out-of-hours services, and I would appreciate it if the HSE were to pursue that.
I wish to get back to the issue of workforce planning. We had long discussions on this, as the witnesses will know, with Mr. Reid a number of weeks ago and we were promised a lot of material. We were told there were workforce plans and so on. There is no evidence of them. In the winter plan, there is a one-pager on workforce planning. I am just flabbergasted by the low level of workforce planning within the health service generally, at both Department level and HSE level. There is no medium-term planning, let alone long-term planning, and I just cannot understand why there is no serious function doing that. We end up, then, with money being provided for services, no staff being available, the HSE going all around the world spending a great deal of money and so on. The HSE does state in the winter plan that it will ask the emergency departments in hospitals and associated CHOs about this. The plan states that they "will outline what is required". It has been said delivery within six months is not possible, so why have the EDs and CHOs not outlined that long before now? Of those organisations, the EDs and the CHOs, which the HSE says will outline what is required, how many have provided plans in respect of the staff they need, and can the witnesses provide us with those plans?
Mr. Stephen Mulvany:
Each of the 29 hospitals with an ED has a local plan. Colleagues can talk about the specifics of the language and the word "will". To go back to the bigger workforce planning issue, maybe we need to provide more information, but I would be surprised if we have not provided everything we said we would provide. We will certainly check that.
The bigger issue, however, is that we know that the number of places for graduating nurses, healthcare professionals and doctors needs to be increased. We have seen the recent ESRI report, which makes it clear that the number needs to be more than doubled in some cases, and the committee has heard the Secretary General of the Department say that. Inside the HSE we have established a specific HR resourcing piece to look at our input to that process, so there is a lot of focus on growing the number of places. As the Deputy will know, that takes time and investment, so-----
Róisín Shortall (Dublin North West, Social Democrats)
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I have not seen any evidence of a workforce plan. The HSE talks about recruitment. There is no evidence of it doing a workforce plan to take us through, say, the next five to ten years.
Róisín Shortall (Dublin North West, Social Democrats)
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It was promised by Mr. Mulvany's predecessor.
Róisín Shortall (Dublin North West, Social Democrats)
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Can Mr. Mulvany provide those figures to us?
Róisín Shortall (Dublin North West, Social Democrats)
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Who is responsible for workforce planning?
Róisín Shortall (Dublin North West, Social Democrats)
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I would appreciate that. If the HSE could also give us the global figures in respect of the winter plan, not the individual plans, arising from its consultation with the EDs-----
Róisín Shortall (Dublin North West, Social Democrats)
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The figures as to what the EDs need. The HSE states in the plan that they "will outline" what is needed. Can the HSE tell us-----
Róisín Shortall (Dublin North West, Social Democrats)
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Has Dr. O'Connor global figures to address the EDs? How many?
Dr. Mike O'Connor:
From the point of view of the 447 WTEs, general support is 8.5. That extremely important therapy grade of health and social care professionals is 100. Management and administration, particularly around patient flow issues, which is also extremely important, is 46. Medical and dental, - although it is hardly dental, I suspect it is medical - is 40. Nursing and midwifery is 173.
Róisín Shortall (Dublin North West, Social Democrats)
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Are they contained in the plan?
Róisín Shortall (Dublin North West, Social Democrats)
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The plan says they "will outline".
Róisín Shortall (Dublin North West, Social Democrats)
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Can the witnesses just repeat that request for any details of workforce plans they have?
Róisín Shortall (Dublin North West, Social Democrats)
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I ask that they be provided soon, please.
Seán Kyne (Fine Gael)
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I welcome Mr. Mulvany and the team. I listened to the opening statements in the office, and I got most of the debate from members. I have a couple of questions. The sum of €6.8 million has been allocated to the National Ambulance Service for winter initiatives including the deployment of rapid handover teams. Are there rapid handover teams in all existing hospital EDs? Is this something new or how would it operate?
Dr. Mike O'Connor:
The purpose, and we did mention it earlier on, was that there would be a national ambulance person deployed in the emergency department to take patients from the inbound crews, which will then go back to doing the job they do so well. This has been piloted in Wexford and it proved very effective from the point of view of handover delays. On the basis of that Wexford pilot, the National Ambulance Service, which is very focused and always looking to the future, is looking to roll this out across the hospitals.
Seán Kyne (Fine Gael)
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Last year we had a debate on the winter plan and there was an allocation of 205 beds nationally, of which University Hospital Galway was getting zero. I had a big debate with Paul Reid and the team because at the time, one in eight patients on trolleys were in University Hospital Galway but we were not getting any additional beds. I note this year that, according to the local winter plan, University Hospital Galway currently has the highest average 8 a.m. trolley count for the year to date. We are told we are getting an additional two acute beds in University Hospital Galway this year, and an additional 19 public intermediate care beds. Yet in the same report we are told that last year, they provided an additional ten acute beds, six critical care beds and 37 public intermediate care beds. I am confused because last year we were told there were 205 additional beds nationwide but we were getting zero. Yet we were told after the fact that ten acute beds, six critical care beds and 37 public intermediate care beds were provided. I am a little bit confused between what is envisaged and what is delivered. I welcome any additional delivery but where is the lack of foresight in terms of what is going to be provided and what is actually delivered?
Ms Mary Day:
I just have details. I will come back. In relation to those 12 beds planned and as of 26 October 2022, 13 beds were delivered. However, I know in relation to Galway when they were putting in the new emergency department, they released beds back into the system. It is quite a nice interim development there. They have released 30 beds back into the system. That has happened in the last month. I think that will be seen in the trolley figures. They are still at an unacceptably high number but they are coming down relative to where they were during the summer.
Seán Kyne (Fine Gael)
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Okay. It relates to the opening of the temporary emergency department.
Dr. Mike O'Connor:
It is fluid and dynamic and in particular connected with the opening opportunity of the emergency department that 30 beds come on stream. I would, for the record, relate it to our engagement as asked by the CEO and the chief operating officer. They are very clear in their ask. The infrastructure in Galway rapidly needs attention. The ask for Galway, from the point of view of the beds, for the record from themselves, which has been validated more or less as 222 additional bed capacity.
Seán Kyne (Fine Gael)
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That is proposed to be provided in the cancer care centre on the grounds of University Hospital Galway. What University Hospital Galway has told us is that the current inpatient bed numbers of 683 are not sufficient to deal with the demands. However, we are providing two additional acute beds for the winter. I know last year they told us there was physically no space to put any bed anywhere, which I find hard to believe but that is what we are told. What can be offered from the HSE with regard to support around fast-tracking developments required in University Hospital Galway? There are four areas that Saolta hospital group is pushing. One of these is the emergency department plus maternity and pediatrics, which is with the Department in respect of the strategic assessment report, SAR, and the preliminary business case. There are the elective hospital plans in Merlin Park and the cancer care, which is to do with the 222 absolutely critical beds. There also are the new labs that are required. The winter plan is fine but this is the bigger picture of what is needed to ensure we will not be talking about additional capacity or the need for it. Those are the things we need to push as part of the winter plan.
Mr. Stephen Mulvany:
As the Senator said, the winter plan is not a solution to the overall infrastructure problems in Galway. The key points are that we accept there are significant infrastructural problems in Galway hospital. Its ED is probably the last of the EDs that has not either been refurbished or replaced in recent years. Generally speaking, there are a lot of challenges with the infrastructure. That is acknowledged. We will push ahead with those investments as quickly as possible but as the Senator knows, they are all multi-year investments. We will do what can be done to progress them and prioritise them in the overall sphere. In addition, and my colleagues may want to talk about individual detail, we are also focused on working with Galway to make whatever improvements they can make with the resources they currently have. As I have said, each of those investments is a number of years away. We will support the hospital site and the local community to make sure all the process improvements that can be made in advance of those developments are made, . However, there is no shortage of support from us in terms of progressing the capital developments.
Mr. Damien McCallion:
As Mr. Mulvany has said, capital developments take time. The winter plan is not the forum for beds and what we want to get to is having a clear plan, not just for Galway but for all sites. However, they are going to take time. The cost of capital investment etc. is rising, as the Senator knows. As part of the process, it is all the other investments too, such as the older persons teams, specialist teams, chronic disease management, the work around general practice, using community beds and private capacity. We are trying to use all of those to assist over the coming years while the other projects are advanced because they will take time. Clearly, we cannot have people in the situation they are in. We have to try to minimise that in an environment where demand is increasing. We talked about the numbers earlier. There has been a more than 5% increase year on year in ED attendances and higher numbers of older people being admitted to and attending EDs. All of those other pieces are really important and that opens up the wider questions about workforce and so on and how we structure the services, both inside the hospital and between the hospital and community.
Seán Kyne (Fine Gael)
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The local winter plan also talks of an occupational therapy seating clinic in University Hospital Galway to facilitate discharge. Is that something local to Galway or what does that initiative mean in practice? Is it for people who have been discharged on that day, that they have an area, or is this ongoing to be able to discharge them quicker?
Mr. Damien McCallion:
Each site would have identified their own local priorities around it so I could not say exactly what it is. There are the national pieces that are said are overarching. That is something Galway identified that would make a difference to them because we want to give people flexibility. We can certainly get that back to the Senator through his own local contacts.
Ms Yvonne O'Neill:
To the best of my knowledge, the seating clinic is about how an enhanced physio team can assist with getting people home more quickly, relating to their seating and movement requirements. I think that older people remaining at home, OPRAH, might be the initiative mentioned there. It was very specific in the plan that came back from University Hospital Galway,. It is a team with assistance and physios.
Seán Kyne (Fine Gael)
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I want to draw the witnesses' attention again to part of the winter plan, regarding discharge from University Hospital Galway to the regional hospitals. There have been issues in Clifden which they may be familiar with. That relates to staffing and to the lack of available staff and is something being faced across the more remote areas of public clinics and private clinics. There will be statements in the Seanad today on private nursing homes. Is there more that can be done on international recruitment for nursing and care staff for public homes, particularly the regional homes?
Mr. Stephen Mulvany:
We are very aware of the specific situation in Clifden with the two sites. In fairness to the staff, they have done everything they can to be as flexible as possible in managing both sites. The solution in the longer term is a new site on which the two services can be brought together.
We are focused on recruiting internationally. As I said, approximately 1,400 nurses have been recruited and have arrived already this year. A further 300 are in pipeline for arrival either late this year or early next year. Much of the recruitment for home support and home care assistant staff is done locally, with local community teams trying to recruit. I have seen some of the information on this and, in fairness to the teams, they are doing what they can to staff those units.
Seán Kyne (Fine Gael)
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This particular facility is an hour away from GUH and is very much in demand. The local doctors wish to see it continue in operation and to ensure there is a palliative or end-of-life service as well. The number of deferrals has dropped because of the lack of physiotherapy services in Clifden. Recruitment can solve the problem of a lack of service and reduce pressure on GUH by getting people closer to family support, allowing for visits and all of that. I ask Mr. Mulvany to keep an eye on the situation and to do what he can to ensure that the service is enhanced. There is funding and capacity there, but recruitment and retention of specialised staff is an issue.
Seán Crowe (Dublin South West, Sinn Fein)
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A number of issues were raised during our discussion. The witnesses have said they will come back to us in regard to workforce planning, overall waiting lists and several other matters. This has been a useful meeting. We wish the HSE well with its winter plan. A number of members questioned the credibility of the plan and asked whether additional beds, staff and so on that have been announced will be in situthe following year. That is an issue. There is a case for multi-annual planning rather than having a specific plan for each year. I wish the witnesses well and thank them for assisting the committee with this important matter. We will continue to monitor closely progress and developments in regard to the winter plan. We also look forward to considering the HSE's plan for 2023 when it becomes available. I wish Mr. Mulvany and his team well.