Oireachtas Joint and Select Committees
Wednesday, 1 March 2023
Joint Oireachtas Committee on Health
Sláintecare Implementation: Centre for Health Policy and Management, Trinity College Dublin
Seán Crowe (Dublin South West, Sinn Fein)
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Apologies have been received from Deputy Neasa Hourigan. Before we get to the main item on today's agenda, the minutes of the committee meetings of 15, 21 and 22 February 2023 have been circulated to members for approval. Are they agreed? Agreed.
The purpose of today's meeting is for the joint committee to consider issues relating to the implementation of Sláintecare reforms with representatives of the centre for health policy and management from the school of medicine, Trinity College Dublin. I am pleased to welcome Dr. Sara Burke, associate professor in health policy and management, Professor Steve Thomas, Edward Kennedy chair of health policy, and Dr. Bridget Johnston, research assistant professor.
All 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 and it is imperative that they comply with any such direction.
Members are reminded of the long-standing parliamentary practice to the effect that they should not comment on, criticise or make charges against a person outside the Houses or an official, either by name or in such a way as to make him or her identifiable. I remind members of the constitutional requirement that they must be physically present within the confines of the Leinster House complex in order to participate in public meetings. I will not permit members to participate when 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 any members participating via Microsoft Teams, prior to their contribution to the meeting, to confirm that they are on the grounds of the Leinster House complex.
To commence our discussion, I invite Dr. Sara Burke to make her opening remarks on behalf of the centre for health policy and management, Trinity College Dublin.
Dr. Sara Burke:
Good morning. I thank the Chair and committee for inviting us to appear before the committee to discuss Sláintecare's implementation. The chair has introduced us already. One reason I am here is that I lead on a project funded by the Health Research Board, which is harnessing the lessons from the Covid-19 health system response to inform Sláintecare. With me is Dr. Bridget Johnston, who is leading her own research project on palliative care. She led on an aspect of Foundations, which was reviewing the international evidence on population-based resource allocation policy, which is particularly relevant to the roll-out of Sláintecare in the regions. Professor Steve Thomas, is the Edward Kennedy chair of health policy in Trinity and a Health Research Board research leader with his RESTORE project, which is evaluating international health system reform and resilience, which is also really relevant today. The three of us had the privilege of being part of the Committee on the Future of Healthcare, chaired by Deputy Róisín Shortall, which produced the Sláintecare report.
Sláintecare is a ten-year plan for health reform which outlined a high-level road map to deliver universal, timely access to quality, integrated health and social care in Ireland. In July 2019, the Oireachtas report on Sláintecare was adopted by Government in the form of the Sláintecare implementation strategy. Laura Magahy was appointed Sláintecare executive director, heading up the Sláintecare programme implementation office in the Department of Health in September 2018. The first annual action plan was published by Laura Magahy and her team in February 2019. While there are differences in emphasis in the reports, in its essence, Sláintecare is quite simple. It is about how everyone in Ireland can get timely access to the right care, in the right place, at the right time. Achieving this plan was underpinned by delivering much more and better public health so that everyone is supported to live healthier lives, a universal entitlement to the public health system with much greater provision of care outside of hospital, and the delivery of quality, integrated care at the lowest level of complexity.
Other important components include the removal of barriers to care such as charges, waiting times - a key component was the reduction of waiting times - supporting the workforce and building up the capacity of the public health system to deliver this care, including the removal of private practice from public hospitals. These actions, as well as strong implementation measures, will ensure the system is accountable and transparent and, critically, that it strives to meet the needs of everyone but particularly those who need it most.
Early progress on Sláintecare has been slow. The Government was slow to adopt the report and then slow to act on it. One of its first actions was to bring the Sláintecare office into the Department of Health contrary to the original Oireachtas report's recommendation for it to be in the Department of An Taoiseach.
Up to early 2020 and Covid-19, there was not the financial resource allocation or political priority needed to implement extensive reform such as Sláintecare. This was evident in the failure to match free care commitments in the original report. That said, in the months approaching the start of Covid, momentum was building around Sláintecare. That was evident from joint work between the Department and the HSE on the regions, the beginnings of good community and stakeholder engagement, the establishment of the Sláintecare integration fund and the publication of the de Buitléir report, which endorsed the removal of private practice from public hospitals.
When the pandemic arrived, pretty much everyone involved in Sláintecare was redeployed to the Covid-19 health system response. It quickly became apparent that Covid-19 was not a short-term crisis. People began to realise that many of the most appropriate Covid-19 health system responses were closely aligned to Sláintecare, including a big push on prevention in public health, keeping people out of hospital, significant extra investment to build up the health system’s capacity and the roll-out of all Covid-related services as universal, free at the point of delivery, with access based solely on medical or health need. Furthermore, there was a fresh realisation of the high value of a well-functioning health system to the economy and broader society.
Key publications during Covid include the 2020 programme for Government, the HSE corporate plan and the 2021 Sláintecare implementation strategy and action plan. These showed much stronger alignment between the different parts of the system with the Government, the Department of Health and the HSE operating in tandem with the aim of delivering on Sláintecare. This combined with significant additional resource allocation during Covid to health allowed the system to boost its capacity with there now being an extra 18,000 whole-time equivalent HSE funded staff as well as many more hospital beds, and community investment. These have all helped to advance Sláintecare.
Research led by Dr. Sarah Parker shows an agile health system response during Covid with those in leadership and on the front line freed up to provide universal access to integrated care during the crisis. The research found that this was nurtured through the whole system having clear, common and shared goals and information, as well as harnessing, sharing and supporting innovation. The research also found that trust and relationships were key to providing better and more accessible care during the pandemic. Finally, the research found that the system is at significant risk of reverting to type now and not holding on to the positive impacts of the pandemic.
Other research led by our colleague, Dr. Padraic Fleming shows that while there are significantly many more staff in the health system, we are still continuing to make the mistakes of the past and putting those staff in acute hospitals. We need many more staff in hospitals but, ultimately, for Sláintecare to succeed we need many more staff in primary, community and social care settings.
While our research has found positives during the Covid response, there are negative impacts of the pandemic, which is most evident in longer waiting times to access care and a demoralised and tired workforce. Another paper we jointly published in The Lancet Regional Health in 2021 concluded that Covid boosted Sláintecare’s implementation and had the possibility to transform the Irish health system. However, within days of The Lancetpublication, Sláintecare’s lead, Ms Laura Magahy, resigned citing slow progress in three key areas requiring dedicated, focused reform, which are regional health areas, RHAs, ehealth or digital health and waiting lists. Upon her resignation, Ms Magahy specified that these reforms required a governance and oversight structure other than that which existed, in particular in light of the substantial additional funding being allocated towards the reform of the health services. Professor Tom Keane, chair of the advisory council also resigned. What followed the resignations was the dissolution of the Sláintecare programme implementation office and the Sláintecare implementation advisory council with the Minister for Health, Deputy Donnelly, appointing Mr. Robert Watt and Mr. Paul Reid as co-chairs of the newly-established Sláintecare programme board. There were various appearances by the co-chairs in front of this committee, in 2022 as well as by the acting CEO, Mr. Stephen Mulvany at the previous meeting of this committee. Last year also saw the publication of the business case for the regions, the Sláintecare progress report for 2021 that was published in April, and the 2022 Sláintecare action plan that was published in June. Of note, no Sláintecare progress reports have been published since December 2021.
On the plus side, last October’s budget detailed health measures that are very much aligned with Sláintecare, for example, the abolition of hospital fees. which were originally earmarked for year 1 of Sláintecare; more significant budget allocation to health and plans to extend free GP care to 500,000 people based on low income. These measures are all significant for people in the midst of a cost-of-living crisis. Last December, the Government announced its approval of a public-only consultant contract and the next steps for the development of two elective-only hospitals with the Minister, Deputy Donnelly, retaining the health brief despite a Government reshuffle. What we can see was another loss of momentum after the Sláintecare resignations but greater momentum built again in 2022, and this happening alongside most new services being universal and free at the point of delivery.
Work we are currently conducting on the implementation of the regions is finding a changing governance architecture and an absence of clarity on roles and responsibilities, leading us to question if we have ever had the right governance architecture for Sláintecare. A key question for this committee, which monitors Sláintecare's implementation, is: what is the optimum governance structure for Sláintecare? This research is also finding that the RHA design is a top-down process and it is not inclusive of key stakeholders such as GPs, voluntary organisations and citizens. That makes us question the type and quality of engagement and participation in the reform process as well as conflicting policy directions. The committee has significantly argued those here and one such example is the regions, an issue to which we can return. There are also persistent delays. For example, the RHA implementation plan was due to be published last year and remains unpublished. There is no HSE national service plan yet, even though today is 1 March 2023 and there is no Sláintecare action plan for 2023. That said, progress is happening in the context of significant extra Sláintecare health budget allocation, and political priority in the form of strong ministerial support for universal healthcare and most services being introduced as universal and free at the point of delivery.
In conclusion, in terms of Sláintecare implementation we have a mixed score card. Each change that happens is welcome but not enough when situated within the bigger picture of whole-system reform. An example of this is the current Government commitment to give GP visit cards to all households whose income is €46,000 or less from April. The original report envisaged the roll-out of universal primary care not just GP care, and that primary care would happen in tandem with GP care. That would allow care to be provided at the lowest level of complexity and cost, and not overwhelm GPs. It will be hard or impossible to realise Sláintecare with piecemeal reform. What is needed is whole-system reform and recognition that we are only now at the starting point of proper implementation. Delivering Sláintecare in full will require years more of high political priority, resource allocation and skilled leadership, as well as meaningful and consistent engagement with all stakeholders, including citizens and those on the front line. We look forward to questions and discussion. I thank members for their attention.
Seán Crowe (Dublin South West, Sinn Fein)
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I thank Dr. Burke and call Senator Martin Conway.
Martin Conway (Fine Gael)
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I thank Dr. Burke for attending and for her work over the years in supporting, in particular, the Oireachtas Committee on the Future of Healthcare, which was chaired by Deputy Shortall.
Can Dr. Burke understand why Ms Laura Magahy stepped down? Did her resignation significantly set back the roll-out of Sláintecare? Has Dr. Burke engaged with Ms Magahy since she stepped down? Can she shed further light on Ms Magahy's reasons and rationale for stepping down?
Dr. Sara Burke:
My understanding and my read is only from what is in the public domain about Ms Magahy.
She was the lead knowledge user on my research project, so I worked closely with her. I have had personal interactions with her since then but have not discussed the details of this.
My read on it is that during Covid, much more money was allocated throughout the health system, and while about half of it related to Covid, about half of it could be also considered as relating to Sláintecare implementation and, in particular, to the areas she cited, namely, the roll-out of the regional structures, digital health and waiting lists. Big money was put in and there was a big push on implementation. Ms Magahy was deputy secretary general in the Department of Health and was leading on the reform programme but, in fact, it is the Health Service Executive that will deliver on that reform. She was given responsibility, therefore, without the authority to deliver on it. For me, that is the crux of the matter and it is why I raised the issue of governance.
Martin Conway (Fine Gael)
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Does Dr. Burke think the Sláintecare programme board that has been established, with the Secretary General and the CEO of the HSE as co-chairs, is a structure that has the authority to drive it forward? Does she have more confidence in that structure?
Dr. Sara Burke:
I think it has the authority but there are fundamental problems with it in that it is responsible also for the day-to-day delivery of the health system, which is consistently under pressure. Therefore, it is difficult for that board to have the time or headspace to deliver on reform. Moreover, delivering on reform requires doing very differently what is being done every day, hence the original recommendation that there be an engine to drive the reform. I still think we need to have an engine to drive the reform but also to do the sort of boring tasks such as producing progress reports, action plans and key indicators of success such that the likes of this committee and those of us on the outside can monitor the programme’s success. We need that engine room but I do not see it.
Martin Conway (Fine Gael)
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Does Dr. Burke think the appointment of those two individuals - I refer not to them personally but to their positions - presents a conflict of interest in driving the change agenda?
Dr. Sara Burke:
I am totally absorbed in this but even I do not understand who is actually responsible for Sláintecare. The head of the HSE reports to his board and the head of the Department of Health reports to the Minister. Who is actually responsible for delivering on Sláintecare?
Martin Conway (Fine Gael)
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The argument that might be made to counter that is that the entire healthcare system should be responsible for implementing Sláintecare.
Martin Conway (Fine Gael)
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What changes would Dr. Burke make to the Sláintecare programme board?
Professor Steve Thomas:
I might return to the Senator’s question in a roundabout way. In the austerity era, one thing that really held back some of the reform initiatives related to dealing and coping with the crisis. The pressure of Covid on waiting lists and staff has absorbed a lot of headspace, not least for those at the top of the Department of Health and the HSE. There probably needs to be a distinct governance structure that would lead on Sláintecare and provide the relevant resources, brainpower and energy and focus to it. Ultimately, of course, the heads of the Department of Health and the HSE will have responsibility, but there is a danger the authority lines will be blurred for those who can provide the relevant capacity and energy to drive the reform.
Martin Conway (Fine Gael)
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I accept that. What are our guests' views on the new consultant contract? Does it embody where we want to bring consultants in the context of Sláintecare?
Dr. Sara Burke:
Yes. It was a small but important component of the original recommendation. It would not be possible for there to be universal access to public hospital care if private patients could get in more quickly. That would not be universal access because some people would be getting speedier, privileged access. The Government has tried many mechanisms that have failed to deliver on access to care in this way, so the introduction of public-only consultant contracts is a key component of the delivery of universal access to the public health system. It has been very slow. It was first recommended in 2017, the de Buitléir report recommended it in 2019 and we are still not quite out of the traps on it. I recently spoke at a conference with Mr. Robert Watt and the head of the Irish Hospital Consultants Association, IHCA, and the mood music between them was very positive. They felt that within weeks, the contract would be agreed. The head of the IHCA indicated he expected a good uptake of the contract, especially among younger consultants.
The system will not move overnight to public-only consultants. Any consultants who sign a contract today, if they sign a public-private mix, will be able to continue with that mix for the rest of their lives. I think Deputy Shortall had to get Attorney General advice regarding the legality of it when we worked with the committee on this. It will take ten, 20 or 30 years to wash out the public-private mix contracts from the system and that will be a good safety net.
Martin Conway (Fine Gael)
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The pandemic has shone a strong light on public health. Does Dr. Burke, having worked on the Sláintecare report, agree we are much closer now to where we want to get to with public health than she earlier envisaged we might be? Does she consider that to have been one of the upsides of the pandemic?
Dr. Sara Burke:
There are upsides but we are starting from decades of underprovision. Public health doctors were not approved as the equivalent of consultants until the pandemic. I am not sure how many consultants or specialists are now in the system but we are decades behind international progress in public health. What has happened is good and there is much better public recognition of the importance of public health and of the logic of planning the delivery of our health system, but we need many more public health specialists in the system and they do not have to be just medics. In other countries, there are lots of multidisciplinary public health people.
Martin Conway (Fine Gael)
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We are a long way from the public having a mindset whereby, if people want a public health service, they have to pay for it, and that means forgoing tax cuts. Dr. Burke posed a question to us in her opening statement regarding governance and stated it was a matter for the committee to consider in the context of the future governance architecture of Sláintecare. How does she envisage the governance architecture of Sláintecare?
Dr. Sara Burke:
This goes back to the Senator's first question, regarding the programme board. I take on board his point that we need the Secretary General and the head of the HSE to be part of that reform leadership, but what we are leaning towards is that there is a good case to revisit that. The original recommendation was that there would be an office in the Department of the Taoiseach. We need that level of political accountability whereby somebody would lead on Sláintecare reform in line with the Secretary General of the Department of Health and the head of the HSE.
Martin Conway (Fine Gael)
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Turning to the regional health areas and the structure that has been proposed, should they be their own legal entity? What is Dr. Burke's view on that structure?
Martin Conway (Fine Gael)
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What is Dr. Burke's view on it?
Martin Conway (Fine Gael)
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I appreciate that. We will see what the officials have to say.
David Cullinane (Waterford, Sinn Fein)
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I welcome our guests. I apologise that I will have to leave after my contribution given a motion on the National Ambulance Service, on which we have to speak as party spokespersons, is to be taken in the House.
It is unacceptable that all these years after Sláintecare was created, we are still having discussions about delivery mechanisms, who is accountable for what and governance issues. That, in and of itself, sums up the approach. We have gone from having Ms Magahy as the executive director of Sláintecare and the Sláintecare programme implementation office to a structure that now designates the heads of the HSE and the Department as the two key drivers of Sláintecare.
They have, of course, an important role to play in their leadership positions, but there is no identifiable person whose sole job it is to ensure all the elements of Sláintecare are pulled together.
It was a mistake to not have gone with the committee recommendation of placing this under the Department of the Taoiseach. That would have given it the prominence and political leadership Sláintecare needs. There should have been a Cabinet subcommittee made up of the Minister for Finance, the Minister for Public Expenditure, National Development Plan Delivery and Reform, the Minister for Health, and the Minister for Further and Higher Education, Research, Innovation and Science because workforce planning is such a crucial issue to healthcare delivery as well. I will not ask our guests if not doing this was a mistake because I do necessarily want them to step into the political sphere. Would they contend that it is the best option and that we should still look at placing the delivery of Sláintecare under the Department of the Taoiseach? Is that their view as people who were part of the process when the programme was being put together?
Professor Steve Thomas:
I thank the Deputy for the question. Sláintecare requires a massive amount of investment. It is a complex system reform. It is not really part of the day-to-day management. As we have looked at, there is competition between the day-to-day management and radical reform processes. Also, the proof of the pudding is in the eating. We do not have free GP care. We do not have reduced waiting lists. We do not have private care out of public hospitals. We do not have the regions. This is all despite us being six years on. Thus, the current mechanisms do not seem to have delivered, although it could be argued we have had lots of different things going on in the background. There are big questions to ask about the appropriate governance and obviously the appropriate political commitment and resourcing that go along with that. I am supportive of going back to the original design if that then means we have the appropriate political commitment and the appropriate drive and resource allocation to back it.
Dr. Sara Burke:
I argued contrary to my colleagues and many people on the original committee. I felt at that time like it should be in the Department of Health. I thought if that Department is not doing it then what Department should it be, but it was the committee that determined it should be under the Department of the Taoiseach. The committee was right. A fundamental issue with the Department of Health and the HSE leading on Sláintecare is they must change for it to be delivered. This is not about everything new that is happening, namely, universal services free at the point of delivery, because to a certain extent that is actually happening. It is instead about the 95% or 98% of other work in the system that needs to change. The structure of the Department of Health pretty much still operates in those old pillars of primary care, community care, disability and mental health.
David Cullinane (Waterford, Sinn Fein)
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I will come in on my second issue, because that is what I wanted to deal with. I have four areas and probably will not get to all of them. Governance and regional health areas was my next topic. I was not part of the original Sláintecare committee, but part of the logic of the regional health areas was to end that siloing whereby primary care was over here, acute care over there, community in the middle and a bias towards investment in acute hospitals as opposed to investment in community care. We do not seem to have learned the lessons.
I will get to the regional health areas in a second, but if we look at what happened over the last couple of months in emergency departments, we have had the wrong people going to the wrong place. It is estimated about 40% of people who are in emergency departments cannot get access to out-of-hours GPs and are not being managed in the community despite the enhanced community care programme put in place. There is movement there but we are still not getting that right. It strikes me we are a long way away from the simplicity of the argument for Sláintecare, which was right care, right place, right time. That is not happening and the evidence of that is in the first instance in our emergency departments. It is also in hospitals where people are not discharged into the community.
My understanding of the regional health areas is they were to pull all of that together into a single structure, and then we would be able to start prioritising what we spend our money on and where, in order to get good value for money and better patient outcomes. I may as well finish my question because we have limited time. An argument we, as politicians, get back on healthcare is we are spending all this money, which is now €22 billion, and our guests want us to spend more money, but at what point do we ask whether we are getting value for money. In that context, do our guests agree putting in place the regional health areas and having that single structure to ensure we are making the right investments in the right place is going to be key to that, if we are to convince people Sláintecare is actually going to improve healthcare? What people look at are the waiting times and waiting lists. There are still just under 900,000 people on waiting lists in hospitals. There are 240,000 people waiting for a diagnostic scan and 230,000 more people on community waiting lists. Waiting lists are lengthening in some areas and shortening in others but they are still unacceptable. I would like our guests' thoughts on the logic of the regional health areas. There is a debate around what power they should have versus the HSE centre, but how important are the areas to the delivery of the reforms?
Dr. Sara Burke:
They were key. Again, they were an issue the committee spent a lot of time on. We realised we had to have them. Some sub-national structure was needed to allocate resources on the basis of need. We do not do that at all at the moment. Dr. Johnston has done work on population-based resource allocation, so she may want to come in on that. It was a mechanism for that and a mechanism for governance and accountability so we stop having the command-and-control centralised structure we currently have, and also for the delivery of integrated care. It would acknowledge that different regions would want to provide care in different ways, because if you are doing it in Donegal it is very different to doing it in Dublin or Cork. The regions are essential to that delivery.
David Cullinane (Waterford, Sinn Fein)
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I will leave Dr. Johnston to come in on population-based budgeting, which is going to be part of the regional health areas and is important.
I have a quick query on free GP care, which obviously needs to happen. However, do our guests agree we must get the foundations right? This would mean ensuring we are training more GPs, looking at a new contract for them and also examining directly-hired GPs, which is something I am supportive of. Have our guests given this some consideration? GPs tell me if we go too quickly on this and the capacity is not there, we will end up with longer wait times. How important is it we put that infrastructure in place?
Professor Steve Thomas:
On the GPs, it is critically important the capacity is there, otherwise we will have an experiment that brings a notional reform we cannot actually deliver. What was always in the heart of Sláintecare was we would have a transition fund to fast-track the training of GPs and other primary and social care professionals to deliver meaningful universal community healthcare.
David Cullinane (Waterford, Sinn Fein)
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Have our guests considered directly-hired GPs?
Dr. Sara Burke:
I think it was. There was stuff around having them in deprived and places where it is hard to get them, including the islands and rural areas. That is a model used internationally, because that is something the committee looked at then too. There is no reason not to do that as well, but we really need the nurses and allied health professionals. In a way, we now need to provide everybody with free access to them and 24-hour triage up front before doing the free GP care because we just do not have the capacity to deliver free GP care at the moment.
Dr. Bridget Johnston:
Population-based resource allocation, PBRA, is a mechanism that will underpin the regions. There is no point in the regions without the regional models of allocation because that is the way we can respond to the needs and ensure there is equitable allocation. One of the main points in terms of implementation is that the key lesson internationally is the co-design, bringing people on from the beginning and having transparent governance, structures and reporting around that are key to getting to stakeholder engagement and buy-in. It is a major change to how things are done right now. We fund what we have always funded and we continue to do it that way in these block grants. To get people into major system change it is important open the doors and be honest and transparent quickly. We need to be nimble, update the model as it goes, accept the limitations of the data and work through it with people.
David Cullinane (Waterford, Sinn Fein)
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We are waiting for it as well.
David Cullinane (Waterford, Sinn Fein)
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Agreed. I thank Dr. Burke.
Róisín Shortall (Dublin North West, Social Democrats)
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I thank everyone for attending and for their presentations. It is always worthwhile hearing expert voices from outside the political system and to have an assessment of performance. It strikes me the points made about the experience during the Covid-19 pandemic are very important. The approach taken during the pandemic encapsulated the kind of principles underpinning Sláintecare. A point I sometimes make outside is that I do not think that anybody, for a moment, would have contemplated dealing with Covid-19 through a two-tier system where people could buy their way to receiving treatment for Covid-19 or access to vaccines or testing. It had to be a single-tier system. Strong lessons from that experience must be taken on board in respect of the necessity of taking a population-based approach and provision on the basis of need. Nobody would have contemplated having a situation where people with private health insurance who had Covid-19 could get quicker treatment or a ventilator faster in hospital.
As was said, the major problem is that after the main threat of Covid-19, we reverted to type and went back to a situation where people could buy their way into healthcare. This is obviously regrettable. There is no doubt, however, that there are big interests pushing private healthcare and it is very difficult to counteract these. One area I must say I am particularly concerned about now is that while, in theory, the Government is supporting expanding access to public health services, particularly at community level, the major thing holding us back is the lack of staff. We now have a situation where substantial additional money is being provided but the staff are not there. This results in the outsourcing and buying-in of services and leaving it to the private sector. We have this creeping privatisation of the health service. While, in theory, everybody signed up to developing a full universal public health service, what is actually happening in practice is this creeping privatisation. My concern is that we will get to a tipping point in this regard. At the back of all this, is the fact we have virtually no workforce planning going on at all within the health service. We have raised this issue several times at this committee. No significant workforce planning is going on.
I would like to get the views of the witnesses on this point. Where should this work be done? I know that when Sláintecare was being developed, Professor Stephen Kinsella from the University of Limerick, UL, was supposed to undertake work in this context. I do not think it was ever done. Unless we have the staff available we will not be able to expand public health services, especially at community level. I refer as well, of course, to the availability of hospital doctors, GPs and so on and so forth. What are the views of the witnesses on these aspects? Do they share this concern about the absence of workforce planning?
Dr. Sara Burke:
I might make a brief comment and then pass the ball. I totally agree with the Deputy. A key part of the original Sláintecare report was integrated workforce planning. Aspects of workforce planning are happening in the system but a bit like the management side of things, this is happening in silos. It is only for doctors, specialists or nurses. To deliver Sláintecare, we need this integrated planning, especially at the lower level of complexity. This aspect is, therefore, really needed. One of the reasons we are in the situation we are in is that there is not this dedicated drive on reform, pushing these underlying important building blocks to deliver on reform. This is because the system is so focused on firefighting now. Professor Thomas is doing a lot of work on workforce planning and he may wish to comment on this point
Professor Steve Thomas:
Yes, I will. Internationally and across Europe, the countries that did well during Covid-19 were those that had universal systems. These give us much better preparedness for shock. As we go forward and face the cost-of-living crisis, the argument for having a universal system is even stronger. This is a general point. Resilience is always founded on a well-motivated, well-engaged and protected workforce, with the right people in the right places at the right time. One of the things we have got to be very careful of in the context of Covid-19, and again this has been the case across Europe, is that we have taken our workforce for granted. We have required people to go above and beyond the call of duty. Now, there is a real problem with staff turnover, with disengagement and with demoralisation. The importance of workforce planning, therefore, in its broadest remit is incredible.
One of my critiques of workforce planning to date is that it has tended to be quite siloed. It is often concerned with a particular type of consultant or just GPs, rather than thinking about things in the round in relation to the provision of integrated care. Workforce planning, therefore, must go hand-in-hand with the regionalisation process. I do not see these two things connecting at the moment and this is very much at our peril. There are very high staff turnover rates now, not just for consultants but also for therapists, psychologists and key people in the system. If we do not protect them, then we will be in real trouble in trying not only to deliver Sláintecare but to recover from the cost-of-living crisis and to get through Covid-19.
Dr. Sara Burke:
One of Deputy Shortall's questions was who should do this workforce planning. I heard her ask the Secretary General, Mr. Watt, whether help was needed and if a team was needed to work on this aspect. He said "No, we are fine", or that is my memory of his response. I disagree. I think we need that. The most crucial issue in delivering on reform is our workforce and we have staff who are very tired and burned-out being continuously asked to do more. In this context, what is needed is a national task force, with all the key players working together and with an engine room of academics, and obviously I would say that, and other people. A lot of number crunching and important processing work must be done, as well as collecting data and getting people on board. This undertaking, therefore, should be a really high political priority. A national task force and a team with independent expertise should be supporting the Department of Health and the HSE in this endeavour. I say this because, from my perspective, they do not have the capacity to do this work themselves.
Róisín Shortall (Dublin North West, Social Democrats)
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Yes, okay. There is probably a strong argument for having a unit of the Central Statistics Office, CSO, based in the Department of Health as well. I am not aware of there being any number crunchers in the Department.
Róisín Shortall (Dublin North West, Social Democrats)
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I am referring to number crunchers from the perspective of population projections and these kinds of aspects. I know that on the economic-----
Dr. Sara Burke:
On the Deputy's previous point concerning creeping privatisation, a good example of this is access to diagnostics. This is, again, a key component of Sláintecare. Good progress was made on this during Covid-19, in that GPs got access to diagnostics. This is, however, in the private sector and I do not know how much is happening to build up this capacity in the public sector. This is what needs to happen. It is not just about diverting this need to the private sector but about building up the public capacity to deliver this as well.
Róisín Shortall (Dublin North West, Social Democrats)
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Yes. I think Dr. Burke's points on governance are well made but we must also be getting the big elements right. Workforce planning is one of these, as is e-health. We have had sessions here recently where we heard that hardly anything is happening in this regard. We are pursuing this aspect with the Department.
Moving on to the question of the regional health areas, RHAs, separately, as a committee, we have been having briefings with the Department on this matter. I think it is true to say that the Department is shifting its position. We very much welcome the advice from the advisory body. We had Leo Kearns in here and he was very impressive. Many of us, however, cannot help thinking that the actual business case is going to constrain progress in this regard. Three options were set out to the Cabinet and it opted for the second one, which was to do a bit but not to do the whole lot. The RHAs in this scenario will also not be legally underpinned in respect of accountability or responsibility. I would like to hear Dr. Johnston's perspective on this point. Is she of the view that this business case will need to change, if we are to realise the potential of RHAs?
Dr. Sara Burke:
I might come in on this point, and then Dr. Johnston can comment as well. I have been doing more work on the regions and Dr. Johnston has been busy with palliative care policy for the last while.
If we are going to do the regions properly and allocate resources through them, I am not sure that can be done without a legislative underpinning. Clarity from the Department and the HSE is needed because that takes time. If we were to begin that now, I do not know how long it would take, but I think it is needed. I do not know how else the money could be funnelled so that they have the power to allocate it without some legislation.
Róisín Shortall (Dublin North West, Social Democrats)
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Power has to be devolved.
Róisín Shortall (Dublin North West, Social Democrats)
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The third business case that went to Cabinet proposed a lean centre. That is what we need. Unless the centre of the HSE is lean, authority and responsibility will not be devolved to the regions.
Dr. Sara Burke:
The Deputy and I discussed this five or six years ago. There are issues with introducing new structures in that the system is disrupted so much that it takes it five years to get back to the starting point again. It is not a simple issue. The transfer is a very complicated and tricky issue
Róisín Shortall (Dublin North West, Social Democrats)
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I accept that but the counterpoint is that clear commitment from Government to introduce reform would give people confidence and would help to retain staff or attract staff back to Ireland. People would see that the Government is at last serious about reform.
Róisín Shortall (Dublin North West, Social Democrats)
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All these things are connected, I suppose.
Dr. Bridget Johnston:
Regarding the regions, I have spent the last year in the Department of Health helping with the new national palliative care policy for adults. We have seen the ambiguity around regions and what that leads to regarding being able to set out policy directions for health services going forward. From my own experience, I see the need for strong structures at the regional level to bring together providers. Integrated care relies on providers being able to work with each other and not work against these different structures or silos. The regionalisation, if put forward as envisaged in the original report, would remove some of those artificial barriers and allow true integration and flexibility to respond to the population there rather than it being dictated from the centre control where everybody does more of the same but with the money being allocated slightly differently. This is about a real shift, so the two come together. Without them, the intention of either is weakened.
Gino Kenny (Dublin Mid West, People Before Profit Alliance)
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I thank the witness for her statement. It was quite a refreshing critique of Sláintecare. We have been speaking about this for a considerable amount of time. On the implementation of Sláintecare, it was said it has a mixed scorecard. What score would the witnesses give it out of ten?
Gino Kenny (Dublin Mid West, People Before Profit Alliance)
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Four out of ten thus far.
Gino Kenny (Dublin Mid West, People Before Profit Alliance)
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That is really low.
Dr. Sara Burke:
It is, but it is really hard to change. We often talk about the health system as like being on an enormous aircraft carrier where it is really hard to change direction. We are changing the direction in the right way but much more needs to be done. There are key building blocks of governance, digital health, workforce, continued political leadership and drive, coherence at the top and the Department and the HSE reforming that need to be addressed. There is lots to be done to deliver on Sláintecare but maybe my colleagues would be less harsh in their appraisals.
Professor Steve Thomas:
The commitment to remove hospital inpatient fees was planned for the first year of Sláintecare. It is now being delivered in year six or year seven. It is not a very expensive thing to do. It was an early win that would have signalled the seriousness and commitment of the Government of the day to implement Sláintecare. It has no system implications other than a funding gap. I have no idea why it was not done but it is quite reasonable.
Gino Kenny (Dublin Mid West, People Before Profit Alliance)
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Piecemeal reform was mentioned in the statement. Is that how the witness views progress regarding Sláintecare?
Dr. Sara Burke:
In preparation for this appearance I read the most recent minutes of the Sláintecare programme board and they talked about strong progress on projects. For me, even talking about projects is part of the problem. They look at waiting lists, they look at enhanced community care and then there is a section around digital health that is unreadable and does not tell me anything. Part of the problem is that it is viewed as a project rather than the whole system reform we described previously. It is like the back side of a clock and all these cogs need to be turning to deliver the reform. This is why we need the engine room of oversight and dull things like progress reports and action plans with specific targets so that there is a transparency between what the system is saying it is doing with €20 billion plus of public money and what is actually happening. Are we making progress or not on waiting times? Are we delivering? How many more people are getting their care in the community?
Gino Kenny (Dublin Mid West, People Before Profit Alliance)
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It has taken a crisis like the pandemic to expedite some of these reforms. As Deputy Shortall said, during the height of the pandemic the notion of private and public health care just went out the door. Sláintecare is trying to provide universal healthcare for everybody. However, that is not the reality. More than 50% of people in this country have to rely on private healthcare. That says something about our health service. Why did it take the crisis of the pandemic to expedite some of these reforms? Surely alarm bells should ring straight away that it took a pandemic to move things on.
Professor Steve Thomas:
We should give credit where credit is due. The Government put a lot of money into the system during Covid. It realised the huge value of healthcare. Unlike in many other countries, a lot of the money was directed towards system capacity and changing things for the better. Why did it not happen earlier? Did it really need to take Covid to do this? Did it really need to take the cost-of-living crisis to show us that people need help when they are accessing care? Unfortunately, it appears that it did. There is a certain amount of ruefulness. From some of the conversations I have been having with some of the decision-makers in the Department, the system would have been much better prepared for Covid if they had advanced the universal agenda earlier. That is now spilled milk, as if it were. Nevertheless, there is a new realisation that healthcare is not just important for people who are sick but it is also important for the economy and for society going forward. If something good has come from Covid, it may be that there is this renewed focus, that the money that has gone into health can stay in health and actually help us deliver universal care, which is what we need.
Dr. Sara Burke:
It often takes a crisis to instigate major policy change. The NHS was born out of World War Two so it is not that unusual. It is a good question and I think understanding it is a key part of delivering the reform. By its nature, what does the Department of Health do? It does incremental change in the fullness of time; it very rarely does radical reform so that is the pace. That was the logic behind the idea of the original committee of having an engine room outside of the Department to motivate it to move more quickly. We saw big changes during Covid. We did pretty well. Mistakes were made but the system - the Department, the HSE and those on the front line - responded really well during Covid so there is that. The policy system changes slowly and therefore it really needs political leadership and pressure from public representatives and a watchdog over the resources.
There is also a broader societal issue around the status quo. If the majority are doing okay, then it is hard to shift that. That is a false argument because even though nearly half the population have private health insurance, it does not actually get a person many of the essential parts of care that one needs in society. Yes, one gets faster access to elective care, but it does not get one a home care package in rural Ireland or access to a public health nurse in a wealthy suburb of Dublin.
It does not get you access to a public health nurse in a wealthy suburb of Dublin, because that depends on whether you have medical card status. A body of work is to be done with citizens and communities to make the case. If people are driving a public health system and universal access, it will be much harder for politicians not to follow that.
Dr. Bridget Johnston:
As Dr. Burke has alluded to, it is about a crisis of confidence. If the public does not have confidence, of course they will continue to look for the safety net they perceive to exist through private healthcare.
On people wanting affordable care, we found before Covid and the cost-of-living crisis that almost 20% of Irish households could not afford what they spent on healthcare. The expenditure either impoverished them further or pushed them into poverty. They were spending more than 40% of their monthly budget on healthcare. I am referring to the direct charges paid at the time of access and the cost of private health insurance premiums. It has been a slow-bubbling crisis for a long time for the majority or a significant minority of Irish households. When the data are eventually available again – the household budget survey is taking place only now – we expect the trend will have only deepened with time.
Gino Kenny (Dublin Mid West, People Before Profit Alliance)
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I thank the representatives. Unfortunately, I have to go because I have to speak in the Dáil.
Bernard Durkan (Kildare North, Fine Gael)
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I welcome our guests and thank them for their ongoing work and expertise in this area. Recently, I became one of those who experienced the need for emergency treatment in hospital. It was a Dublin hospital in which Trinity College has a teaching role. Any compliment that can be given is well warranted.
To go back to the business at hand, Dr. Burke mentioned holding on to measures effective during Covid. Which of the measures have not been taken on board? I was of the same opinion as Dr. Burke and made a suggestion in this regard at a meeting of this committee. It would be easy enough to see how the measures effective during Covid worked in the general health service. Maybe Dr. Burke will expand further on that.
Dr. Sara Burke:
I will have a go at the answer. New care pathways emerged during Covid. Really quickly, the hospital system devised Covid and non-Covid pathways, and telemedicine was introduced. We could all ring our GP for a consultation without charge. Obviously, it was a problem that we could not go to see our GPs but the fact that we could ring them was innovative. The system has now almost totally reverted to one that requires the patient to present in person. At one point during the pandemic, when I had a sick child, I was able to ring a triage nurse in the middle of the night and get advice on managing the child's temperature at home and not seeking any other care. Innovations like that happened and were resourced during Covid, and people on the front line were trusted to innovate and given the resources. The research we have done indicates their experience is now of pullback in this regard. It is as if to say we should revert to type as Covid has gone. That is a real pity.
Some of the new pathways and innovations were scaled. For example, there is a range of projects whereby, instead of an older person having to go to a hospital, the ambulance goes to his or her home and manages the care there. Under Sláintecare funding, some such initiatives were scaled during Covid, but we need many more successes scaled so they will not just be in Beaumont or St. Vincent's hospitals or wherever they were innovated but will instead be presented across the country. It is about harnessing the really good things that happened and supporting people on the front line to do so.
Bernard Durkan (Kildare North, Fine Gael)
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Dr. Burke very correctly identified the situation. I am one of the people who, during the original committee debates, was of the opinion that the centre should be based in the Department of Health on the grounds that dividing any Department into two or three locations always has the effect of turf wars on the one hand and divided responsibilities on the other. Where there are divided responsibilities, nobody takes responsibility. I will say more about that in a second.
There was no update since 2021 on the progress on achieving the objectives of Sláintecare. What can be done to speed up the provision of the updates now required to determine progress? Again, my question is for Dr. Burke.
Dr. Sara Burke:
The Deputy is referring to the Sláintecare progress reports. Ms Laura Magahy and the Sláintecare programme implementation office published biannual progress reports, in June and December. They did not always come out in June and December but pretty close to those dates. It is now March 2023 but we have not had a report since December 2021. It is a question of the regular publication of the progress reports. The progress reports in question maintained the integrity of the earlier ones, which had very clear targets. They had a traffic light system, with green, orange and red, indicating whether targets were being met increasingly. In the reports published, there has been an increasing number of oranges and reds because of the failure to deliver on time. It is about the Department publishing those reports.
Bernard Durkan (Kildare North, Fine Gael)
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With regard to the structure of the HSE itself, we now have a board that is, on the face of it, representative of the regions. Are the regions adequately represented? Do they have a right to believe or expect that their views are being heard in the right places at the right time and that appropriate action is being taken? This relates, of course, to overcrowding in hospitals in the south west and, needless to say, hospitals in other areas. Is the message getting across in the way it should in sufficient time so necessary provisions can be made to ensure, if not the best options available to patients, a better one than we have?
Dr. Sara Burke:
The board was re-established in 2018. It was a key Sláintecare recommendation. It is very much a national board, operating in advance of any development or progress on the regions. There is no regional input, per se, into the board, if that is the Deputy's question. It is very much a national board.
Bernard Durkan (Kildare North, Fine Gael)
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I expect it to be a national board but one reflecting the opinions of the regions. If a board is isolated in one location and not sufficiently alert to the situation in the regions, obviously regarding health, it creates problems. What is the appropriate structure to address this if it is not happening? I suspect it is not. In fact, I know it is not.
Bernard Durkan (Kildare North, Fine Gael)
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How do we address the issues that exist in order to prevent their recurrence? I am referring to the considerable overcrowding that is taking place. It is taking place to a greater extent in the regions. The waiting lists are a separate issue.
The overcrowding in accident and emergency departments is taking place specifically in a number of very sensitive locations. The same ones are coming up again and again. How do we address that? We have a national board. Do we have a national service?
Professor Steve Thomas:
I think the points about overcrowding are well made. It is often a critical sign of system dysfunction when there is such overcrowding in hospitals and such high numbers of people on trolleys in emergency departments, EDs, etc. All this speaks to the massive need for system reform and the move to integrated care, which will be backed up through regionalisation. The Deputy could well be right that the regions are not getting their voices heard adequately. Certainly, the emphasis on regionalisation has not been pursued as fast it could have been. I think that move towards regionalisation and integrated care will shift some of the pressures out of hospitals into primary and community care settings. That is something that needs to be focused on and pushed forward. Certainly, the different voices of regions will be important to feed into that whole process at every level.
Bernard Durkan (Kildare North, Fine Gael)
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Why do we not see the evidence of that now? There are some regions throughout the country that seem to have a good turnaround, insofar as access to EDs is concerned and no major overcrowding, whereas more of them have a serious problem that keeps recurring again and again. In the event of there being a national board or organisation, as Dr. Burke has mentioned, the HSE is supposed to extend its realm all over the country to all areas and regions, including Dublin, and have a reasonably high quality of service in all. We are not getting that at the moment. My question simply is this: what actions need to be taken now to prevent the kind of things we are experiencing in the regions?
Dr. Sara Burke:
I will have a go at answering that. The issue of why some emergency departments are overcrowded and others are not is complex and often very context-specific. It depends on the demographics, the number of people in the area and the number of people seeking care. It depends on the availability of resources, for example, whether there is a minor injury clinic, there are other hospitals in the area that can take care, and whether there is good 24-hour GP cover. There are lots of components that influence why some hospitals do better than others. I cannot answer that specifically for the Deputy. The Deputy is right that there are some hospitals, Limerick being one of them, which have nearly perpetual long waiting times in the emergency department and difficulties with accessing elective care because the hospital is so overcrowded with emergency patients. However, if you speak to people like Professor Colette Cowan, who is responsible for running that hospital, she would make the argument that if the mid-west was an integrated care area and if she had access to the resources in the community, then she could free up 50 or 100 beds, with people either moving into rehab beds, nursing homes or home care packages. That is another reason for the reform. Our blocked up emergency departments and hundreds of thousands of people waiting for that first outpatient appointment is an indication of our failure to reform the system we have, which is connected to all our other previous discussions.
Bernard Durkan (Kildare North, Fine Gael)
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We are talking around the answer to my question all right but I have not yet seen or heard that if we had more of X,Y and Z we could do greater things. Of course, we could. At the same time, we have an expensive health service, without doubt. It is supposed to operate. There are elements of the health services that operate very well to the highest possible standard and to international standards. We could be, would be and are the envy of other countries but there are awful glitches in the system, for instance, in the Limerick area but also in general. Having embraced Sláintecare, we now need to have the elements of Sláintecare implemented in such a way as to ensure that delivery is evident to everybody. Whatever part of the country they may come from, the patient is entitled to that universal treatment. If there is one board for the whole country, then the patient is entitled to that treatment. I am not certain that we are on the route to it yet. I would be interested in hearing comments as to how the witnesses see the measures that need to be taken now that will have an immediate impact of such a nature as to give the public the recognition that something is being done. Are there any takers?
Professor Steve Thomas:
The Deputy was part of the Sláintecare committee that signed off on the report. I would refer the honourable gentleman to his earlier comment in terms of the report and its implementation. That is what needs to happen. It is a complicated package of different things. I certainly think accountability and transparency is a key starting point for that but it needs to be backed up with the measures to provide sufficient resources to expand capacity throughout the system. I am sure my colleague knows that very well, Deputy.
Dr. Sara Burke:
I will come in briefly on that. If we were to pick one place or one measure of where to start now, it is that investment in primary community and social care. Even though that is the intent and it is happening, it is not happening fast enough and it is not happening enough. We need to be training more carers, nurses and allied health professionals, who will work within our system in years to come.
Bernard Durkan (Kildare North, Fine Gael)
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We do not have them.
Dr. Sara Burke:
That is why we need to start training them now. We also need to be doing that system reform in order that it is a more attractive place for them to work. We need to be putting measures in place that mind the staff that are currently there. I do not know what hospital the Deputy was in, but if you go to most Dublin hospitals, most of the people who work there commute for a long time each day because of the housing crisis and because they cannot afford to live near the hospital. We need to find ways of addressing that. A few of the voluntary hospitals are buying apartment buildings to house their students and some of their nurses because accommodation is so difficult to find. We need make their place of work a more appealing place to work, which requires the reform. We need to support and nurture those who are there to stay, and to train more in order that we can hire more in place. It is that focus that must take place in the non-acute setting.
Colm Burke (Cork North Central, Fine Gael)
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I thank the witnesses for their presentation and for the work they have done in this area. I will begin with the issue of the new consulting contract. I am open to correction but my understanding is that under the new contract, consultants will be required to work a set number of hours, and there is nothing preventing them from working in the private sector outside of those hours. Am I correct in my interpretation of that?
Colm Burke (Cork North Central, Fine Gael)
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That is what has occurred in the UK as well, as I understand it. For example, instead of consultants working 37 or 39 hours per week, they may decide to work in the public sector for 20 hours and there is nothing preventing them from working in the private sector for any number of hours they wish, but not in the HSE hospital. In other words, there will be no private work in HSE hospitals.
Colm Burke (Cork North Central, Fine Gael)
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I accept that. I think that will ease out faster than what we think because the number of private hospitals that are now looking for consultants is actually increasing and some of the private hospitals have expanded. For instance, in Limerick the sod was recently turned on the new Bon Secours Hospital in Limerick. It is expected that that will be up within 23 months. We were talking about elective hospitals. I spoke to a Department official who said that there are 17 further steps to go through in the Department before we even go to planning for the elective hospitals. It does not make sense as to why the public side takes so long to deliver projects. As a result, the only way we can then deal with the healthcare sector is by looking for support from the private sector. Is that not correct?
Colm Burke (Cork North Central, Fine Gael)
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What should be done? For instance, in one of the places where we need an new elective hospital, it took nearly five years to identify a site. We have now identified a site and I am still being told by the Department that it will take a further 17 steps before we go to planning. There must be some way of expediting that. If we want to deliver a public health service, why does it take so long to deliver the infrastructure that is required? This is an issue that needs to be looked at as well.
Róisín Shortall (Dublin North West, Social Democrats)
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Is that not a political question?
Colm Burke (Cork North Central, Fine Gael)
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It is a political question, but it is also within the remit of the Department. It took nine months for the Department of Health to send a proposal from the South-Southwest Hospital Group to the then Department of Public Expenditure and Reform. There must be a way to expedite these projects when the private sector can build a hospital in 23 months. When talking about healthcare, there is a need to look at the delays in the delivery of infrastructure. Why does it take so long within the public service mechanism?
Colm Burke (Cork North Central, Fine Gael)
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What I am saying is that we cannot look for the delivery of a range of areas of Sláintecare without having infrastructure in place. That is one of the problems we have.
Róisín Shortall (Dublin North West, Social Democrats)
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Whose responsibility is that?
Colm Burke (Cork North Central, Fine Gael)
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We need the infrastructure.
Professor Steve Thomas:
Yes, we do. Part of Sláintecare was the development of some of that capacity through the transition fund in the early years. We also made special reference to the need for expanding hospital capacity along with the capacity review. They are key bottlenecks that need to be addressed. Having said that, one of the big pushes of Sláintecare is to move care out of the hospital arena and into primary and community care.
Colm Burke (Cork North Central, Fine Gael)
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On the issue of moving care out of the hospital system. Several GPs have told me that there is a problem in hospitals in that there is a huge shortage of physiotherapists because they have left to provide community care. Yet, in the context of providing community care, I spoke to a GP who was trying to arrange a physiotherapist. He rang the HSE service and found out that the earliest he can get an appointment is in six weeks' time. However, he can get in touch with someone in the private sector who can provide a physiotherapist within 24 hours. A problem with community care is that hospital care is provided seven days a week. In other words, a hospital is functioning for seven days a week whereas community care is provided five days a week. Is that correct?
Colm Burke (Cork North Central, Fine Gael)
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It is a problem.
Dr. Sara Burke:
The Deputy is right. I have heard that a lot of the new posts in the community around the management of chronic diseases or Sláintecare-like initiatives are attracting staff from the hospital to the community. Obviously, that is a problem for the hospitals but I would argue it is good for the community. I completely take the Deputy's point. We need much more care in the community that is not just nine to five.
Colm Burke (Cork North Central, Fine Gael)
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Care in the community is provided five days a week.
Colm Burke (Cork North Central, Fine Gael)
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The reality, however, is that it is.
Colm Burke (Cork North Central, Fine Gael)
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The question is how we deal with that. If I want a particular service, it is provided either Monday to Friday or it is not available on Saturday or at any stage over the weekend.
Colm Burke (Cork North Central, Fine Gael)
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What I am saying is that I have not seen that being referred to-----
Colm Burke (Cork North Central, Fine Gael)
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If we are talking about rolling out community care, there needs to be an emphasis on this and I do not think there is. We are very much focused on a five-day week. This is the same issue with GP care. It is very much a five-day service. We give out about the focus on hospital care, but the reason there is such a focus on hospital care is that it is available seven days a week. That is an issue we now need to challenge as well. How do we develop community care seven days a week?
Professor Steve Thomas:
How one increases the capacity in the system to do that is an important point. We also need to be clear that we are dealing with a lot of burned-out and demoralised staff for whom there is a limit to what they can work, which means we have to train extra staff. This brings us back to Sláintecare and some of the targets that were set very early on, in the first few years, to expand our capacity in that area so that we could move towards providing an enhanced capacity within community care. Once we do that, we can move care out of the hospitals, which will liberate them to deliver more elective care. The whole system will then fit together. I agree that we need to focus on the expansion of primary and community care. That goes back to the earlier point of liberating capacity to deal with elective care in the hospital setting.
Colm Burke (Cork North Central, Fine Gael)
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I refer to the issue of GP care being provided five days a week. An awful lot of people who require a GP to provide care for them over the weekend are being pushed towards attending accident and emergency departments. How do we deal with that to make sure community care can be provided seven rather than five days a week?
Professor Steve Thomas:
To do that will either require existing staff to work more days a week or it will require new staff. I refer to the earlier point about capacity. Our existing staff are probably working to the max. They are burned out after Covid, demoralised and need supports. I do not think a solution is to say we should have the doors open on more days because we are going to need more staff to do that. It comes back to a training issue and, therefore, a primary care team issue about how we allocate our human resources in the community setting.
Colm Burke (Cork North Central, Fine Gael)
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Then there is an issue with GP care in that we need more support staff within the GP structure as well.
Colm Burke (Cork North Central, Fine Gael)
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That is one of the challenges we now need to face. We have GPs doing a lot of work where nurses would be well qualified to do much of it.
Dr. Sara Burke:
Yes. That is the case with the triage nurse who was on a telephone and available through the HSE during Covid. That surely would be a way of spreading the load of the out-of-hours burden. At the moment, the only out-of-hours calls made are to a GP where a person will probably be triaged or to the health insurers that provide helplines. We need to look at a broader response to 24-7 community care and the lowest level of complexity, which is what is at the heart of Sláintecare. However, we should not push everybody into GP surgeries and the emergency departments.
Colm Burke (Cork North Central, Fine Gael)
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That is what I am saying. The issue is how we expand community care so that it is not just available five days a week, because that way one still needs to have the numbers in the hospitals. On the numbers in hospitals, one of the things that has to change is in regard to the number of doctors and nurses, which has grown over the past six years. In 2014, 103,000 people were working in the HSE. Now the figure is around 135,000, which is an increase of more than 30,000. The problem is that we have also had an increase in population.
What is Dr. Burke's view on looking at the role of people working in hospitals. Many junior doctors are doing work that nurses are more than qualified to do. Nurses are doing a lot of work that care assistants could do. Many private hospitals are going towards theatre assistants. They still have theatre nurses but they are also training theatre assistants. Do we need to look at that whole system both on a community level, in the sense of having a lot more nurses working with GPs and making sure we provide the funding for that, but also making sure we get the message out that nurses are more than qualified to provide a lot of the care that GPs are currently required to provide?
Colm Burke (Cork North Central, Fine Gael)
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Is there enough debate or focus on changing roles?
Nurses are highly qualified, and, yet, we are still getting them to do an awful lot of the work that people would not need a college degree to do.
Colm Burke (Cork North Central, Fine Gael)
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How does one open up that debate in order to move matters on?
Professor Steve Thomas:
Political leadership from the likes of the Deputy would be very important. We have done considerable work on task shifting, with an emphasis on looking at workforce planning, not just in the silos of our professions, but in the whole primary and community care team. Who can do what? What kind of task-shifting do we need? What kind of oversight do we need in order that the tasks GPs do not need to do can be given to public health nurses and the tasks public health nurses do not need to do can be given to some kind of medical assistant or something such as that? Integrated workforce planning, which came up earlier, is incredibly important. Technical discussions have to happen in that regard, but there are quite a few political issues involved because the roles of different healthcare professions will change. That is in a slightly different domain when it comes to the politics involved and power of different professions.
Colm Burke (Cork North Central, Fine Gael)
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Looking to the NHS in the UK, where mistakes have been made - the same as mistakes were made in the Irish system - was anything done there that we should seek to avoid in the context of developing our system? I visited GP surgeries in the UK. I came across one practice where all GPs resigned on the same day. There were 20,000 patients left without a doctor. All of the doctors involved were employed by the State. I do not know what the issue was, but 20,000 patients were left without a GP service. Are there other issues relating to the NHS that we should look at in order to ensure that we do not make the same mistake?
Dr. Sara Burke:
We should definitely avoid what England has done with its NHS over the past 20 years, which is to constantly reorganise and privatise vast swaths of it. It is not a particularly useful model for us to look at right now. The work Dr. Johnston has done around population-based resource allocation is one of the keys to changing how we provide care and how those resources are allocated to meet a population need. If we were doing population-based resource allocation, which is the plan, but it is not yet happening, and if that had a strong need equity focus, issues such as the points made by Professor Thomas would roll out of it. How many people do we need to provide care for this population? What are the different roles of those people, be they carers, assistants, nurses or doctors? Using mechanisms such as population-based resource allocation and integrated workforce planning are probably more useful in an Irish context.
Seán Crowe (Dublin South West, Sinn Fein)
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Dr. Burke made the point that when the pandemic arrived, pretty much everyone involved in Sláintecare was redeployed to the health system response to Covid. Is she criticising-----
Seán Crowe (Dublin South West, Sinn Fein)
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We all accept the importance of having a public health system that works and delivers. There is general consensus across the board on that.
Seán Crowe (Dublin South West, Sinn Fein)
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It is probably important to we remind ourselves that there was so much that worked during the pandemic. Dr. Burke mentioned some of the innovative things, such as the GP diagnostics and so on, but there was much that did not work or deliver. There was talk about a single-tier health system, but we know that private beds were not fully utilised. Was there a pushback within the system, in that it did not necessarily wish to go down that road? We still have not gotten satisfactory answers on why we did not fully utilise those beds. It seemed crazy that we were not using empty beds as part of a fully functional health system. The only conclusion most people could come to was that there was pushback within the service or wherever, but we did not get answers.
Dr. Sara Burke:
One of our colleagues in the Public Gallery carried out some research on this, which I will be drawing on. The safety-net agreement, which was the initial deal done with private hospitals in the early weeks of the pandemic, was concluded within ten days or three weeks. A big contract was put in place with all private hospital providers. That was when we were looking at New York and Bergamo, where they were running out of ventilators and hospital beds. I fully praise the health system for what it did in that short period in that it bought capacity in case we needed it. We did not actually need all that capacity, and it ended up being an expensive option, but it allowed many patients to have critical cancer or brain surgery during the pandemic, because they were the ones who went to the private hospitals and the public hospitals, by and large, dealt with the Covid patients. I am not as critical as the Cathaoirleach is regarding what happened. It was the right thing to do at that time. It is easy to look back in hindsight and say we did not use all the beds and it was expensive. The measure was important.
One of the point coming out of the research was that the public system did not really understand how the private system worked and, therefore, if we wish to utilise all the resources of the State, we need to better understand the different components of the system, especially when we have a system that is so dependent on private aspects.
Seán Crowe (Dublin South West, Sinn Fein)
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Did it highlight a lack of flexibility within the service, that we did not fully utilise? We are still dealing with the waiting lists, such as those mentioned at the start. Some 900,000 people are waiting for appointments and 200,000 are waiting for scans. Much of that could have been done by utilising those beds, even though the health system was trying to save them for the awful day that did not come to pass. It just seems crazy that we have such lists.
Seán Crowe (Dublin South West, Sinn Fein)
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We made the appeal for medical people to come home and get involved in the system. Many of them said they were not contacted. The system failed those people. They wished to get involved. You can only make those appeals so many times before they stop having an impact. It is a bit like clapping front-line workers. We said we would deliver childcare for them. That did not happen in most cases. We had people in here last week talking about the ambulance service and Dublin Fire Brigade. Some 120 Dublin Fire Brigade 120 have still not received the pandemic payment. Dr. Burke is talking about the importance of trust and relationships. If one seeks to underpin the strength of that trust and those relationships, it will be difficult to get people to do it again.
Dr. Sara Burke:
Completely. Recruitment is still an issue. We asked people to come home to work and then they could not get jobs. However, even for people who are offered jobs across the system, it can take months or years for the post to start in that job. When they start in the job, they do not have an office or a clinic or a team to work with. There are blockages to reform through the HSE recruitment process. Improvements there could be really helpful.
Seán Crowe (Dublin South West, Sinn Fein)
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One example of what frustrates elected representatives the most is when families try to get an assessment for children with special needs and, it is hoped, the supports will come. However, the team does not have the key people, it does not happen and people move to the private system to get an assessment. When they have the assessment, they think they will get the supports, but that does not happen either because the team is missing those key components. It is a system failure, but it is impacting considerably on those children and their families.
Dr. Sara Burke:
An independent inquiry into how we managed Covid is needed. I know it is promised, but it has not happened. When we look back, we can see how people with disabilities were denied access to their day-care services, respite care and care in their homes. Support for the parents of children with disabilities is one of the matters in respect of which we failed most during Covid. We need to prepare for how we do that differently and better. Children's disability services are one of the black spots within our health system. We continue to fail parents of children with disabilities.
Seán Crowe (Dublin South West, Sinn Fein)
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Many of us remember the old health boards. People ask if RHAs will mean the same again. We discussed the importance in establishing RHAs of accountability so that it is not Paul Reid, Mr. Gloster or whoever who comes in and defends the situation by saying the system has collapsed in Sligo, Galway, Limerick or wherever else, but the CEOs of the regional authorities. Do the witnesses agree that is the only way the decentralised structure will work?
The implementation board was replaced by a centralised structure. Where is the pushback coming from? It is difficult for us. We are having meetings. Regional authority, we are told, is happening and is full steam ahead; but you talk to people in the service then and it is not happening. Why is the system reluctant? We are in agreement politically across the spectrum that this is the way forward and the health service is supposed to agree. Is the pushback that people do not want to release that power? Is it that they feel the current structure, bad as it is, will deliver and that if we give people power, some areas will not deliver? We accept some regions will be better than others.
I agree with what has been said on innovation. Regarding pathfinder, what is the delay? It has been established in Beaumont Hospital and rolled out in many areas but not across the State. We raised this with the ambulance service. It does not make sense. Everyone believes this will work. Where is the pushback? Is it this thing called the dead hand, where you cannot get movement on it? It would be useful to get insight on that for the committee's next meeting we have with-----
Dr. Sara Burke:
Will the Chair let us go off and do some homework on it. It is a great question. What is stopping it? I do not know but I think power plays a big part in this. For Sláintecare to be delivered, the people who currently have power have to give it away and are very slow to do so. That is what happens if there is not an engine driving reform or a Sláintecare programme implementation office, as the Deputy earlier suggested. The original mechanism was that it be linked to a Cabinet sub-committee with political clout and leadership and that a committee like this one monitor it and act as a watchdog for implementation. Those components are not in place. It needs to be devolved. I think everybody agrees on that.
Seán Crowe (Dublin South West, Sinn Fein)
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The Committee on Health has members who feel strongly about it but we do not have the resources to drive this forward.
Dr. Bridget Johnston:
Some of the roadmaps that show how the power will be devolved and trust built to allow that to happen are not in the public domain yet. The governing structures for the RHAs, what the legal framework might look like or if it will be there, what the population base resource model will be, who will oversee it, how it will work: any of those things we need to begin to take the steps or get buy-in are not there for people to engage with. That is one of the fundamentals. Whether they are still being decided or just not in the public domain is not fully clear to me. They are fundamental to making the next decisions. They are the underpinnings of what we do next and without them how do we continue to shift some of these things that are so important?
Professor Steve Thomas:
Look at the internationally sticky problems in health systems, such as waiting lists. A key move ten or 12 years ago in Europe was to try to shift waiting lists down, which we have a huge problem with now. It was done with a mixture of capacity resources and much accountability, transparency and information sharing. We do not have the information sharing or the data. We probably do not have public discourse around that either. The element of information sharing is needed around the system to mobilise interest and accountability and therefore start to drive the reform process. We do not know where the blockages are and that is partly to do with the lack of appropriate information disseminated to all stakeholders.
Seán Crowe (Dublin South West, Sinn Fein)
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The private route to reducing waiting lists is short term. It is a contradiction then. We need to build capacity in the service itself.
Professor Steve Thomas:
Sure. Some countries have used the private sector and some have not. I do not think there is a magic bullet. Denmark did not really use the private sector, while Portugal did. That is a bit of a red herring. Sufficient capacity and information about what is going on and about waiting times and waiting lists to the public and providers are required and missing. Regionalisation should give much better information on the resources going in and the outcomes.
Róisín Shortall (Dublin North West, Social Democrats)
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That brings up digital health again.
An important question has been asked. What are the blockages? There is no doubt there is institutional resistance, as there is for any major change programme. It has to be recognised that institutional resistance is a thing and a response made to it. That has not been taken on board and there is not a recognition of that and the need to work around it.
Another thing that cannot be ignored is vested interests. Many individuals, companies and organisations are making a lot of money out of private healthcare in this country. They are working against reform because it is in their commercial interests to maintain the two-tier system. That has to be put up there as an issue and blockage. We have got back to this a few times today: the political system has to deal with that and there has to be political will to address both of those blockages.
We spoke on the importance of the implementation office. The work done by that office was really good on many fronts. One role it played was its staff went out and engaged with the community and with staff. Where are the people who were involved in that? Were they on temporary contracts? Are they still in the Department?
Dr. Sara Burke:
There were a few key programme managers working with Laura McGahey, often on secondment, so they maybe went back to the hospital or part of the HSE they came from. They are largely dispersed back into the system, but not on Sláintecare. There is no Sláintecare programme office, per se. The Department’s response to that is “We’re all doing Sláintecare.” To give them credit, when you deal with them on specific issues, Sláintecare is front and centre of their work but it is missing that drive towards reform.
Róisín Shortall (Dublin North West, Social Democrats)
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As Dr. Burke said, there is no engine there
Róisín Shortall (Dublin North West, Social Democrats)
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Is Gráinne still involved?
Róisín Shortall (Dublin North West, Social Democrats)
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The Committee on the Future of Healthcare came to the conclusion very quickly that we needed support from experts in the field, like the witnesses, to provide that evidence base, put the research at the disposal of the committee and help us design the system.
What engagement has the Department or the HSE had with the witnesses in respect of the outworking of those recommendations?
Dr. Sara Burke:
It has had none specifically, but each of us is funded by the Health Research Board, HRB, which is Irish public money. My research, in particular, is funded on the basis of a partnership. The partnership originally included the Sláintecare programme implementation office, and includes the Department of Health and the HSE, which puts in small pots of money to supplement the much larger funding from the HRB and the Higher Education Authority, HEA. We do engage with the Department and the HSE. We believe the work should be co-produced and we should be feeding the evidence into the system. We have been invited to departmental policy seminars and have presented on our research. We recently started a similar series with the HSE. We find there is an openness to engagement but it is us pushing that engagement because we have HRB funding that is contingent on us making an impact on the system and also that we believe-----
Róisín Shortall (Dublin North West, Social Democrats)
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The Department does not come looking for Dr. Burke.
Professor Steve Thomas:
One of the things I found interesting in the first two or three years of Sláintecare was that I was expecting a knock on the door and was waiting for the phone to ring. I was going to respond that I would give it my best shot but that knock or call never came. I was incredibly surprised by that. I was surprised that the Department did not want to get inside my head and find out what we were discussing, thinking about and deciding. There were many things we could have debated. It was strange that the interaction never came. I must say that Dr. Burke and I now have large research programmes about which we link in with the Department and the HSE. We are having some of those discussions now. However, at the start, there was very little contact. It was almost like there was radio silence.
Dr. Sara Burke:
Dr. Johnston has been on secondment to the Department of Health, working on the palliative care policy. In a way, that was not Sláintecare specific. That secondment came about because Dr. Johnston is an expert in palliative care and the chair of the palliative care group. The Department brought Dr. Johnston in.
Dr. Bridget Johnston:
Our paper on population-based resource allocation underpinned the spending review on the potential models for PBRA at the Department. Having said that, the first engagement was an invitation to peer review it once it was written rather than to engage in the process of development. Whatever co-production might look like, it was not a type of co-production. It was more a case of the Department telling me the review was done and asking me if I would like to look at it and tell the Department what I thought.
Róisín Shortall (Dublin North West, Social Democrats)
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Dr. Johnston spoke about PBRA. Is that something our guests were working on separate from the regional health authorities, RHAs, or was it regarded as a piece of that work? Was the purpose of the work linked to the RHAs?
Dr. Sara Burke:
It was. It was a part of the foundations project, which originally was around informing the design of the regions. We identified components that would be useful to the Department. Learning from past reorganisations was a piece of work conducted by our colleague, Dr. Sarah Barry. PBRA was another piece of work we did. We then shifted to focus on the Covid-19 pandemic response because the regions were put on hold during Covid. It was very much driven by our research agenda, trying to meet the needs of the Department. It was that way around, rather than the other way around, to answer the Deputy's question.
Róisín Shortall (Dublin North West, Social Democrats)
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Very good advice is coming from that advisory body about the RHAs but we cannot get access to its advisory letters that are sent to the Minister every couple of months. That seems ridiculous.
We talked about various big-ticket items relating to digital health, workforce planning and so on. Another of those is the whole question of a legal entitlement to healthcare, which has come up recently. There is no legally based entitlement to healthcare unlike social protection and so on. All there is at the moment is eligibility if the service is there. Do our guests know if that issue is being addressed at any level within the Department or the HSE? We have not seen that it is.
Róisín Shortall (Dublin North West, Social Democrats)
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The Sláintecare plan sets out five pieces of legislation that are required to underpin it. We never hear plans for legislation, which concerns me.
Róisín Shortall (Dublin North West, Social Democrats)
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That lack raises concerns about the seriousness of the intent.
Professor Steve Thomas:
It is certainly an issue we published on in the early years. There was no mention of entitlement in various Sláintecare reports and lots of discussion of eligibility. I thought there was a little bit of a shift in the mood music with Laura Magahy in respect of appreciating the importance of entitlement but when she went, it seemed to fall away again.
Róisín Shortall (Dublin North West, Social Democrats)
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That was my fear, all right. I thank the witnesses.
Bernard Durkan (Kildare North, Fine Gael)
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The nub of the problem we are discussing is who has the power to change things. Whence should we take advice? I do not want to go over old sores, but we were all advised many years ago that we needed to reduce the number of hospital beds and have less capacity. We have less capacity now. We realised that was the wrong decision because it leaves us in a very difficult situation whereby we cannot produce hospital beds as quickly as we would like to. We have a problem in that regard. Regardless of who has the power, how do we prevent going down the road of taking the wrong advice even when it comes high vaulted towers?
Dr. Sara Burke:
We have much better research now to inform decisions, whether they are made by politicians or senior people in the HSE and the Department. We are in a different space to where we were, say, 20 years ago when those initial bed cuts were made.
Bernard Durkan (Kildare North, Fine Gael)
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Some of us mere politicians strongly opposed the reduction in bed numbers precisely because we would not have sufficient capacity to meet the situation, particularly in the context of an increased population. The next thing we come to is care in the community and in the home. I have always held the view that it will take at least twice, if not three times, as many staff to operate care in the home effectively. I accept it is an admirable approach to take and we should aspire to it. Such an approach is far and away the best for patients. However, how achievable is it in the present environment?
Professor Steve Thomas:
All we can do is look at the best available evidence and try to progress the situation in terms of expanding our workforce and scenario planning in that regard. It is quite possible to look at what the requirements are in that regard, if there are minimum standards and a package of care that we want to deliver. There is a technical piece of work that needs to be done on that basis. It is really then a matter of thinking about political priorities and engaging with stakeholders so they can buy into that programme. It is possible to do, but a number of steps need to be put in place. That needs to be resourced.
Bernard Durkan (Kildare North, Fine Gael)
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Surely all aspects of the delivery of health services are a priority. If any element is removed, it throws the weight or burden onto some other sector within the services. Dr. Burke asked which hospital I was in recently. I was in St. James's Hospital. I went in as a public patient, not as a private patient, through the public hospital system to test the system we are always talking about.
I have to say the hospital did very well. It would have scored very highly in the management of the queue in the accident and emergency department. Some people were obviously in need of urgent treatment and they got it. Some people were not as much in need of urgent treatment, which is a possibility.
There is another thing that comes to my mind. The delivery of health services is demand led. We do not arrange to be in need of health services on a particular day of the week or a particular month of the year. We cannot deliver services to every individual who wants them at the hour they want them, even in emergency care, because there can be many people demanding and requiring attention at the same time. A means has to be found to spread the load to ensure the queue is kept moving. I give St. James's Hospital full marks in that area.
Dr. Sara Burke:
As members of staff at the school of medicine in Trinity College, we are delighted Deputy Durkan got such good care because St. James's is one of our teaching hospitals. On the issue the Deputy raised about not doing one given thing and about how everything is a priority in health, he is right. Part of the challenge of health policy and health system reform is that it is very complex and there are competing priorities. However, in a way, the job of the political system is to decide, at a very high level, what the priorities are. It is then for the system to deliver on those priorities. I disagree with Deputy Durkan as to delivery being demand led. Some of it is demand led but, if we are doing things right, much more is needs led. We should be doing much more prevention, public health work in the community and empowering patients to manage their own chronic diseases. There will always be points in most of our lives when we will need acute hospital care, but most care is not acute hospital care. That is where planning, care outside of hospitals, care in the community and empowering patients become very important. A reformed system would not always be demand led. It should be led by population need.
Bernard Durkan (Kildare North, Fine Gael)
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I know where Dr. Burke is coming from but the counterargument is that, if 100 people arrive in an accident and emergency department, some will obviously be more severely in need of care than others. There could be a situation whereby many people require emergency treatment at the same time. If that is not demand led, I do not know what is. I am just mentioning that to Dr. Burke. There are many factors that affect the system. For example, if 100 patients, 50 patients or whatever the case may be are waiting, it helps if they see some progress and see somebody moving on. However, if they come to the conclusion that they will be there for four or five days or a week before anything happens, that will have a debilitating effect on their mental health on top of everything else. It creates further problems. Essentially what I am saying is that we cannot have sufficient attendance to deal with all emergencies at the same moment but we need to put in place structures that are capable of moving the line along and tackling it. That is important for both the service providers and those seeking service. It is very difficult for medical staff to be in very tight situations with overcrowding and all of the other issues arising at the same time. That is not good for staff morale. We need to be mindful of that at all times.
I will make one last simple point. The community care centres were originally deemed to be the answer to everybody's prayers. Some of them are and are working very well but some of them are not. An assessment should be carried out as to how effective they are in picking up the issues that need to be picked up at community level. That is a comment and a question.
I went into a hospital. I did not tell anybody who I was. I did not tell anyone that I would be bringing up the results of my visit at the next meeting of the Joint Committee on Health. There was none of that. The staff went about their business unimpeded and, as I have said, I give full marks to how they did their job. The hospital's system was working as it should.
Dr. Sara Burke:
That is great. That is what everybody should get. Everybody should get timely access to quality care, although I hope there will not be 100 people arriving into the emergency department at the same time. The Deputy's point as to how well the community primary care centres have been working is absolutely valid, with some working more effectively than others. I believe that also comes back to whether there is a GP in the centre and how much it has been resourced to provide capacity and care in the community.
Seán Crowe (Dublin South West, Sinn Fein)
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This morning's discussion was very useful and will certainly help us with our deliberations on the roll-out of Sláintecare. The committee will try to follow up on some of the points made, particularly with regard to the five pieces of legislation that form the pillars to hold this up. We may be able to find out what is happening there and whether any work is being done in that regard. From the contributions of many of the members, I believe we are all in favour of an agile health service that can react and respond. That is the frustrating thing. There are many positive things happening within the system but we are so slow to do anything about them. There was mention of beds, University Hospital Limerick and the awful tragedy of people being on trolleys all of the time. There are plans for additional beds but these will not bring us to the level recommended ten years ago. In a similar vein, there were recently 11 ambulances outside of Tallaght Hospital because there were no beds inside. There is a proposal for a 71-bed unit in the hospital. If we had that unit, the issue would be resolved. There are sites at hospitals where work will not interfere with the everyday running of the hospitals. Again, an agile system would allow work on many of those sites to be fast-tracked.
Today's meeting was useful and I very much appreciate the witnesses coming in. I thank the representatives of the centre for health policy and management at Trinity College for their assistance to the committee on this very important matter. We will continue to consider this matter at future meetings.