Mr. Damien McCallion:

I will kick off. Others may also wish to come in. The Deputy referred to variation and how to ensure the learning is taken from places such as Waterford, Tullamore, Portlaoise, Beaumont, Connolly and other hospitals, which are doing really well, and apply them to other settings. That is always the challenge. Each place has a unique set of challenges. We are not talking about a carbon copy, which we must recognise. In some industries, you can lift and implement quickly but healthcare is not one of them. Factors such as capacity, resources and ways of working and links with the community also come into play. To summarise, we bring the locations operating best together. We have run a number of sessions with staff from University Hospital Waterford, both clinical and operational. We bring staff from other hospitals together to examine the lessons and how they can be lifted and applied. Some are based on clinical best practice, which Dr. Henry will speak about shortly, while others are based on pure operations and how the flow into the emergency department is managed but also out into the community. For example, there has been a huge increase in admissions and attendance of older people, at more than 10%, whereas it is approximately 3% for the general population. We, therefore, need to do more for older people to stop them coming into hospital and, if they do, allow them to get home sooner. To give one example, I visited the older persons team in St. Mary's Hospital, Phoenix Park, north Dublin recently, which takes direct referrals from the emergency department in Beaumont Hospital. There were three in that day, which allows those people, instead of being admitted to hospital, to be cared for in the community. Those are important examples. Dr. Henry may speak to that. Best practice is important and that needs to be clinically-based, evidence-based, and applied. There is also an operations piece, which we also try to do.

The second piece is that some sites - we referred to Limerick - are under more pressure than others. An improvement team works with those sites to try to take that on, which is on the ground to support sites in places like University Hospital Galway, UHG, Cork University Hospital, CUH, UHL and one or two others, in which we work intensively. Small improvements can be important. In CUH, for example, the ambulance turnaround time has been reduced by more than 25% through an initiative over the past six months, taking best practice from other hospitals. That is an important example because probably one of the biggest risks in the emergency department is delayed ambulances, particularly in large geographical areas.

The final piece s performance. We, from the centre, work with sites on their performance every day in regard to emergency care. It is a weekly process for waiting lists. Overall performance is monitored and measured on a monthly basis. We look at targets and how the sites are doing, and readjust based on what we see. They are the levels of engagement and intensity with the sites. Ultimately, it is about trying to empower them to improve the services in their hospitals with their staff for their communities. As the Minister said regarding available resources, it is important that it has to be a system solution. When we move to the regions, it will important, but even now, the community is a key part of those engagements. I will ask Dr. Henry to speak about one or two of the key pathways and clinical, evidence-based approaches that have been shared around the country, some of which Deputies referred to.