Oireachtas Joint and Select Committees
Wednesday, 24 May 2023
Joint Oireachtas Committee on Health
HSE National Service Plan 2023: Discussion
Seán Crowe (Dublin South West, Sinn Fein)
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The purpose of the meeting today is for the joint committee to consider the HSE National Service Plan 2023. To assist the committee in this matter I am pleased to welcome, from the HSE, Mr. Bernard Gloster, CEO; Mr. Damien McCallion, chief operations officer; Dr. Colm Henry, chief clinical officer; and Ms Mairéad Dolan, assistant chief financial officer.
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.
If witnesses' statements are potentially defamatory in relation to an identifiable person or entity, they will be directed to discontinue their remarks. It is imperative that they comply with 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 a member to participate where he or she is not adhering to this constitutional requirement. Therefore, any member who attempts to participate from outside the precincts will be asked to leave the meeting. I ask any member who is participating via Microsoft Teams to confirm that he or she is on the grounds of the Leinster House complex prior to making a contribution to the meeting.
As we commence our consideration of the HSE's 2023 National Service Plan, I now invite Mr. Bernard Gloster to make his opening remarks on behalf of the HSE.
Mr. Bernard Gloster:
I thank the committee for the invitation to meet with it today. I welcome the opportunity to engage with the committee on the two items listed for discussion today: namely, the HSE's 2023 National Service Plan and community neurorehabilitation services.
I am joined by my colleagues, as outlined by the Chair, and I am also supported by senior staff: Ms Sara Maxwell and Ms Niamh Doody. The 2023 National Service Plan comes against the backdrop of the drive to return to the normal functioning of services, at the best of times complex in themselves, following the sustained impact of the pandemic since early 2020. The winter period of 2022 into 2023 saw unprecedented demand in a range of critical services, including emergency departments, general practice, social care, mental health, and new outpatient referrals.
The 2023 National Service Plan seeks to achieve two headline objectives. These are the restoration of health and personal social services in the first full year post the pandemic and the advancement of the programme for Government and Sláintecare in achieving universal healthcare.
The 2023 core revenue budget on which the national service plan is based is 5.7% higher than the opening position in the previous year. When some further once-off Covid funding is included, the total revenue for the plan is €21.7 billion. This includes the provision of additionality in existing levels of service of €900 million and €240 million for new service developments. The NSP is supported by a capital plan of almost €1.2 billion. This takes account of previously agreed projects and is aligned to both the programme for Government and the strategic priorities of the HSE, supporting the mitigation of infrastructural risk and the delivery of safe and quality healthcare.
The year 2022 saw the introduction of a targeted waiting list action plan. In view of the significant demands and the need to continuously reduce waiting times, the 2023 National Service Plan is supported by a separate waiting list action plan for the year. The national service plan and the waiting list action plan, in addition to the National Treatment Purchase Fund, NTPF, activity, will again ensure record numbers of people are seen and treated this year. While improving waiting times, we will continue to see high volume lists overall as the numbers of new referrals are at an all-time high, an experience not unique to Ireland.
To give the committee an understanding of the scale of our acute activity, the most recently available 12 months of data show there were 3.4 million outpatient and 1.7 million inpatient and day case attendances. In addition to this planned or scheduled care, our hospital system also treated 1.6 million patients during this same period in emergency or unscheduled care. That represents a 10% increase on 2019, the pre-pandemic level measure year, and reflects the ongoing pressure on hospitals from viral surges and increased emergency department attendances. The 2023 National Service Plan will also see the advancement of new structures for the health service as the regional health area, RHA, concept is advanced.
In February 2019, the National Strategy and Policy for the Provision of Neurorehabilitation Services in Ireland – Implementation Framework was published. The strategy aims to integrate neurorehabilitation services, offering care in specialist centres where needed or as close to the patient's home as possible. To achieve this, the strategy outlines the configuration of what are referred to as managed clinical rehabilitation networks, MCRNs, at a population-based level. Following the transfer of functions in the programme for Government, this matter is now led by the Department of Children, Equality, Disability, Integration and Youth in its disability function and the HSE is directly engaged with the unit there on the implementation of this strategy. The managed clinical network model consists of a multi-tiered system of neurorehabilitation services, which includes the following. Tier 1 is the national neurorehabilitation inpatient facility. Tier 2 refers to the regional neurorehabilitation inpatient facilities. The aim is to have four to six facilities of approximately 20 beds per 1 million population. Tier 3 covers local community-based neurorehabilitation teams, CNRTs, which is the interest of the committee today. The progress and next steps in regard to each of the managed networks for neurorehabilitation services is listed in the presentation. I will move to Tier 3, which is what interests the committee today. The objective is to establish nine community-based neurorehabilitation teams. They will include approximately 13 professionals, comprising a wide range of therapy services, led by a consultant in rehabilitation.
In 2023, full local community-based neurorehabilitation teams will be place in CHO 2, CHO 4, CHO 6 and CHO 7. We note the dependency on the availability of staff for recruitment to complete the teams. The impact of these teams will vary in 2023 due to the recruitment processes, but they are intended to be fully functional by early 2024. The 2024 Estimates will include the remaining CHO areas, recognising that in CHO 1 and CHO 3 there are partial teams in place which predate the strategy. These will provide a good foundation to bring those areas into line with the strategy. That concludes my opening remarks. I am happy to assist the committee.
Seán Crowe (Dublin South West, Sinn Fein)
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I thank Mr. Gloster very much. I will now open the meeting to committee members to discuss matters with the witnesses.
Colm Burke (Cork North Central, Fine Gael)
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I thank Mr. Gloster very much for his presentation and for all the staff being available here this morning.
I will open with the issue of long-term planning. I raised the matter yesterday at the private meeting about the winter plan for last year when we had significant challenges dealing with the flu. My understanding is that the Department has now requested HIQA to examine the roll-out of enhanced flu vaccination. When is the health technology assessment, HTA, report going to be available? We are competing on the world market for a lot of medication and I am concerned that there may be a delay in the production of this report. My understanding is that two analyses are being done: one for those aged 55 to 65 and the other one from age 65 up. When is the analysis going to be back and when will we have a decision about making sure that we have adequate supplies of the vaccine?
Mr. Bernard Gloster:
I might let Dr. Henry talk about the supply of the vaccine. I do not have a timeline for any HIQA assessment on that issue. The formulation of the flu vaccine, based on the previous year's evidence, is usually what dictates the determination of the supply rather than necessarily any readiness on our part. Dr. Henry might want to give Deputy Burke clarity on that.
Dr. Colm Henry:
I am not aware of the HTA report. Every year the national immunisation office begins engagement in the spring, and it bases its purchase and advance ordering on the most effective vaccine based on the most likely strains that will emerge in the coming winter. The evidence usually comes from the southern hemisphere. That is a cycle that we are well used to. In recent years we have had more than adequate supplies. In fact, we have had surplus supplies of vaccine in place both for adults and children, and available and aligned with our communication campaign from autumn onwards. It is factored into our national immunisation year.
Colm Burke (Cork North Central, Fine Gael)
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So Dr. Henry does not foresee that there will be any delays. My understanding is that HIQA has been asked to do an assessment or HTA report and my concern is that it may then delay the final decision the Department will make.
Colm Burke (Cork North Central, Fine Gael)
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Have lessons been learned from what occurred last year to make sure that we are well prepared? We must remember that the age profile of the population is changing as well.
Therefore, we have more and more people living longer. We have more people over 85, we have more people over 65. Is that factored in as well?
Dr. Colm Henry:
The primary lessons we learned were through the very successful campaign during the pandemic when we learned about more effective ways, primarily through the GP network, of administering the vaccine. Drawing on the past couple of years, if there was one disappointing aspect of the flu vaccine roll-out, it was the uptake of the live, attenuated influenza vaccine, LAIV, among children. We are reviewing the mode of administration of that now, which is primarily through GPs, to see if we can engage our school immunisation teams where there is a higher uptake of the established vaccination regimes for children, to see if we can increase the current uptake of 13 or 14%, which is too low, to a higher level that has been achieved in other countries.
Colm Burke (Cork North Central, Fine Gael)
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Dr. Henry spoke about the roll-out at national level of the neurorehabilitation inpatient facilities, an issue I have raised previously. My understanding is that a new modular hospital was built in Mallow. There are 40 rooms in addition to the 50 rooms that are required to complement the existing hospital. What is the proposal for the use of those 40 rooms?
Dr. Colm Henry:
At this point in time, our national model for neurorehabilitation includes a tiered system, a managed clinical network, which begins with a national centre for complex rehabilitation, which is the National Rehabilitation Hospital, NRH, and then a number of regional inpatient facilities, numbering four to six centres.
Colm Burke (Cork North Central, Fine Gael)
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What I am saying is that there is a building that has been almost completed, or 95% completed, at least. As I understand it, there are 40 rooms available on the ground floor and first floor of this building. Are they going to stay vacant, or can they be put to use to get this up and running?
Dr. Colm Henry:
At this point in time, we are completing a survey of all existing neurorehabilitation beds in the country. The survey will be completed this month. It will be analysed over the next month. We will look at the gap between what we have now, including the recent facilities developed in Peamount in Donnybrook, and what we need as a population, which is of the order of around 60 per million of population, and will then establish a number of regional hubs.
Colm Burke (Cork North Central, Fine Gael)
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There is a serious problem in the south in relation to rehabilitation, overall. We have a huge challenge in this regard, which I have raised previously. There are long delays in getting people out of the hospital setting. As a result, there is a logjam getting people in, because we cannot get people out. Is it not time to address this, especially now that we are facing into a time when there could be a huge growth in demand coming into the winter months?
Dr. Colm Henry:
Yes. In short, there is a deficit of inpatient neurorehabilitation facilities. That is why we are completing the survey of existing facilities to inform our estimates for this coming year. Cork University Hospital, CUH, is one of the two major trauma centres in the country. A significant part of our national trauma strategy is of course to improve the rehabilitation experience of patients undergoing major trauma. There is an alignment with our major trauma strategy and our stroke strategy, which we published last year.
Colm Burke (Cork North Central, Fine Gael)
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The strategy for the neurorehabilitation and community-based teams is very welcome. I think the right approach has been taken. Multiple Sclerosis Ireland, MS Ireland, has also proposed a community-based service to reduce the number of people having to go to hospital for their care. Where are we with that proposal? It has set out a very detailed proposal, with nine people being appointed in the community.
Dr. Colm Henry:
In his opening statement, the CEO outlined where we are at this point and our ambition with regard to those community teams. We have established four and hopefully by the end of this year we will have four complete working teams and our submission to estimates will look for expansion to nine.
Colm Burke (Cork North Central, Fine Gael)
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MS Ireland has shown that it has worked very successfully in Galway where people are treated outside of the hospital setting and as a result, the time that people spend in hospital is greatly reduced, leading to less demand on the hospital services.
Dr. Colm Henry:
Our strategy is not condition-specific. It does not refer specifically to spinal injuries or stroke or MS or any other neurological diseases. It covers the whole range of neurorehabilitation, including trauma, and would of course include patients with MS and their neurorehabilitation needs.
Colm Burke (Cork North Central, Fine Gael)
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Mr. Gloster made reference to the 1.6 million unscheduled attendances in hospital. That figure has not improved over the last 20 years. It is getting worse and worse. People are being referred from nursing homes into hospitals. When this happens, the person often ends up in the accident and emergency department of the hospital. Can we set up a different structure for dealing with that? It is not working out and it is really traumatic for families, for the patient and for everyone involved. Can that issue be reviewed at the present time?
Mr. Bernard Gloster:
Yes. There are two approaches and the Deputy is 100% correct on it. While while we have seen somewhat of a reduction in attendances this year versus last year, it is increasing for the over-75s. This is part of and implied in the question the Deputy is talking about. My colleagues will be aware that in the short few weeks that I have been here, I have already yesterday mandated the hospital CEOs and community healthcare chief officers to test this coming into the bank holiday weekend. We have a range of services in the community at the moment that do not go into private nursing homes. I have now mandated that all primary care services and specialised teams in the community, like the integrated care for the older people's team and the chronic disease management, would be available to see patients or residents, potentially patients, be they in public nursing homes, private nursing homes or at home. Depending on the demand, there may be some delay or time within that, but that is a new departure for us because the model we have at the moment essentially means that a resident in a nursing home is solely dependent on the determination of the staff in the nursing home and perhaps a GP, in relation to things like a hospital referral.
Colm Burke (Cork North Central, Fine Gael)
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Does Mr. Gloster accept that referring someone whose health has disimproved from a nursing home to an accident and emergency department is not the way to deal with it? Is it not time to look for a new structure to deal with this? Can we have that in place reasonably soon? Quite a number of families have come back to me querying whether the right decision was made in referring the person in the first place. Then the days the person spent in the accident and emergency department were really traumatic for both the patient and the family. This issue needs to be looked at carefully
Regarding the 1.6 million unscheduled admissions, what percentage of that is from Saturdays and Sundays? One of the problems is that we are talking about rolling out community healthcare but a lot of the community health care finishes at five o'clock on a Friday evening. That is a huge challenge now that we need to start looking at as well.
Mr. Bernard Gloster:
Regarding the nursing homes, I was in St. Vincent's hospital the week before last and they now have a specialist team based out of the emergency department. It is a consultant-led team with a dedicated vehicle and they go out to private nursing homes in the area. They assess people who are potentially a query for referral to the hospital. If they can apply a level of intervention that will help the person stay in the nursing home appropriately, they do that. Their conversion rate in to hospital at the moment is only about 9%, which is very good. If 250 patients are seen per month they are probably only referring 20.
Colm Burke (Cork North Central, Fine Gael)
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Is it possible to roll that out in the rest of the country?
Mr. Bernard Gloster:
It is part of the plan to expand that service. There are different models around the country. In some places it is called Pathfinder, in others it is called emergency department in the home, EDITH, and so on. That is the type of model we are trying to do. From my perspective, all of the services we have in the community currently are not available to people in nursing homes and that is the part that will change in the coming months.
On the issue of Saturdays and Sundays, it was done by my colleagues in January for a period. We had a very detailed engagement yesterday with hospitals and community healthcare staff. While people have contracts at the moment that I cannot unilaterally change, the chief clinical officer and I will be confirming in writing to all of the services today that we are asking people to volunteer to change their deployment arrangements in order that we can cover the Saturday, Sunday and Monday of the bank holiday weekend. We know from the May bank holiday weekend, that we were caught very badly, by virtue of the fact we do not have that availability at the weekend.
We would obviously have to look at additionality of staff if we were going to sustain that every weekend. Essentially, if the health service does not move from on-call working at weekends to actual service delivery in the community and in hospitals, it will continue to experience serious problems every Tuesday morning. I am on the public record as saying that I am intent on changing that. That will take a period of negotiation but we are trying it on a voluntary basis first.
David Cullinane (Waterford, Sinn Fein)
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I welcome Mr. Gloster. I know of one case of a 78-year-old woman who arrived in an emergency department, referred by her GP. She arrived last week into University Hospital Waterford at 3 p.m. with her daughter. She was triaged very quickly but was then left on a chair for hours on end. Her daughter had to leave her in the early hours of the morning because she was working the following day. She arrived back at about 7 o'clock the following morning and her mam was still sitting in the same chair and had not been admitted to a bed. She was not admitted to a bed until 3 p.m. the following day. She waited for 24 hours. In the first quarter of this year, over 17,769 patients waited longer than 24 hours in emergency departments. Mr. Gloster will be aware that in some departments that is an average for all patients. The average is about 11.7 hours across the board. Is that acceptable, given the levels of investment we are putting into acute hospitals and into healthcare generally? We are spending tens of billions of euro to have patients of that age, including this patient who was later diagnosed with a serious cardiac issue, sitting on a chair in an emergency department for 24 hours. It is not just her. Countless people are in the same situation every day in acute hospitals across the State. Is that acceptable?
David Cullinane (Waterford, Sinn Fein)
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What would Mr. Gloster say to the families who experience that every day? It is like Groundhog Day. We are having the same discussions all the time but this seems to be the norm. The trolley figures range from somewhere between 500 and 600 every day. It has almost become normal. How are we going to change that?
I would just pick up on the issue of the seven-day service. I understand that there are industrial relations issues. Everybody here understands that. A big part of the health budget - billions of euro - goes to acute hospitals. They operate at full tilt five days a week. They do not operate at full tilt at weekends. There is only so much you can get from those five days, with the best will in the world, even with additional capacity. How important is it that we can get more from the weekends and bank holidays? They always seem to be a disaster when it comes to emergency departments and hospitals. Mr. Gloster says there are discussions and that he wants voluntary changes. I accept why that is, that it is because there are contracts and all the rest of it. Can he explain to people listening and to those family members and patients who have had those horrendous experiences in emergency departments and hospitals, although that is not always the case, what changes he is going to mandate to ensure we actually get to grips with that issue?
Mr. Bernard Gloster:
The Deputy asked what would I say to those families and, indeed, those patients. It would be disingenuous of me to say anything on the public record other than that I am extremely sorry that that is the case for one person, let alone for thousands of people. We cannot ever stand back from saying that. I know that might sound easy to say and some people might ask what good that is but it is an important place to start from. That is regardless of explanations about increases in attendances by those over 75 and the increase in complexity and length of stay for over-75s. Lots of really hard work has gone into reducing the overall conversion rate of admissions from emergency departments and so on. People have worked very hard on that but with that demographic, the prevalence of chronic disease and other things is very significant.
Regarding practical steps to deal with that, I would expand on what I said to Deputy Burke. One of the practical things we can do is look at the access points that are not available to those people before they present at emergency departments. Some of them do have to present because they are very unwell. It is important that we do not lose sight of that. The length of stay has gone up in some hospitals by about two days because of the level of frailty and acuity. For a lot of people, an alternative would be better. What we can mandate, regardless of contracts or job descriptions or other things, is to take the very extensive resource that has been invested in the community over the last two and a half years and ensure it is not just available to people in a health centre or people who live at home but that it is also available to the 20,000 people who are in nursing home care, many of whom present in hospital. Those referrals could be avoided or they could be discharged more quickly and supported by that. That has now been mandated. That is the first thing.
The second thing is that we can focus more on the delayed transfers of care out of our hospitals. We now have the number down to just above 500, from just below 600. I am not happy that we are anywhere near that. People are working exceptionally hard. Yesterday evening, I permitted chief officers to extend the rules and to extend the application of the definition of transition care to the widest parameter they feel is needed to facilitate people leaving hospital. If appropriate, they can also use what was transition care for people coming out of hospital as a form of respite that might support somebody to avoid them going into hospital. That is a very practical step. If we can reduce the delayed transfers of care further, we should be able to catch up to some degree with the patient experience time, as we call it. Simply put, that is the waiting time for that woman in that chair. That is a measure we can mandate.
David Cullinane (Waterford, Sinn Fein)
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My time is very short.
Mr. Bernard Gloster:
On the voluntary working, I have discussed with the Minister and the Secretary General of the Department my intention to put that as the highest priority of the health agenda this year. Any new public sector agreement should include a move away from recruiting anybody on a five-over-five contract to recruiting everybody on a five-over-seven basis.
David Cullinane (Waterford, Sinn Fein)
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That is really welcome. When I hear the word "mandate" I think that is exactly what we need to hear. Where there is best practice, it needs to be mandated. We need to move away from talk of "encouraging" and saying we will talk about something and examine it. Where things need to be done, they need to be done and we need decisive leadership. I welcome the fresh approach Mr. Gloster is taking. When he talks about mandating, that is what we need to hear.
There are two other issues I want to raise and time is tight. The committee had a very distressing session a number of months ago with front-line healthcare trade unions, or trade unions representing front-line healthcare workers. They raised issues around the high level of assaults. I know those numbers came down in the first quarter of this year but there are also issues around how the HSE deals with bullying within the organisation. I ask Mr. Gloster to give us an understanding of those two areas and to explain what changes, if any, he intends to make to protect the welfare and safety of those on the front line.
I have been raising the outsourcing of healthcare for some time. We are talking about the service plan and the spend of money. We are spending hundreds of millions of euro outsourcing and a lot of that is on management consultancy. We saw what happened in a hospital in Cork recently. We have established a cottage industry, to be honest, of management consultancy and outsourcing where huge amounts of profit are being made. A lot of that should be done in-house. Is that something Mr. Gloster has examined? Does he want to take a different approach? We have to start reining in that spending and ensuring there is not such an overreliance on management consultancy.
Mr. Bernard Gloster:
On the issue of assault, which is quite a significant issue based on what is reported on the system, there has been a decrease since 2018. There were 11,674 recorded incidents then and that figure is now down to 9,249. Some of those are associated with very complex inpatient work and so on. In fairness to those patients and staff, nobody would want to be disparaging about that. I have been very clear that there is one thing I will just not accept and that is anybody who believes, regardless of how frustrated they are with the health system, that it is okay to assault a healthcare professional. We will make every effort we can to deal with that.
On the issue of bullying, we have very extensive dignity at work policies. I could rehearse those but I think the Deputy is familiar with them and they are available on our website. A significant amount of training and work goes on to try to train people to work differently with regard to how they manage the grievances staff might have, how they manage staff to get the best from them and creating the right environment for staff.
The reality is that all the policies, procedures and training have to be matched by a parallel change in culture. That is a very significant focus and one of the top three priorities I have set for my tenure as CEO. If we do not treat each other according to the values we claim to espouse as an organisation, we are probably coming up well short for staff.
On bullying, the deliberate, repeated unfair treatment of anybody is abhorrent, certainly to me. We have to be able to manage, performance-manage and challenge people, but these must be done appropriately and respectfully. There is no doubt that bullying can have a lasting and dreadful impact on those who experience it.
On management consulting, I am aware of some of the reports this week. With regard to management consulting in 2022, there are different figures for outsourced services, specialist services, legal fees and so on. However, when stripped back to management consulting, it looks like our expenditure profile will land somewhere between €120 million and €180 million for 2022. There is active analysis in this regard at the moment. Certainly, our dependency will have to be reduced quickly.
David Cullinane (Waterford, Sinn Fein)
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That figure for management consultancy is extraordinary. Given all the staff and experience we have in the healthcare system, healthcare expenditure of up to €180 million on management consultancy is not what people want.
Róisín Shortall (Dublin North West, Social Democrats)
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Good morning to our guests. They are very welcome.
I want to start on the issue of hospital beds. The service plan states the intention is to deliver an additional 184 general acute beds and 26 critical care beds. At the end of last year, there was a shortfall of 258 beds on the basis of previous commitments. Are the figures in the service plan in addition to the 258 outstanding?
Mr. Damien McCallion:
No. The commitments in the service plan are what will be delivered in the year. There were 970 beds delivered under the previous initiative, and we plan to deliver 209 this year. There were 40 in the plan in respect of which we are now considering alternatives because the original solutions proposed for two sites will not work. The number is the number of acute medical beds being delivered under the initial initiative.
Róisín Shortall (Dublin North West, Social Democrats)
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The figure I received at the end of December was 258 outstanding.
Róisín Shortall (Dublin North West, Social Democrats)
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So 209 of those overdue ones will be delivered this year-----
Róisín Shortall (Dublin North West, Social Democrats)
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-----plus the 200-odd in the service plan.
Róisín Shortall (Dublin North West, Social Democrats)
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So the commitment for new beds in the service plan is a catching up on what has been promised over the past three years.
Róisín Shortall (Dublin North West, Social Democrats)
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So they are not additional beds?
Róisín Shortall (Dublin North West, Social Democrats)
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They are not additional to what was committed to.
Róisín Shortall (Dublin North West, Social Democrats)
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That is quite disappointing. It is deceptive for the figures to be set out as they are. This is about catching up on the HSE's commitments over the past three years.
Róisín Shortall (Dublin North West, Social Democrats)
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There is an element of smoke and mirrors here. There were 258 beds due under earlier commitments.
Róisín Shortall (Dublin North West, Social Democrats)
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We have clarified that. I thank Mr. McCallion.
I want to go back to the issue of the neurorehabilitation community teams. When the Neurological Alliance of Ireland representatives were before us, I made the point that the battle is usually to get a strategy. We have had a strategy since 2011. We have had an implementation plan since 2018 but still have only two of the teams in place, and they are not even fully staffed. What is the reason for the delay in implementing the earlier commitment to put in place the teams in CHO areas 6 and 7?
Dr. Colm Henry:
It was delayed. We would like to have had the teams in place earlier, for sure. A lot of the work of the implementation framework happened just before the pandemic and the work of the oversight group that was meant to be implementing the strategy was certainly hampered by the pandemic, but we are focusing on this again and expanding from two existing teams to four by the end of this year. As I said earlier, in our Estimates process we will be making a submission to staff all 19-----
Róisín Shortall (Dublin North West, Social Democrats)
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We are talking about four out of nine teams by the end of this year on the basis of a 2011 strategy. This is actually a no-brainer. Very often, a person who develops neurological difficulties has to give up work, or a partner has to give up work. A person's life is greatly impacted. There is a massive case to be made, on the basis of a cost–benefit analysis, to ensure the teams are in place at community level so as many people as possible with brain injuries, including acquired brain injuries, and various neurological conditions can get back to working and living independently as quickly as possible. Why is there an incredible delay regarding the strategy?
Róisín Shortall (Dublin North West, Social Democrats)
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Why is it not happening?
Róisín Shortall (Dublin North West, Social Democrats)
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Why is it not happening?
Róisín Shortall (Dublin North West, Social Democrats)
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Twelve years after the strategy was developed, the HSE has not yet put in the third and fourth teams, which were funded last year.
Róisín Shortall (Dublin North West, Social Democrats)
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Is Dr. Henry committing to funding the other five next year?
Róisín Shortall (Dublin North West, Social Democrats)
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This goes to the very heart of what Sláintecare is supposed to be about, which is getting people as well as possible through community services. There is incredible foot-dragging in the strategy. It is very hard to understand why there has been such an extraordinary delay.
I want to make a point about emergency departments that I made to the Minister here recently. Mr. Gloster was not present at the time. The point was that there needs to be a strategic approach taken to dealing with the pressures in emergency departments. I do not know how the HSE can take a strategic approach if there has been no analysis of the reasons people are attending emergency departments. Can we achieve that analysis? Is it possible to find out what proportions of people are attending for social reasons, for sports injuries or for heart conditions, or owing to diabetes and various chronic illnesses? Unless we have that analysis and data on why people are attending, how can we ensure there are alternatives to turning up at the local emergency department?
Mr. Bernard Gloster:
I do not think it is the case that there is no analysis. We already know from the very high numbers of ambulatory patients seen, treated and discharged in record times at emergency departments, which patients are never seen when the trolley numbers are discussed, that a large proportion of them could be treated in alternative locations.
Róisín Shortall (Dublin North West, Social Democrats)
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That is a generalisation.
Róisín Shortall (Dublin North West, Social Democrats)
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We do not know the reasons they are presenting; that is my point. For the past 15 years, we have been talking about moving chronic illness management out into the community. Do we have a figure for how many people attend as a result of an asthma attack, for example? Are there alternative ways – we know there are – of providing asthma services?
Róisín Shortall (Dublin North West, Social Democrats)
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I am not talking about acute asthma.
Róisín Shortall (Dublin North West, Social Democrats)
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Do we know how many people are turning up with acute asthma attacks?
Róisín Shortall (Dublin North West, Social Democrats)
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I do not know how the HSE can be strategic about the services it is providing if it does not have that analysis.
Róisín Shortall (Dublin North West, Social Democrats)
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Okay. I am looking for the data.
Róisín Shortall (Dublin North West, Social Democrats)
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I asked about this previously. I am making the point that I do not know how strategic decisions can be taken unless the HSE has the data I have mentioned.
The next point I want to check with Mr. Gloster relates to his welcome initiative to seek volunteers to work weekends. Again, why on earth are all healthcare staff not required to do so? Many of them do. Is he asking all grades of staff to volunteer?
Mr. Bernard Gloster:
Coming into the June and August bank holiday weekends and the balance of this year, while we are waiting to secure what I hope will be more fundamental agreements on the recruitment and contracting of people, the predominant focus is on people who can make decisions about inpatient beds; who can provide the diagnostics to enable decisions to be made for inpatient beds and emergency departments; and community services that can facilitate the normal avoidance of someone coming to hospital or facilitate discharge. It cuts across all grades including medical, nursing, especially allied health professional grades in the community, some administrative staff and general practitioner out-of-hours services.
Róisín Shortall (Dublin North West, Social Democrats)
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I take from what Mr. Gloster said that the intention is to change people's contracts from now on.
Mr. Bernard Gloster:
I do not want to be unfair to staff representative organisations. I am sure they will have something to say when I meet them about it, but my starting point will certainly be to secure by agreement, now or in the next public sector pay agreement, whatever about existing contracts, that all new recruitment would be on a five-over-seven day deployment basis for all grades in the health service, even if it is not needed today, on the basis that it may be in the future.
Róisín Shortall (Dublin North West, Social Democrats)
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It is important to acknowledge the large number of grades which already do that, such as nurses, ambulance staff and so on.
Róisín Shortall (Dublin North West, Social Democrats)
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It also raises questions about the terms of the recent Sláintecare contract which is for six rather than seven days.
I will raise one other question about outsourcing. We will continue to seek details of the extent of outsourcing that is happening in the HSE. It is a question of shirking responsibility. It is a bit like the National Treatment Purchase Fund. It is much easier if services are bought in and the responsibility that goes with it is not taken on. It is a poor practice in many ways. We must cease it and go back to providing a proper level of public services. One case that concerns me is that of a 91-year-old woman who was referred by her GP to hospital for an intravenous, IV, antibiotic. She waited eight hours. Her daughter brought her home. The family clubbed together and came up with the €200 to go back to the private part of the same hospital the next morning and she was seen immediately. Is there not a serious conflict of interest in that? Hospitals that have public and private sections are making a lot of money from the private part and are not providing adequate services in the public part.
Róisín Shortall (Dublin North West, Social Democrats)
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It is a separate hospital on the same site. Is there not a serious conflict of interest for the hospital?
Róisín Shortall (Dublin North West, Social Democrats)
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The hospital is not providing an adequate public service and is getting money for forcing people into the private service.
Seán Crowe (Dublin South West, Sinn Fein)
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Perhaps the Deputy could raise the matter privately after the meeting.
Róisín Shortall (Dublin North West, Social Democrats)
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It is the principle of it.
Neasa Hourigan (Dublin Central, Green Party)
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I will go back to the neurorehabilitation teams so that we can be clear about the dates and everything. We have two teams and the witnesses stated that we will finish 2023 with four further teams. Are those implementation teams already in place or how far along or they?
Neasa Hourigan (Dublin Central, Green Party)
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Every team in the country could probably be characterised that way. Are there four additional teams? It is not two plus two.
Neasa Hourigan (Dublin Central, Green Party)
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At what stage are the two that are coming on line this year, which, as Dr. Henry stated, are in addition to the two that already exist but are not fully staffed?
Neasa Hourigan (Dublin Central, Green Party)
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When Dr. Henry says they are at recruitment stage, does he mean that the posts have already been advertised?
Neasa Hourigan (Dublin Central, Green Party)
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Is an implementation team in place for the five remaining teams in each CHO that is looking at what is required?
Mr. Bernard Gloster:
I will assist. In two of the five cases, pre-existing multidisciplinary teams are in place doing a form of this work. It is a case of bringing them up to scale and perhaps modifying some of the practice. That could bring it to six teams relatively quickly. The other three teams are subject to the approval of the Estimates process. We need 39 posts for three teams.
Neasa Hourigan (Dublin Central, Green Party)
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Two of those would need relatively less funding than the other three which are a whole new ball game.
Neasa Hourigan (Dublin Central, Green Party)
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Mr. Gloster mentioned Limerick. Where is the other team that is almost in place?
Neasa Hourigan (Dublin Central, Green Party)
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Does Mr. Gloster have the other three that will be more difficult and take longer on his piece of paper?
Neasa Hourigan (Dublin Central, Green Party)
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A few of those are CHOs with large catchment areas.
Neasa Hourigan (Dublin Central, Green Party)
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Does that present a particular challenge in getting them over the line in 2024?
Mr. Bernard Gloster:
Apart from the approval of the resources to recruit the teams, the challenge essentially is the recruitment. Apart from the consultant-led part of the team, these teams predominantly comprise allied health professionals across the core therapies, including speech and language therapy, physiotherapy and occupational therapy. They generally require therapists with some experience or a capacity to develop a specialist interest experience in neurorehabilitation. In the general pool, we are competing against ourselves for the children's disability network teams; the child and adolescent mental health services, CAMHS, multidisciplinary teams; the inpatient hospital teams; the enhanced community care teams; the chronic disease management teams; and the integrated care of older people teams. I do not want that to sound facetious but a limited number of therapists will graduate and that is what we are competing against.
Neasa Hourigan (Dublin Central, Green Party)
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I understand. Some of the last three teams are in areas where we have the highest concentration of people, staff and specialists and so on.
Neasa Hourigan (Dublin Central, Green Party)
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To be clear, those are the community teams. Are the inpatient neurorehabilitation services that are being developed through the managed clinical networks at the same level of development? Do they work in parallel?
Mr. Bernard Gloster:
The objective for the regional facilities is to establish four to six facilities of approximately 20 beds per 1 million people. Since 2022, 27 of those beds have been identified and are in place in Donnybrook and Peamount. As Dr. Henry said, many beds are quasi-rehabilitation beds and are referred to as such or are stroke-rehabilitation beds. In Limerick, there is a rehabilitation stroke unit in St. Camillus Community Hospital and so on. Those are being assessed this year to see how many could come up to the standard required for the 20 per 1 million head of population. We will then add the balance to those. The national top tier is in the National Rehabilitation Hospital.
Neasa Hourigan (Dublin Central, Green Party)
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Let us take the beds in St. Camillus Community Hospital, which is being used in this manner by proxy. What would it mean for its use and services if these were to become full rehabilitation beds? Would they be hived off? That is unclear.
Mr. Bernard Gloster:
No, as Dr. Henry said, neurorehabilitation cuts across a range of conditions. If we take a consultant-led rehabilitation bed that is used for post-stroke care today, we will essentially be resourcing, equipping and skilling that unit to come up to a multi-condition response bed.
Neasa Hourigan (Dublin Central, Green Party)
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To meet a particular standard. Okay.
Mr. Gloster stated that we have 27 beds. How many are we short?
Neasa Hourigan (Dublin Central, Green Party)
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We are quite short in that regard. I will move on to the service plan. I will take a minute to talk about GP services. I have the information open in front of me and so much of the work that needs to be done links in with GP care. The HSE has identified GPs as key to providing diagnostic texts and early identification to take the pressure off emergency departments. There are a couple of things I want to ask about. There was a story recently about attracting GPs from other countries.
Neasa Hourigan (Dublin Central, Green Party)
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What work are we doing in that regard? This matter has been raised to me by constituents who work in the field. Many medical professionals have to come here before they are assessed as to whether they pass the standards for language and meet all the requirements. Other countries sometimes allow those assessments to happen in the medical professionals' home countries to facilitate attracting people who are at a level that we want. That way, assessments happen before people have to pay for travel to or accommodation in Ireland. Have we considered that?
Mr. Bernard Gloster:
In respect of the totality of trying to increase the availability of GPs and sustainability of GP care, it is important to make a couple of points. We must be honest that we just do not have enough GPs. We will not try to fluff that in any way. The number of training places has increased. A decade ago, there were approximately 120 places per year. There will be 285 entering training this July. That will give us approximately 940 GPs in training across the four years. We are hoping to get to 350 in each year by 2026, which would bring us up to a profile of 1,200 in training. Separately, under the non-EU doctor scheme, which is predominantly associated with South Africa, there already 50 doctors from South Africa in the country. They are coming in cohorts of 25. They come into the country and work as doctors. They are contributing. Where we can, we are targeting them at areas where there are deficits, while respecting that people have choice. They will be under a certain regime of supervision approved by the Medical Council of Ireland and supported by the Irish College of General Practitioners. Those South African GPs will be able to register as GPs, subject to certain requirements, after two years. That will add to the base, along with the trainees themselves.
In terms of international recruitment, we of course try to assist people however we can. There are particular schemes from time to time that might help people with travel, the cost of travel, the initial cost of relocation and whatever else. Those schemes vary and fluctuate so there is no set piece in that regard.
Neasa Hourigan (Dublin Central, Green Party)
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That might be something to think about. The other point I want to make will return us to the discussion around those larger catchment CHOs, including CHO 8 and similar areas. We tend to think of the dearth of GPs in rural areas but for areas of deprivation, the lack of GPs is a massive issue. One model that has come across my desk is GP care for all, which is organised on a not-for-profit charity basis. I am aware there is a large cost to starting a GP practice and it can be difficult, particularly in an area of deprivation where many service users are medical card holders. It can be difficult to get a practice off the ground. Is the HSE exploring a not-for-profit model and a support basis for GPs? I know there have been some pilots in this regard. Supports could be provided for GPs who choose to work in areas of deprivation or in areas where there are many low-income households.
Mr. Bernard Gloster:
I am not sure about the not-for-profit model. Dr. Henry might respond on that point. I am conscious there are negotiations going on with GPs at the moment around the increased eligibility piece so I do not want to stray into that area. Reasonable efforts have been made. I will not overstate the case but there have been reasonable efforts in recent years to support practice nurses in practices, for example, and the development and scope in that regard. Equipment, ICT and accommodation in certain primary care centres in certain areas have also been provided. Without creating a national scheme, we are as creative as we can be in trying to attract as many GPs as possible into the areas we find hardest to fill. I am not sure about the not-for-profit model. I will put my hands up and say that.
Neasa Hourigan (Dublin Central, Green Party)
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Perhaps I could come back to Mr. Gloster in a private moment and make a pitch for such a model.
Mr. Damien McCallion:
To flag one other point, we track the number of GPs per CHO population. As the CEO said, we try, where possible, to direct people towards areas where there is a deficit. However, GPs have the choice as to where they go to work. We examine the proportion of GPs per 10,000 population in each of the CHOs and try to address areas in which there are large populations.
Neasa Hourigan (Dublin Central, Green Party)
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I promise Mr. McCallion that is definitely an issue in my area.
Dr. Colm Henry:
There is a marked variation in the provision of GPs in different CHOs. Nationally, we are at 6.92 per 10,000. Scotland, by comparison, has over nine per 10,000. That is the kind of model to which we aspire. In addition to more people coming onto the training scheme, those non-EU trained doctors from South Africa are being directed towards those CHOs with a lower ratio of GPs per population to try to support those areas until we get these trainees through the system.
Martin Conway (Fine Gael)
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I was going to ask about MS and neurological disease but it has been well covered. It will come as no surprise to Mr. Gloster that I am going to ask about University Hospital Limerick, UHL. I know he visited UHL very recently. It is at the top in terms of the numbers of people on trolleys. We see that consistently in the trolley figures of the HSE and the Irish Nurses and Midwives Organisation, INMO. He said in response to Deputy Shortall that for 52% of the people who turn up at accident and emergency departments, that is their first point of contact. I know Mr. Gloster has only been in the job for a couple of months.
Martin Conway (Fine Gael)
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He has already instigated some changes in the senior management. Could he give us an update on the position in UHL? It is now nearly the test case nationally for how we deal with accident and emergency services. It is a constant issue. The numbers are too high. Even in recent days, the numbers have been too high. I would like to hear Mr. Gloster's thoughts.
Mr. Bernard Gloster:
The numbers are high. We spoke earlier about the frailty piece in respect of people over the age of 75. That is a very significant factor. We all know that UHL is challenged and that comes up in lights. Other sites have similar challenges but they are not as visible. We have taken practical steps. When I commenced in this role, one of the pieces of work that Mr. McCallion did, shortly after Christmas, was a temporary expansion of the medical assessment units at St. John's Hospital and Nenagh hospital to bring them up to seven-day functionality, as is the case in Ennis hospital. I have now put that expansion in place permanently. I have given approval for the recruitment of 55 additional staff and a budget of €5.5 million to do that. That plan is being rolled out by the hospitals as quickly as possible. They are using a mix of overtime and agency staff until they can recruit but they have approval to permanently recruit. It is important for us to bring certainty to that model.
I am sure that when he drives past the hospital, the Senator will see the ongoing construction of the 96-bed tower ward on top of the emergency department. That building is moving at pace. It will, I hope, come on stream in early 2025. That 96-bed tower will comprise roughly 50% new beds and 50% replacement beds because some of the existing bed stock is quite challenged. UHL got additional beds during the pandemic. I am hoping, subject to some further and final thoughts, that the Minister will have more to say on the issue in the coming while. UHL has received an expansion of emergency department consultants in the recent winter plan piece. It has filled, temporarily or otherwise, a number of those positions. Quite a lot is happening.
Part of the issue for Limerick, as Deputy Shortall rightly raised, is not what we do in the hospital but what we do outside the hospital. Similar to other groups, yesterday evening I gave the chief officer in UHL full permission to test the expansion of transition care not only for people coming out of hospital but for people potentially going in. It is a form of respite. We will be dependent on the availability of private nursing home places to do that. Substantial new infrastructure is going into place in the Senator's own country. Planning permission for 100 beds in Ennis hospital has been granted to replace St. Joseph's Hospital.
The Senator is familiar with the history of that.
Martin Conway (Fine Gael)
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What is the timeline for that?
Mr. Bernard Gloster:
It is at planning stage at the moment. My understanding is that it may be subject to some objections so I do not want to stray across the statutory provisions of another agency. The answer in part to Limerick is capacity, the answer in part is process within the hospital and the answer in part is availability of pathways in the community. The availability of pathways in the community and process are things I can do something about but capacity takes time to build.
Martin Conway (Fine Gael)
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Mr. Gloster spoke earlier about seven over seven or at least consultants being available on any of the seven days and hoping for voluntary buy-in. How is that working out in Limerick?
Mr. Bernard Gloster:
After Christmas, there was a very significant positive response to Dr. Henry's request of his clinical colleagues. Regarding working over seven, I really want to be clear about this. I dealt with this in a radio interview on RTÉ two weeks ago. I know the Senator does not mean it this way but when we talk about one discipline, there is an awful danger of demonising that discipline and transferring the blame for a problem on to that discipline. When I talk about seven over seven working, if a queue of consultants lined up to work next Saturday and Sunday, they would be very limited unless I could give them what they needed around them to make their decisions effective so I am talking about the totality of disciplines. I will let the Senator know after the June bank holiday weekend how it actually worked because the request is going out to them today but that is just testing it. My plan is to permanently change it. The new consultant contract allows for it over six but it relates to all of the staffing services such as radiographers and allied health professionals. I am intent on pushing that to the greatest extent possible.
Martin Conway (Fine Gael)
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That is great. Could Dr. Henry give us an update on Covid, particularly long Covid? What are the figures in terms of long Covid? Have we scaled up to deal with the impact of long Covid? I would be interested in hearing Dr. Henry's views on it.
Dr. Colm Henry:
Dr. Tedros Adhanom Ghebreyesus recently announced, as I am sure the Senator is aware, that it is no longer a public health emergency of international concern and is now part of normal healthcare business and is factored into our figures. We have thankfully noticed a lull in figures here. There are emerging variants all the time but thanks to the natural resistance of the population either from the vaccine programme or from acquired infection, and it is safe to say that nearly everybody must have been exposed to it at this stage, we are in a very different place from where we were a few years ago and as such, we were freed from the social restrictions and all the difficulties and secondary health problems that emerged with those.
Regarding long Covid, during the pandemic, we devised a model of care and have since checked it with HIQA the following year. We asked HIQA to do a review of updated evidence regarding our model of care, which was a layered model of care on self-awareness, self-management, GP supports, six clinics for long Covid and six for post-Covid based on the areas where we saw the highest incidence of Covid.
Martin Conway (Fine Gael)
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What is the difference between long Covid and post Covid?
Dr. Colm Henry:
Timing. Long Covid pertains to those over 12 weeks. There is still emerging evidence from this. There is substantially more than just weakness and headaches. There is also fatigue and some neuro-cognitive issues. As part of our model of care, we set aside funding for a unit at St. James's Hospital to deal with the neuro-cognitive issues. I can come back with a report on the activity of the-----
Martin Conway (Fine Gael)
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Perhaps Dr. Henry can send us a note? Could Dr. Henry update us on how the catch-up programme relating to the HPV vaccine going?
Martin Conway (Fine Gael)
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I would be interested. There is a clear interest in that area and I think it is very important.
Gino Kenny (Dublin Mid West, People Before Profit Alliance)
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I thank all the witnesses for their statements. Has the concept of the winter plan been shelved?
Mr. Bernard Gloster:
In the next week to ten days, we will finalise with the Minister the approach for the rest of the year. That is similar to what I just said about the June bank holiday weekend. The core component will predominantly be work practices with some additional capacity measures. Very quickly after that, we hope to present to and agree with the Minister a three-year approach to the management of unscheduled care so not unlike what Deputy Shortall was saying regarding our strategic approach. We no longer have a problem in winter. We have a problem so it is a three-year approach to managing that capacity. A big part of that would be seven over seven working along with bed capacity that is coming on stream, the additional staff on top of the 20,000 we have already recruited since 2019 and the safe staffing levels for nurses, which will bring an additional 660 nursing posts into the service as soon as we recruit them. That will replace the winter planning.
The three-year plan as opposed to the rest of this year plan will include an ask of Government for certain things that might have traditionally been part of the winter plan. I think the Deputy will be familiar with it because it has been well rehearsed many times in this committee that by the time we get the winter plan written and agreed, the money that comes with it is very hard to spend in the winter. We are trying to take the unpredictability out of it and this sense of an annual event in that everyone is waiting for this big plan, which is not that big actually. It has served us well in the past but we have to move to an all-year-round plan.
Gino Kenny (Dublin Mid West, People Before Profit Alliance)
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The national service plan has two objectives. How much did the pandemic stall the main objectives in health and personal social services? Obviously, there was a significant amount of confusion and disruption to say the least. What did the pandemic essentially do to those core objectives in health and personal social services and the implementation of Sláintecare?
Mr. Bernard Gloster:
Dr. Henry can talk about the clinical dimension, the epidemiology factors and so on in terms of impact of things like cancer and diagnostics. Regarding the totality of the development of the health service, two fundamental things happened with Covid-19. One was the demographic continued to come against us in terms of the increasing age profile but the development of normal improvements in services and the ramping up of services were essentially put on hold or diverted towards responding to the pandemic so you got a double hit on both ends of that. While the health service worked enormously well and very successfully in terms of mortality during the pandemic, the normal development of and pathway towards things like universal healthcare or individual improvements in community neuro-rehabilitation teams or any other team essentially went into suspended animation so we are playing catch up with the development of normal service, which I said is one of the two parts of the service plan, and we are also trying to fight against what we knew was additional demand that was going to come our way. One of the things we did not see involved what happened since Christmas. The number of new people who have come on to our outpatient waiting lists far exceeded any projections and modelling and that is not unique to Ireland.
Gino Kenny (Dublin Mid West, People Before Profit Alliance)
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Off the lists.
Mr. Bernard Gloster:
Yes. We could still have the same number of people on the waiting list even thought we are seeing and treating more people than ever so at least, the length of time they are on it is reducing but the volumes are enormous. Does Dr. Henry wish to comment on the clinical dimension?
Dr. Colm Henry:
We are seeing this debt built up from the secondary effects of Covid, that is to say, people not coming. In the very acute period during the first surge, there was a drop off even of people presenting with time-critical conditions such as stroke and myocardial infarction. We and other healthcare systems noticed an understandable drop off in people presenting not just to rapid-access cancer clinics, and we facilitated that by creating extra clinics and resources, but also a drop off in registered cancers for 2020 of 12% so, as will happen in other healthcare systems, those cancers will present in a delayed way and perhaps upgraded. We have also seen a threefold increase in presentations and admissions for eating disorders. There was clearly a drop off in screening so we are doing catch up with that as well. Like other healthcare systems around the world, we are playing catch up on delayed presentations and deferred presentation of people.
That is a post-Covid phenomenon worldwide.
Gino Kenny (Dublin Mid West, People Before Profit Alliance)
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Is that manifesting itself now?
Gino Kenny (Dublin Mid West, People Before Profit Alliance)
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What does that mean for those in that situation who did not get that particular intervention at that critical time?
Dr. Colm Henry:
The trajectory of most of these cases shows that the earlier people present and the earlier they are diagnosed, the easier and less invasive the treatment is and the better the outcome is. What it means for time-critical conditions such as cancer is that people are presenting later and may be what we call upstaged from before. That is a drop-off from the National Cancer Registry Ireland, NCRI, notice of 2020 of about 12% of registered cancers, which is, of course, a concern. Working with the national cancer control programme, we applied and secured additional resources to buttress access to cancer services and to remind people of the importance of coming in if they develop symptoms. Likewise with screening, we had to react to the fall-off in attendance. The screening programme played an exemplary role throughout the pandemic in catching up with breast screening, cervical screening and, of course, retinopathy. It is a huge challenge worldwide.
Gino Kenny (Dublin Mid West, People Before Profit Alliance)
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My final question is about the Neurological Alliance of Ireland. It was here last week and it was an interesting session. It said 800,000 people in the State would have a neurological condition, which is one seventh of the population. It is an enormous number of people. What was stark about the statement was that 85% of the neurological patients will not have access to a community neurorehabilitation team. That means a huge number of people just will not get the intervention at that time. How can the HSE address that? I know the witnesses' statements go some way to addressing some of this stuff, but many people are not getting the intervention that they should.
Mr. Bernard Gloster:
Traditionally, we know that people with neurological conditions are referred from their GP to outpatient services and are then diagnosed by a consultant. The hospital or consultant team determines the intervention for that part. The evidence has moved on substantially and shows that outcomes are greatly improved by having a multidisciplinary team in the community that people can access. The only pathway to reducing the impact of what the Neurological Alliance of Ireland told the Deputy about is the establishment of those teams. There will be four this year and the remaining five will hopefully be commenced next year. Even then, I think there will be some demand, but at least there will be a basis for responding in a consistent way across the country based on the best international evidence.
Gino Kenny (Dublin Mid West, People Before Profit Alliance)
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I presume that if all those CHOs were covered, that 85% would go down dramatically.
Gino Kenny (Dublin Mid West, People Before Profit Alliance)
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Obviously, that is not in place. I think only two have that cover at the moment. How long do the witnesses think it would take for those CHOs to be completely covered?
Dr. Colm Henry:
As I said earlier, we are hoping to fully resource four teams this year and, of the remaining five, two are partly in place. During the Estimates process, we will make a submission to secure the manpower, consultant resources and allied healthcare profession resources to fully staff those teams. To go back to the Deputy's earlier point, which is important, we find, if one looks at neurorehabilitation, which is under-resourced here and internationally, that when one starts to put services in place, it starts to drive demand. The services do not just address the most severe end but other cases come to light that would benefit from those teams. There is a phenomenon in healthcare that when there is underprovision, particularly in therapy, demand will be driven up once resources are put in place because people who would otherwise have availed of a service which did not exist will now expect to get the same level of service. I expect to see this being a moving target in the coming years which would see demand go up.
Gino Kenny (Dublin Mid West, People Before Profit Alliance)
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My final question is about additional beds in the health service. Correct me if I am wrong. Some 162 beds were added to the public health system last year.
Mr. Damien McCallion:
In total, under the programme, as I was saying earlier, 970 beds were added over the last number of years under the additional bed capacity programme. Another 209 are planned this year. There is a balance of 40 beds, give or take, where there are difficulties on the sites. We are looking at alternatives for how we might provide those beds. I should say those are acute medical beds. There are also critical care beds and community beds, which are separate.
Seán Crowe (Dublin South West, Sinn Fein)
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Before we move off the issue of the Neurological Alliance of Ireland, the witnesses say there are four teams. How does the HSE select those teams? Is it based on the highest demand in those areas? Is it because there is a partial team in the area? We do not have a team in some areas with the highest numbers in the country.
Dr. Colm Henry:
With a new service like this, while I do not like to use the word "pilot" because it is not exactly the right term, it starts with a couple of sites so that we can learn what is right and what is not. That was quite instructive in this particular case because the view of our national lead in rehabilitation, Dr. Carroll, is that the teams for the first two sites selected were perhaps too small and did not have a consultant in place. As such, they did not have the scope and capability to manage all the cases they should see. It is not unusual for us. We would select not necessarily based on the area of greatest need but to try out a team to see how it works and then to tweak the design as we roll it out nationally, which is exactly what we are doing here.
Seán Crowe (Dublin South West, Sinn Fein)
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The HSE has a partial team and has identified a number of people to move ahead with that. Granted, it is in an area where there is nothing.
Seán Crowe (Dublin South West, Sinn Fein)
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Would it not make more sense if it was in an area of higher demand?
Dr. Colm Henry:
Yes, based on needs, but if one is going to get the design right, one would like to have the initial teams in the areas of greatest demand, but it is generally good practice to start off with one or two sites where the teams are tried out and learned from before it is rolled out nationally.
Annie Hoey (Labour)
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I thank the witnesses. This is all fresh in our minds because we had the neurological session last week, so I will not go back into that. Deputy Gino Kenny was asking about the winter plan being shelved. Now it is an all-round, three-year plan. Are there any plans to do that in other areas or sectors? I am thinking of the likes of section 39 agencies. Those are a subset or an outside group but are under the HSE grouping. Those groups are struggling with the one-year model. I was in Limerick last week with a women's refuge, which gets its funding from the HSE and other services but really struggles with the one-year element because it just cannot retain staff.
Mr. Bernard Gloster:
There is a distinction between the plan and the funding cycle. The plan I am talking about is our approach to managing unscheduled care, because of the lightning rod situation that occurs in the emergency departments and the requirement to focus on other parts of the healthcare system. There is no problem in the emergency department if every other part of the healthcare system is actually doing what we need it to be doing.
Senator Hoey is talking about the annualised funding model, which is a service agreement. We have an overarching agreement with most funded agencies, which is called part 1 of the agreement and can be for a number of years. That states the intention and basic requirements. We are not in a position to change the annual funding cycle because that is exactly the cycle we are in ourselves. The health service is part of the Vote of the Oireachtas after the budget. Every year, that is what the allocation is. The Minister sets out the priorities for the health service based on that allocation. The only thing I would say is that, leaving aside the minutiae of the exact detail of the money, we and our local managers try hard to agree with organisations what the pathway of their growth, development or sustainability is over three to five years, depending on the service. I am very familiar with the one the Senator talked about from my previous life in Tusla. There is pretty strong certainty that no current refuge will be without its annual budget. The issue is the adequacy of the budget to pay the staff the service wants to pay. That is currently the subject of a fairly significant dispute.
I would love to see multi-annual funding but it is a matter for the Oireachtas. I do not wish to shove it back but it is a matter for the Oireachtas in the budget.
Annie Hoey (Labour)
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That is very helpful for me to understand that the HSE is running annual funding and therefore the way the system rolls down. I had not made the link.
I want to ask about two other areas. Mr. Gloster has touched on the GP distribution. I was also down in Clare last week where there were people very upset about accessing GPs, the ten-day wait and so on. I am aware of the rural incentive scheme and so on. I am not saying whether that is or is not working - it is being rolled out and we are talking about 2023 so I am asking Mr. Gloster to cast further into 2024-2026. There is a feeling on the ground that there is a crisis in access to GPs both in urban and rural areas but with the crisis particularly acute in some rural areas. How do we ensure service provision and aggressively pursue that – I do not like the word "aggressive" but I cannot think of another word – to get that service out into those rural areas? Is there a plan beyond the plan?
Mr. Bernard Gloster:
I would start with my earlier comment to the Senator’s colleague. We have to accept that we just do not have enough general practitioners for the demand and the needs of our population. We cannot put it in any other way. It is very easy for me to say that but the question is what am I doing about it? Over the last ten years, there has been a substantial increase, particularly going into this year, of the number of GPs going into training. It is in excess of 250 going into what we call first year of the programme. They are already qualified doctors so they make a contribution while they are in training. The total number of people in training will be more than 900. By 2026-2027 we would be aiming for 350 to be in on every year of the cycle which would be 1,200. Rural areas are very challenged as well as areas of disadvantage in parts of inner cities, so we have to target both. Already this year, at the end of the second quarter, 50 doctors have come in predominantly from South Africa. They are very good, well-qualified doctors. They are allowed to work here under what is essentially a form of supervision. After two years, subject to certain criteria with the Irish Medical Council, they can be registered as GPs. We have to give them some choice, to be fair, and we cannot dictate to them that they must go to west Clare, Belmullet or anywhere else that is challenged but we try to target them. I was communicating with a doctor in the Beara Peninsula in the last few days who is hoping to secure the entry of a doctor from South Africa to take up post there. That is the part about adding to the supply. We will be challenged beyond that in our capacity to train doctors. When doctors are in training they require training places and placements and so do all the other specialties. A GP trainee will typically spend two years on rotation in a number of specialties in the acute hospital system but for the consultants who are training them, there are also demands on them from the doctors aspiring to be consultants. It is a stepped approach but the increase in the training places this year is a very substantial intervention. It is not enough but it is the right direction.
Annie Hoey (Labour)
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I have a particular interest around lung cancer screening. I know a pilot programme with RCSI should be rolled out very soon. Mr. Gloster mentioned consultants. This matter has been raised when the Irish Medical Organisation and other groups have been in here. Certain doctors from certain countries cannot progress to consultant level in Ireland. If they are good enough to work up to a certain level in hospital they should be able to progress to becoming a consultant and so on. This might be asking Mr. Gloster to look beyond a plan but there have been conversations around how we might change that. I think a variety of things are behind why certain people from certain countries cannot progress further. There is a crisis in numbers of consultants and recruitment; perhaps crisis is too strong but we have a lot of vacant posts. Is that something that has to come back at Oireachtas level? Does it have to come through the Irish Medical Council or does it have to be addressed by the HSE? If there is a will to do that, and I hope there is, how can the problem of certain doctors from certain countries being unable to progress to consultant posts be addressed?
Dr. Colm Henry:
The Senator mentioned lung screening, which I might return to. On the question of doctors from abroad, the subject of a hearing here before was consultants not on a specialist register. The importance of that for us, and it is a function of the Irish Medical Council, is that it is an assurance system for us and, through us and the Irish Medical Council, for the patients that consultants have received a training be it here or in any other healthcare system where there is mutual recognition between us and their system of regulation. While of course we have recruitment problems and challenges, the process for registering doctors and deciding what category of registration, that is how they practice and how patients can be assured of their area of expertise, is a function of the Irish Medical Council that has been developed over many years, going back to the Medical Practitioners Act 2007. That has been a focus of discussion at this committee before in our journey to ensure consultants are on the specialist register. When we look at doctors from other healthcare systems, some of them have mutual recognition with our system and some, particularly outside the EU, do not. We have to make sure their skills, expertise and training are aligned with the services we are providing here so that patients can be assured that they are getting the expertise and training they need.
Mr. Bernard Gloster:
To add to that, it is important to recognise that at the moment, because of approvals of new developments over the last eight or nine years, we have 421 jobs filled by temporary or locum consultants which we are seeking to fill permanently and another 506 which are vacant posts. In the last two weeks, I approved the mobilisation, as it were, of an international recruitment campaign both for Irish doctors who have gone abroad to enhance their training and to see how many we can attract back and also for non-Irish trained doctors to consider coming here. All that is hinged around the new consultant contract. Traditionally our advertising of posts has been the standard public appointments website and medical journals. This will be a very targeted, high visibility campaign across five or six countries. We will see but, as Dr. Henry said, ultimately, one’s determined qualification to be on the specialist register in Ireland is a function of the Irish Medical Council.
Cathal Crowe (Clare, Fianna Fail)
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I welcome the panel. I listened to Mr. Gloster on the radio last week. He was very clear that was over the HSE and not University Hospital Limerick, UHL, but I think the presenter was quick to point out the fact that he is from Limerick. We have a lot of hope in the mid west that Mr. Gloster might understand the situation better than many in this country. I know his role is not specific to that but I welcomed his contribution on the radio last week.
Like others, I want to raise some of the content that the Neurological Alliance of Ireland has been briefing us on. UHL had an expectation that it would be approved to have eight neurological nurses. I believe it got two. Waiting lists in CHO 3 for neurological supports at community level are now six months and more. Are there plans to further address that?
Mr. Bernard Gloster:
The plan on community teams is to fill four CHOs this year. I think it will go into early next year because recruitment pressures against the grades we seek.
We are putting the next five CHOs, of which CHO 3, which covers the mid west, is one, into the Estimates bid this year with, hopefully, the approval going into 2024, in order to add to what is there. The mid west is not starting from zero. It has a pre-existing team, albeit not to the scale of what the new strategy requires, but at least we are not starting from zero. There is a fairly definitive plan for CHO 3, subject to the final Estimates process.
On the inpatient neurological nurses specific to UHL, I am not familiar with the detail of the requirements. I will certainly look at it for the Deputy. I am just not sure what the issue is but there is no issue about looking at it. The Leben Building was developed in association with the Parkinson's Association of Ireland and others. It is a neurologically focused piece, so I imagine it is associated with that. I will certainly take it up with the hospital CEO. If we can support it, of course we will.
Cathal Crowe (Clare, Fianna Fail)
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There has been some mixed reporting in recent days about the medical assessment units in Ennis, Nenagh and St. John's hospitals. We are all hoping that they will be upscaled to 24-7 capacity, thereby alleviating the huge pressure UHL is incessantly experiencing. Yet, there is mixed reporting on whether this upgrading is imminent. I would like to know, categorically, what the HSE's plans are for Ennis, Nenagh and St. John's, particularly the medical assessment units but also the beefing up of the local injury units. As Mr. Gloster answered in respect of the previous question, will staffing be some sort of curtailment to that upscaling?
Mr. Bernard Gloster:
Staffing is pressured but recruitment is well ahead of target across all the grades we have at present. We are some 20,000 whole-time equivalents different from the pre-pandemic 2019 phase. Recruitment targets for this year are well ahead and attrition is not expected to be as high this year as it was last year. All of that will help.
On the medical assessment units, MAUs, specific to the mid west, just before the Deputy came in, in answer to another question, I referenced a trial run that was done for two or three weeks after the Christmas period, which Mr. McCallion approved, to operate the units at St. John's and Nenagh on the same basis as Ennis over a seven-day period. That appeared to indicate a level of success. The CEO of UL Hospitals Group, Ms. Colette Cowan, was very clear with me that it would make a substantial difference to several thousand patients. Very shortly after taking up my post, I approved 54 permanent additional posts and a budget of approximately €5.5 million to extend the MAUs in the mid west to a full seven-day scale over a 12-hour day. The indications are not yet there as to whether MAUs going to a 24-hour basis in a model 2 hospital would make a substantial difference, but it is something we are not closed to. We are trying to target the effort where we can.
It is the same for the local injury units, LIUs. It is about wherever we can scale the capacity. I gave approval yesterday evening, coming into the June bank holiday weekend, as a trial, and the August bank holiday weekend, for hospital CEOs to secure extra capacity in both LIUs and MAUs wherever they can. They have the freedom to do that to manage the capacity as best they can. If they are able to scale the LIUs and secure staff, be it through overtime, agency or recruitment, they can do that. That is where our focus will be.
Cathal Crowe (Clare, Fianna Fail)
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That is welcome clarification. This week, the Limerick Postreported it was a done deal that the three hospitals we referenced at Ennis, Nenagh and St. John's are all moving to 24-7. That is approved, it is a done deal and is happening. Will Mr. Gloster clarify that? I heard what he said but, from what I can gather, it is under examination. It is operating on a seven-day, 12-hour a day capacity basis but the 24-7 has not been nailed down or agreed yet. Is that the case?
Mr. Damien McCallion:
It might be helpful to point out that we are just finishing a bit of work that looked at all the MAUs and LIUs, including the hours of opening and the most effective use. Staff could be rostered late into the night and not have people there. Currently, there is inconsistency in the hours of operation. We looked at what it would take to do that and whether we can get the staff. The learning from that will feed into the mid west.
Cathal Crowe (Clare, Fianna Fail)
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That is good. I will raise the issue of unused HSE buildings. I also raised this quite recently with the Minister, Deputy Stephen Donnelly. I know of many facilities throughout the country. I put down a parliamentary question to ascertain what former nursing home accommodation was still available and not being used on various hospital campuses. There is not a huge amount of such accommodation. Much of it has been converted into office facilities, which is very understandable. We cannot just start pulling out offices. The Minister made it very clear, and I have heard this from several Ministers, that there is a desire to somehow try to see if there can be on-campus accommodation for newly qualified doctors and nurses to ease the pressure they are facing in their personal lives as regards the cost of living and being able to live someplace.
I have repeatedly given the example of the Inis Ghile facility just outside Limerick city in the village of Parteen. It a 19-bed facility with every room en suite. It was fully overhauled in 2019. It temporarily opened during the Covid pandemic as a vaccination centre. It has 19 en suite rooms but to transform it to a clinical environment would be a massive undertaking. It would involve months and months of fitting out and would be very costly. However, with a very simple decision, surely someone here could say that on a stop-go basis, for six or 12 months, until we know what we will really use that facility for, let us open it up and make it available for some of the nurses or doctors. It is already kitted out with brand-new kitchens and everything. It has not been lived in since it was all fixed up in 2019. A decision could easily be taken that would be transformative. By taking 19 nurses or young doctors out of whatever rental accommodation they are in, other accommodation would be freed up within that supply chain. I ask the HSE to please look into that.
Mr. Bernard Gloster:
Sure. I will make two or three points, some of which I addressed in the same radio interview. There is no doubt there is a connection in certain parts of the country between our capacity to recruit people and their ability to access accommodation. To be fair, that is a public sector-wide issue in parts of the country for gardaí, teachers and so on. That is the first thing. Second, we have to be open to the possibility of assisting staff in future but it takes careful consideration. I have identified three groups that might be considered in that context. The first are nurses coming from abroad, of which we will recruit 1,400 this year, and trying to see what assistance can be offered to them in the early stage of their stay here. The second group, and probably the one that is most disadvantaged, are junior doctors and non-consultant hospital doctors, NCHDs, on six-month rotations. Trying to find accommodation in parts of Ireland every six months is a serious challenge at present. The third group is students, including student nurses and so on.
I do not wish to pass the parcel, but I am more of the view that we are already in discussion with the Land Development Agency, LDA, to give it substantial portions of certain lands that are on health campuses, which have not been built on and that it is interested in. I hope that in return for that the LDA would somehow comprehend the healthcare workforce population in the areas where it is developing accommodation. We are not closed to the idea but we are far from saying we have developed something.
I happen to know Inis Ghile very well. I opened it as the first HSE facility for people being decongregated from St. Joseph's psychiatric hospital in 2003. While Inis Ghile could potentially be looked at, the problem is, on any equity basis, what 19 people would accommodation be given to? There are implications to decisions like that which we make. I do not know what the chief officer's plans are for Inis Ghile but I will certainly establish that. I will come back to the Deputy. To be fair, it is a very valid question as to why the facility is still empty.
Cathal Crowe (Clare, Fianna Fail)
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I will squeeze in a final question. The HSE needs to be more agile with accommodation.
Cathal Crowe (Clare, Fianna Fail)
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A young nurse would appreciate the HSE saying that it does not have immediate plans for it but might have plans in eight months' time. However, those are eight months where we could help somebody with accommodation. That is a very sensible way. Rather than having thistles growing up through the driveway, it would be great to see someone open it up.
Cathal Crowe (Clare, Fianna Fail)
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I have raised this matter with the Minister and Mr. Gloster. Hopefully, the HSE or the Department will be able to drill down a little deeper to see who has the keys and how we can do something with it.
The local GP in Newmarket on Fergus has vacated his practice. There is always a risk with that the practice will be lost from the village itself. The HSE has been engaging very well with the community. There was a meeting last week during which I asked why this was not short-circuited a little for the HSE. Members of the community contacted local auctioneers and have identified a facility that would meet a GP's needs and is available. That proposal has gone to the HSE. We cannot talk about it here but someone needs to move on that a little because, as we just talked about, this is a town at risk of losing a GP. That then pressurises the acute hospital system. A solution is on the table somewhere. Maybe someone can also look at that please.
Mr. Bernard Gloster:
I do not know the specific circumstances. I will certainly inquire today of the chief officer there as to what exactly is in play. Subject to the normal terms of probity, we are stretching every boundary to do everything we can to secure, retain or attract new GPs into practices where we are challenged. The last thing I want to see is somewhere such as Newmarket on Fergus lose an established practice based in the town and district.
The simple consequence of that is, whether it is a medical assessment unit in Ennis or an emergency department in Limerick, I will just be adding to that. I have no desire to have fewer GPs but I do not know what the question is as to what is on offer and I obviously have very high probity requirements in terms of being back in here before the Deputy's colleagues in the Committee of Public Accounts among others. I will certainly look at that as creatively as I can and I am sure Mr. McCallion will assist with that.
Cathal Crowe (Clare, Fianna Fail)
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I encourage Mr. Gloster to keep up the good work and thank him for everything.
Frances Black (Independent)
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I thank all the witnesses. I wish Mr. Gloster well going forward because he has a lot of very hard work to do and I do not envy him, that is for sure. The area I would like to speak about is around mental health. This might be an odd question to ask and I hope Mr. Gloster does not mind me asking it, but will he say a little about the importance of mental health services going forward within the HSE plan? As we all know, an awful lot of physical illness can be stress-related. People can be anxious, worried and really stressed. I know from the work I do in the field of mental health that people who are really stressed and anxious can get stress-related cancers, heart and stomach problems and all of that. What I am asking is how important mental health is within the work the HSE is doing and the mental health services.
Mr. Bernard Gloster:
I thank the Senator for the question and for her good wishes. Only yesterday, I met the Minister of State at the Department of Health, Deputy Butler, who has specific responsibility for mental health, and had a very detailed discussion with her about it. Again, it is probably too easy and too glib for someone like me to say that it is high on my priorities but I can absolutely assure the Senator that it is. I am on the record saying that but also on what I have been attempting to do with it. We have a number of significant challenges. We are now into a new policy framework but when the previous policy, A Vision for Change, was established, it was a very good policy. Like any policy, implementation was part of the problem. It never got to the full implementation so the support systems for mental health, particularly in the community and for people with enduring mental health issues, did not materialise to the extent that they could have. Rehabilitation and recovery models were not as developed and everything crystallised around the acute inpatient units where people got delayed. Essentially, some of those beds became quasi-long-stay beds. That is the kind of challenge on the mental illness side. On the positive side of that, the development of community teams and approaches has been quite significant. Investments in counselling and in primary care counselling are very significant. We have to move beyond the issue of mental illness and the parameters of the mental health Act to talk about mental health well-being. Tomorrow or Friday, I will visit the Jigsaw service in Thurles in County Tipperary which is now established across the country. The Minister of State quite rightly said yesterday that we need to move away from talking about child and adolescent mental health services, CAMHS, specifically and only CAMHS. CAMHS is important but we also need to talk about the mental well-being of the youth population and that of the general population. Certainly, from my perspective, we have to plan for, and contemplate on, building in capacity for things like talk therapy and other supports into all of our primary care and other services. We should assume that a greater number of people - in fact the majority of people at some point in their lives - will require some support or attention towards their mental well-being and that in itself may assist in the sharper end of mental illness. It is something that the Senator quite rightly says is contributing to so many other factors and challenges for people. Very often it is at the heart of things. It is a very priority and we have significant investment in it. One of our problems is that we often cannot spend the money in mental health services because of the challenges of recruiting the right people and retaining them.
Frances Black (Independent)
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I totally agree with Mr. Gloster. It comes back to mental well-being as opposed to mental health issues. I am happy to say as Chair of the Joint Sub-Committee on Mental Health, that we have been working on the Sharing the Vision Implementation Plan 2022 to 2024. We brought in representatives from Jigsaw before the committee a couple of weeks ago and we hope to do a report on where we are and where we need to be with regard to sharing division. It is a phenomenal area and what I would hope to bring in next is attention deficit hyperactivity disorder, ADHD. ADHD is something that is now coming to light. There are more people coming forward with ADHD. Within that area, I am hoping our next session will be on ADHD. Can we expect an expansion of specialist clinical programmes for ADHD? It is huge area particularly with young people now and the diagnoses of it is very important.
Mr. Damien McCallion:
Mr Henry may want to comment on this as well. The Senator will be aware of the CAMHS report. I think we were before the sub-committee on CAMHS but as the CEO said, the improvement project that stood up around that is actually about youth mental health, rather than just CAMHS looking into primary care and all the alternatives that have just been discussed. There is a piece of work going on led out by our national clinical lead on mental health around that. Mr. Henry may want to talk to that in terms of that pathway around ADHD because it is a key contributor to some of the pressures around waiting lists but also for people who are obviously waiting for services.
Dr. Colm Henry:
To add to that, a dedicated part of our response to ADHD were the three reports which were looking into prescribing our adherence to the operating guidance for CAMHS and also looking at the experience of service users. As to whether it merits a separate programme, my instinctive view is that we should integrate it with the wider mental health programme to see it as part of a broader response and provision of services to mental health rather than something that is distinct.
The Senator's earlier point about physical health and mental health is well made. We know that people with chronic mental health issues have a lower life expectancy, are higher users of emergency departments and hospital facilities, and have a higher prevalence of chronic disease with poorer outcomes. It is helpful not to see mental health as separate to but rather integrated with physical health.
Mr. Damien McCallion:
I have one last point. Post pandemic, we would have to say that we are seeing an increase in demand for mental health services and mental health well-being. I was with one of the teams in the midlands in the past week and certainly that is coming through quite strongly. That is obviously something we also have to deal with post pandemic because we all know that this impacted on people's lives. This will add to the demand for services and hence the need to continue to invest as has been said earlier but we will also have to look at how we organise the services more towards well-being as well as dealing with the more acute illness.
Frances Black (Independent)
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I agree with Dr. McCallion. Even as Chair of the sub-committee, I find post pandemic that a lot of people are contacting our office looking for supports and guidance and it can be quite overwhelming for an awful lot of people. If I have time, I will ask one more question. Staff shortages were mentioned. Is there any measure that can be taken to improve the issue of staff shortages, particularly around mental health?
Mr. Bernard Gloster:
I think it has to do with an observation I made earlier certainly on the allied health professionals side. We are expanding and developing services at a rate that exceeds the supply chain, if we want to call it that. International recruitment helps for a while with that but what happens is we eventually end up with a dependency on international recruitment that is greater then the domestic supply and that brings its own problems in terms of sustainability. The Minister for Health, Deputy Donnelly, has made very substantial inroads and representations to the Minister for Further and Higher Education, Research, Innovation and Science, Deputy Harris, around generating additional places at university level for the different disciplines. While there is a way to go on that, and we would like to see more, that is part of what we can do but it is a very long-term piece. In the future, we may have to look at instances where we set out a strategy and desire to have a particular way. For example, our desire might be to have 72 or 74 child and adolescent mental health teams and we know we are consistently struggling to populate those teams to the full amount.
The question arises, and it is one I cannot answer, as to whether it would be better to have 55 fully staffed teams and a slightly longer geographic distance or to struggle all of the time with 72 teams that have a variable level of staffing and team members who feel they cannot function to the full multidisciplinary level. That is something about which I would like to consult professionals and clinical staff. I do not think it is an arbitrary management decision but it seems to me to be one possibility. There is no easy answer to the global demand for healthcare staff, which is here now and will be long into the future.
Frances Black (Independent)
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I thank Mr. Gloster, and wish him well.
Bernard Durkan (Kildare North, Fine Gael)
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I welcome the witnesses. I have a couple of questions as I have to go to another meeting. On the national service plan, to what extent have the causes of the logjams been identified in respect of the delivery of services? How have they been identified so far? In some cases, they are still to be identified. What are the anticipated positive effects those identifications and spotting of logjams will have on the delivery of services in coming years?
Dr. Colm Henry:
On the logjams, you need to look at the profile of our population and how it is expanding. It is clear that people with chronic disease and those who are ageing, as well as how we improve their experience and access to healthcare, represent the greatest challenge for our healthcare system. Reference was made to long waits of more than 24 hours in our emergency departments. A substantial proportion of the approximately 67,000 people who waited more than 24 hours were over 75 years of age. Much of the work being done in the service plan, and what we are trying to link up, is on broadening points of access, particularly for older people and those with chronic diseases so they do not have to access emergency departments. We are attempting to capture them earlier in their illness journey, so we can make interventions in the community before they become ill enough to need to attend an emergency department.
That said, when we look at the profile of older people, the proportion of over 65s is expected to double by 2041. People will still come to emergency departments. People with chronic disease will still come, as will people who are ageing. We need to have a more adaptive response than the one we are providing now. The single biggest logjam or challenge is how we deal with the challenge of this generation. Fortunately, it has a higher life expectancy than any country in Europe but they do not always survive that long in good health.
Bernard Durkan (Kildare North, Fine Gael)
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To what extent have the challenges that have already emerged from the various CHOs been evaluated? To what degree is Mr. Gloster satisfied that the remedies for dealing with those issues will suffice?
Mr. Bernard Gloster:
It is important to say that the CHOs come with a historical context. There were 32 community care areas across the 26 counties in the former health boards. They became 32 local health offices in the first HSE. They were purely historical and there was no change to them. The CHOs came after the 32 local health offices and hospitals were merged into 17 areas of the country. We are now moving on to the Sláintecare iteration of that, which is six regions. The delivery system in those regions will be more population focused and measured, as opposed to what we were given by history. What it gave us was that on the western seaboard there was higher propensity to develop community services, but the acute bed capacity did not get developed to the extent needed over the years. In the greater Dublin area, there was historically a more significant investment in acute hospitals and acute hospital infrastructure. The community services were somewhat behind. It is all somewhat predetermined or variable. We are now moving on to the evidence-based and population allocation of resources. That should seek to address the various imbalances. We can see right across the performance measures that we have. Some CHOs will perform exceptionally well over others. It does not mean that the people are any better. It is often determined by the resources they have available to them.
Bernard Durkan (Kildare North, Fine Gael)
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Which CHOs are performing better and which are not performing so well based on populations challenges, etc? For example, I am thinking of CHO 9, which comes up in correspondence on a regular basis. Have the challenges in that area been pencilled in? There are certainly population challenges in that area. To what extent is it likely to impact in a beneficial way?
Mr. Bernard Gloster:
There are huge population challenges for CHO 9. I know from my previous work in Tusla that north Dublin in particular is deprived, and with a high density population in parts. You can see from the various HIQA reports what that translates to. There are different factors affecting the performance. You would have to look and ask what the performance is on therapy waiting lists or primary care access. There is no one CHO performing better than another in totality. They are all quite mixed. Mr. McCallion may be able to comment on some of the specifics.
Mr. Damien McCallion:
We would look at performance across a range of metrics every month as part of the service plan, about which we are speaking to the committee today. Each CHO has an operational plan for the year, which sets out what it hopes to achieve within the resources it has. Mr. Gloster has outlined the history to some of the variation in that. There is not a common thread. Typically, on the western seaboard there was more investment in community and less in acute services. It was the reverse case on the east coast. That is not unique. There are variations across mental health, disability and primary care therapy waiting lists. I have a report in front of me setting out what is called the heat map, which shows those achieving targets. It is varied across areas. We look at the resources there and try to make sure that each CHO is making the maximum of the resources it has.
Bernard Durkan (Kildare North, Fine Gael)
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In the overall picture let us look at the various CHOs, including those under pressure or those not performing as well as they could or should be, for whatever reason. To what extent has the HSE looked at the least performing CHOs to try to bring them to a reasonably acceptable level in addition to them improving, developing and evolving as they move forward?
Mr. Damien McCallion:
The performance process looks at exactly what the Deputy has referred to. I will take the example of mental health. CAMHS has been quite topical. We know some of the CHOs are struggling there. We look at the resources they have in their teams and how they can address that, and we make sure they are dealing with the key targets. For example, in CAMHS one of those targets is that 95% of all urgent cases must be seen within three working days. We had a number of CHOs that were struggling to achieve that target. We worked with them as part of a national improvement to lift that up. That is just one example. Each month in the performance cycle we will look at where CHOs are under target and work to try to address that. However, it varies across the country and between different areas. One of the things factored in will be the resources they have available and issues local to their populations. The challenges in the north inner city will be different from those in rural areas.
Bernard Durkan (Kildare North, Fine Gael)
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I will move on to neurological rehabilitation services and ask the same question relating to the challenges that have occurred previously. There are many challenges. We all know about them. There are patients who have challenges themselves, and they know they have. There are patients who need attention and cannot get attention. There are people who need to go on addiction programmes and they do not get the attention they need. The problem emerging now is that some patients are in desperation. They do not see a way out. In some cases it leads to psychotic and other correlated issues. There is an urgent need for a really serious look at that situation, with a view to bringing services within the reach of those vulnerable people.
Mr. Bernard Gloster:
I do not think that is an unfair observation. We have set out the pathway to the four teams this year, with two partially being built up next year along with the three CHOs that do not have any. What can I say to the people who will have to wait 18 months for those teams to be finished, and depending on demand how long it will take to access them? First, I know local services will do everything they can to access the physiotherapy, occupational therapy and speech therapy they have available to at least try to assist people in some way. That falls short of what we know people need. There is no point in me trying to convince the committee it is all okay. It is not all okay. I fully accept that, and I fully accept there are people who will experience difficulty because of our timeline, delay or pathway to get to where we are trying to get.
Bernard Durkan (Kildare North, Fine Gael)
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Could we particularly look at the area that is affected by population, insufficient staff demands or whatever the case may be? Over the past three weekends, I found myself trying to make arrangements to have a patient seen as a matter of urgency out of hours. Personal illness continues out of hours and does not stop at 6 p.m.
Mr. Bernard Gloster:
I referred earlier to five over seven days rather than five over five. That is the best way we can potentially improve that. Regarding where there are not community neurological rehabilitation teams but where we have therapists, we will always try to assist people in difficulties to the greatest extent we can. However, unfortunately it is not as straightforward as saying that every physiotherapist can respond to somebody a neurological condition. It is a particular developed skill set. The challenge is with the availability of professionals with that skill set. I do not have any easy answer to that and I will not try to fob the Deputy off. The reality is that people are in difficulty because of this. We understand that.
Bernard Durkan (Kildare North, Fine Gael)
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The service needs to be brought up to a reasonably acceptable level in those areas.
John Lahart (Dublin South West, Fianna Fail)
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The chief executive is welcome. It is also good to see Dr. Henry in a different context; we are used to seeing him in the context of the pandemic. I suppose I need to be careful with language. I get a sense that there is not as much space taken up in the room today by ego. I get a sense that there is a practical, pragmatic approach. The witnesses can take that whatever way they want.
The chief executive strikes me as someone with a deep knowledge of the HSE. That comes across in his answers and I wish him well. He referenced the neurological rehabilitation teams and I want to ask about CHO 7, which covers my area of Dublin South-West with Tallaght at the centre of it. CHO 7 was allocated funding by the Minister for Health to establish a community neurological rehabilitation team in November 2020. Responses to parliamentary questions by me about the team stated that negotiations are ongoing to agree a governance model to be able to proceed with the recruitment. We are now three years later. Currently there are only two community neurological rehabilitation teams in Ireland. In reply to an earlier question, I believe Mr Gloster stated that recruitment had been an issue. Has that been an issue over three years? Am I correct that funding is not an issue? Funding has been allocated for it.
When is the HSE likely to establish the inpatient neurological rehabilitation services through regionally managed clinical networks? I ask Mr. Gloster to outline any news he has on CHO 7.
Mr. Bernard Gloster:
I do not know when the money came into profile. It was before my time, but the money is now there for the CHO 7 team. I am not aware of any outstanding issues with the governance model. It is simply a recruitment process, with a target to get the four teams, including CHO 7, operational by the end of this year. I need to be very fair with everybody and qualify expectation on that. Recruiting for those four full teams by the end of this year and having everybody in place will be challenging. Hopefully, we will get that done as early as we can in 2025, if not at the end of this year. That is the first thing. It is important to be upfront with people on that.
CHO 7 is of itself a hard area in which to recruit allied health professionals because the demand we have for allied health professionals far outstrips what is available. The story of the cost of living in Dublin is well rehearsed. I know that area extends into Kildare and west Wicklow but costs are high there also.
Regarding the beds outside the national rehabilitation hospital, earlier we discussed with one of the Deputy's colleagues on the committee that the target is approximately 20 beds per 1 million people. I believe there are currently 27 in place between Peamount and the Royal Hospital in Donnybrook. We have other beds around the country that are called rehab beds, usually for stroke. We will expand their remit and the staffing associated with them to bring us up to 20 beds per 1 million people. That will take a bit of time.
John Lahart (Dublin South West, Fianna Fail)
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I also wish to acknowledge the work the HSE is doing with Bloomfield.
What professionals make up a neurological rehabilitation team?
John Lahart (Dublin South West, Fianna Fail)
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Is this specific neurological rehabilitation nurse training?
John Lahart (Dublin South West, Fianna Fail)
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What is the typical team size?
John Lahart (Dublin South West, Fianna Fail)
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That is 13 people led by a consultant.
Mr. Bernard Gloster:
Under the strategy, the targeted team is 13. Up to that it was very sporadic. Two parts of the country had developed their own multidisciplinary teams but they were not anywhere near 13. It is now a set 13 to try to achieve consistency not just in the numbers of people who can respond but in the modality of treatment. It is a set 13.
John Lahart (Dublin South West, Fianna Fail)
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I ask Mr. Gloster to forward us some details on that.
John Lahart (Dublin South West, Fianna Fail)
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I do not want to bog Mr. Gloster down on the governance details. I presume the HSE wanted a structure it could replicate.
Mr. Bernard Gloster:
I suspect they are the same as every other multidisciplinary team construct we are now creating. The modern day approach to both health and social care services is to have a multidisciplinary team in nearly all parts of our services - primary care, chronic disease and so on. When there are different therapists and different disciplines in one team, being led by one person of one discipline, there is an issue about how to appropriately clinically supervise the individual discipline within its own right. For example, people would say a physiotherapist could manage a team but they could not clinically supervise a nurse. That is where the governance question arises. We face it across a number of areas. I think we have achieved a level of success with it and we are getting better at it.
John Lahart (Dublin South West, Fianna Fail)
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I spent many years as a councillor, as the Chair will be aware given we share the same constituency. I took us a lot of time to get primary care centres over the line. That was not the fault of the HSC. The goodwill was always there but some fell at the last hurdle. Anyway, we opened a tremendous primary care centre in Ballyboden. I had occasion to avail of the services there recently as part of the cardio rehabilitation. It is a fantastic facility. One of the small things is that parking is free. The cardio rehabilitation used to be in a hospital setting and it has now moved out into the community. Aside from the stress, there was the difficulty of looking for a car parking space in Tallaght Hospital. I do not highlight that specifically in respect of myself, but many people attending commented on that.
Mr. Gloster may not know the specific answer to this question. There was a process to bring GPs into that centre and I think there were two GPs. If I am correct, those two GPs were located in the existing community. In what way has the primary care added GP capacity? I do not know whether the GP practices are being replaced. Two GPs were taken from the community and put into primary care centre. There was no additional-----
Mr. Bernard Gloster:
The primary care centre in its original construct and design was not necessarily going to add GPs. It was going to co-locate GPs with all of the other primary care disciplines, public health nurses, district nurses, and allied health professionals such as speech and language therapists, physiotherapists, occupational therapists and so on, so that they could work together as primary care teams particularly on complex cases. More than additionality, it was about co-locating. Certain GPs were quite resistant to it because the business model did not suit and the developers might have been looking for high rent and so on. We became more flexible about it as the years went on. When they were originally described, I remember them very well. We describe them such that every primary care centre would have four GPs.
That was the set frame of it at the time. We found out quickly that in a large portion of them there was not a hope of getting four GPs, because GPs invested in their own buildings-----
John Lahart (Dublin South West, Fianna Fail)
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They are sole traders.
John Lahart (Dublin South West, Fianna Fail)
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Mr. Gloster might provide a note on this. I do not need an answer now. The HSE has kept the old Rathfarnham health centre open and I do not understand why, given we have a brand spanking new primary care centre less than a mile away from it.
Mr. Bernard Gloster:
I need to check it. It could be the expansion of enhanced community care in the past two and a half years and the growth in the number of staff we employ. We have 2,500 extra staff in enhanced community care alone. It could be simply a space issue. I do not know the specifics but will come back to the Deputy on it.
John Lahart (Dublin South West, Fianna Fail)
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The following was one of the things I was proud of last year in the budget. Unions came up with it and persuaded the Department of Education to look at it. The INTO had four asks, one of them around well-being. It was significant the Minister, Deputy Foley, took it on. In my experience, this is the first time a well-being piece was not located exclusively in the Department of Health. That is necessary. Mr. Gloster talked about promoting well-being and that cannot be left to the HSE and Department of Health. I do not mean because they are not capable of it but because we need to develop a mentality whereby every Department, from the Department of Foreign Affairs right through to the Department of Education, has a well-being responsibility and should be allocating budget within that Department to the issue.
Mr. Bernard Gloster:
The allocation percentage towards things like prevention, early intervention, changing lifestyles and changing behaviours towards overall health and well-being needs to increase. It is part of the core pillar of Sláintecare in terms of changing the health status of the population. I agree with the Deputy wholeheartedly. The well-being of the population has many needs and many potentials through schools, employers, local communities, sports clubs and so on. For as long as we think the Healthy Ireland strategy is the remit of the HSE, it will fail.
John Lahart (Dublin South West, Fianna Fail)
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That is a takeaway quote from this session and I agree wholeheartedly. It is up to us as politicians to spread that.
Seán Crowe (Dublin South West, Sinn Fein)
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I do not know if many people will welcome the closure of the-----
John Lahart (Dublin South West, Fianna Fail)
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The Rathfarnham one. I am not advocating that.
Seán Crowe (Dublin South West, Sinn Fein)
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I know that. I am just scoring points.
John Lahart (Dublin South West, Fianna Fail)
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I have my eye on you.
Seán Kyne (Fine Gael)
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I welcome Mr. Gloster and the team. A headline last week in the Connacht Tribuneat home in Galway stated Australia has embarked on a recruitment drive to attract nurses and midwives to relocate from Galway and the west. Recruiters from two New South Wales districts are hosting an information session and interviews in Galway as we struggle to fill nursing vacancies. This is not new. There have been similar headlines over the past ten years in different parts of the country. There are also headlines urging the HSE to poach back nurses from the UK and Australia. It goes to show nursing and midwifery is an international issue. We have seen the moving parts. We talk about cost of living and quality of life and those issues impact on the decisions.
It struck me when reference was made to what we used to call the nurses’ homes. Could we look at that across all our campuses, particularly for new recruits as an incentive? It could incentivise nurses if they were told they had a number of years at low rent while saving for a deposit on a house. Would that work or at least improve the situation in terms of keeping nurses here and attracting them? There is capacity in other places. There are pressures in the building sector but this is something we could plan for. The universities are doing it for student accommodation. That model would assist in the attractiveness of the offering from the HSE.
Mr. Bernard Gloster:
I mentioned this earlier. There are a couple of parts to it. First, the HSE is not a skilled developer and I dare say would not make a very good landlord. I urge caution around that. My focus regarding the available capital budget and capital works has to be on building capacity both in the hospitals and in the community healthcare services. Of course, as part of recruitment and retention strategy, we have to look at that. We have an analysis being done at the moment, which I got a draft of yesterday, as to what the possibilities might be. The Minister, the board of the HSE and I are open to that but I urge caution.
Many public servants have this challenge, including gardaí and teachers, but the three groups we need to focus on are: non-consultant hospital doctors, NCHDs, on the move every six months because it is an impossibility for junior doctors to keep finding accommodation; student nurses, particularly coming into their pre-registration year or intern year, as it is often called; and nurses we recruit from abroad, 1,400 expected this year, who for their first 12 to 14 weeks will be particularly challenged. We need to try to help people with that. I said on the public record and suffered a bit for it - it was one of the first times I put the foot in the mouth in the 12 weeks I was here - that the days of the nurses' home are gone. I do not intend revisiting that. I do not think it was a good model. It was of its day. Having a nurses' home with 40 or 50 nurses on campus was in a very different time. I am not sure that accommodation would suit many people. We have tried to convert those buildings for use.
My direction of travel in responding to those three priority groups or accommodation for healthcare staff generally is this. We have a not insignificant amount of land in the ownership of the HSE. The Land Development Agency has, rightly, its sights on some of that. I would like to see the accommodation built in the environments of hospitals and healthcare facilities comprehending some measure of proportionality towards serving the needs of the healthcare workforce in that area. Strategically, I would be pursuing the Land Development Agency. I am not closed to assisting others. If we are to assist those three categories of staff, we would at minimum need the assistance of an approved housing body. We would not do it well ourselves. I do not say that in any disparaging way to my colleagues.
Seán Kyne (Fine Gael)
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It is an interesting debate. I am not sure I agree on having settings for nurses, whether temporary or for the medium term. It works well in student accommodation and the skills are there. I would not rule it out.
Seán Kyne (Fine Gael)
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Yes, but recruitment will be an ongoing issue and incentives are necessary.
Seán Kyne (Fine Gael)
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I agree with colleagues on the Neurological Alliance of Ireland and MS Ireland. I support their requests. They were before us last week. I know Mr. Gloster has envisaged the CHO 2 team will hopefully be filled this year or early next year, depending on recruitment. Where does he envisage the team will be based? I presume he is talking about all together in one location.
I am sure Mr. Gloster is aware of the plans for Galway. There are four main asks in respect of the emergency department and maternity and paediatric facility, new labs, a cancer centre and an elective hospital. We have lost valuable years in debate in Galway about what we are doing regarding this brand new hospital. As I have said before and said in Galway, I can see for the first time that Saolta has a clear vision of what it wants in Galway. I welcome that. However, the situation at present is cancer patients are in competition with others for beds.
It is not good enough. The witnesses have talked about all the plans in Limerick in regard to planning permission and it being under construction, but I am afraid we do not have that in Galway, where we have a lot of discussion and delay. I know this is for the Department of Health more than for the HSE, but there must be a clear focus on the delivery of those projects that we can deliver. I am not sure what engagement Mr. Gloster has had since he started in regard to the Saolta Hospital Group and its plans.
Mr. Bernard Gloster:
I visited the group from Donegal to Galway over a two-day period a fortnight ago and I saw the infrastructure, along with all of the other challenges. On the community neurorehabilitation team, I am not sure what the plan is for the chief officer or where she plans to locate that team. It is usual that the team would be located together but I am not aware of what the location is for CHO 2. We have certainly marked that to come back to the Senator on.
With regard to Saolta, I have spent quite a bit of time in Galway University Hospital and I have seen the plans. Thankfully, there are now at least plans and there is an overall plan. The new radiation oncology unit there is an exceptionally impressive building. However, it is almost like a stepped jigsaw of a site, and you have to do the labs to do something else to do something else. The temporary emergency department that was constructed during Covid has helped a little, although I would not blow my trumpet about it. I spoke with the consultants there. If I was to put it simply, and I have discussed this with the Minister, without disrespecting the need in other parts of the country, Galway is further behind the curve than everybody else in a lot of its acute hospital infrastructure development by virtue of the fact the debate was too long. While I am not criticising anybody for it, the debate was too long as to whether it was to be Merlin Park or the city. There were a lot of views on and interest in that over the years, and I am not going to revisit it. There is now a clear plan and it is there. Certainly, at every opportunity to expedite capital development there, I will be pursuing it.
I was in some of the wards. They are exceptionally challenged at the moment on every front. There is no question but that we have to try to see how quickly we can step that up.
Mr. Damien McCallion:
To add to that, there are two other immediate things that follow on from Mr. Gloster's visit. The first is in terms of the surgical hub at Merlin Park and that is being advanced and, second, as part of the plan around additional bed capacity, Galway features in that in terms of identifying the site. The key thing, which our hospitals team has been working on with the group, is to identify the priority sequence for the projects the Senator has mentioned. As he said, there is a plan and we need to have a clear priority on those two pieces - the surgical hub and the elective medical beds - which they are weaving into that overall plan there. Those projects will then be advanced, subject to funding.
Seán Kyne (Fine Gael)
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With regard to prioritisation, Robert Watt was before the committee a number of weeks ago. If a project is both politically and health-wise of such importance, I asked him how fast it can go through the stages of the public spending code. It is on the record that he said that, all things being equal, it is six to nine months. Are there projects in Galway that could be fast-tracked? This is not even talking about the planning, which has to take its own course, but is in regard to the various stages of the public spending code, the strategic assessment reports, SARs, and all of that.
Mr. Bernard Gloster:
There are three things that can assist in fast-tracking projects compared to what happened heretofore. The first is the change to the public spending code and the number of steps that introduces. To be fair, it introduces those steps to try to make sure we do the right thing, but the change in the cap on that will certainly help, and will help in the case of Galway, given the size and scale of those projects. Robert Watt has committed to looking at the Department’s approval processes around the various steps associated with the money. Equally, I have agreed with the chair of the HSE that, before the end of this year, we are going to revisit every step of the process within the HSE to see how many steps can be condensed or reduced in terms of the HSE's decision to do this.
What I am particularly concerned about is the fact there are a lot of projects for which no money is allocated yet. For example, we are hoping to advance a project and we have gone for a market expression of interest for 1,500 beds. We do not have any money for them yet but we are trying to get ahead of the process by doing the market expression in order to be ready while the Minister is negotiating the money with the Government. We will do everything to reduce those steps. The part I am most interested in is not the pre-approval stage but, once we get the money, how quickly we can move that. In the context of, for example, the discussion we are having around the 1,500 beds, using modern build technology is probably the shortest way we can condense the time without losing the quality.
Mark Ward (Dublin Mid West, Sinn Fein)
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I welcome Mr. Gloster and his team and wish him the very best in his role. I engaged with him at the Oireachtas committee on children in his previous role and I think we will get unison among those in all parties and none that we wish him all the best in this role, given it is a very important issue.
My first question is in regard to the neurorehabilitation teams. It is an area in which I have a personal interest. I was diagnosed with multiple sclerosis 16 years ago and I know the battles that I had and my lived experience of trying to get the care I needed pre-diagnosis and then post-diagnosis, probably going on 20 years or so. I had a relapse last year. I want to put on the record that once you are in the system, you get a good service of care from the HSE, and the treatment I received in Tallaght hospital neurology department and from the MS nurses there was second to none. I want to put that on the record because I can be critical when people do not get the care they need.
The question has been asked but I want to try to ask it in a different way in regard to the delay in establishing a community neurorehabilitation team in CHO 7. As far as I know, funding was available in 2020. Responses to parliamentary questions that I got on the issue stated that negotiations are ongoing to agree a governance model in order to proceed with recruitment. What I want to know is what the issues are in regard to the governance of this neurorehabilitation team and whether there is a specific timeframe, which there can be, in regard to the adoption of a governance model for this team. Can recruitment proceed while this governance model is being prepared?
Dr. Colm Henry:
There were delays that were contributed to by some uncertainty over the governance model. Also, as I mentioned earlier to one of the Deputy’s colleagues, the fact that smaller teams were not as effective has informed the design and roll-out of the remaining teams, which will be bigger in number, and the CEO has referenced 13 per team. The other contributing factor was that there was an absence of some key specialties, including that of consultant. Part of our risk response in addressing the needs of CHO 6 and CHO 7 will be to address the numbers on the team, the consultant presence and the governance, which would be identical for all of the nine teams, which, as I said, will be of 13 in number.
Although I am not making excuses, it sometimes happens that when we have a new design for a new community-based team, we trial it out in a few areas and we learn from whatever things do not work there. Clearly, the size of the team and the governance were not operating in the way we wanted them to, and that has informed the design and roll-out of the remaining areas.
Mark Ward (Dublin Mid West, Sinn Fein)
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Can the recruitment and the governance issue be resolved in parallel?
Mark Ward (Dublin Mid West, Sinn Fein)
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Thank you. I want to move on to another area in which I have a big interest, that of mental health. One aspect is the area of early intervention in psychosis. I was very disappointed to receive a reply to a parliamentary question during the week stating there is no new funding for early intervention in psychosis team development in 2023. I wonder what impact that is going to have on people who require that service. At the moment, 0% of children under the age of 18 have access to early intervention in psychosis.
Dr. Colm Henry:
I am familiar with one of the established teams in Cork. It is an extraordinary service and they make extraordinary interventions to address an uncommon but very serious mental health difficulty. The team in Cork includes not just a consultant and the nursing staff but also somebody to enable re-entry into careers and the work environment. What they have done is, first, to considerably shorten the time between first presentation and intervention and, second, with the cases they have had to date, they have managed to successfully rehabilitate people through the acute illness, back into the workforce and back into their lives.
As I understand it, we have only two teams. I may supply a note on this. These are big teams that take a long time to build up. They are resource heavy and we want to see these rolled out into other areas because we saw the impact in Cork and elsewhere they have been implemented. There are two stumbling blocks. One is the HSE applying the resources and upscaling it across the country. The second is building the team to its full capacity. With reference to the Deputy's previous question on the community neurorehabilitation teams, half a team is not much good. It takes a while to build up the full team that can have a full impact.
Mark Ward (Dublin Mid West, Sinn Fein)
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I get that but from the information I have, we are talking about an average investment of €408,000 per year in early intervention into psychosis. I am asking whether not having that €408,000 this year will have an impact? It does not seem a hell of a lot of money in the full budget of the HSE.
Dr. Colm Henry:
Certainly, I have seen for myself the direct impact it has on patients where there was no service previously or where the service had to wait until the hospital service kicked in. There are certainly huge benefits to an earlier intervention community-based team intervening at an earlier stage and providing end-to-end support in the way the Cork team does. We want to see this rolled out to all areas and the benefits we have seen and the learning we have had from the Cork team will inform the design and roll-out throughout the country. That is again subject to funding and recruitment. These teams are quite resource heavy in terms of the scope of the healthcare professionals involved.
Mark Ward (Dublin Mid West, Sinn Fein)
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I want to move on to eating disorders. Another response I received from the HSE to a parliamentary question said there is no additional funding for eating disorders in the National Service Plan 2023. I find this to be absolutely horrendous. We heard all the way through the Covid-19 pandemic about its impact on people who have eating disorders. Eating disorders have the highest mortality rate of any psychiatric diagnosis. We currently have only three adult inpatient public beds in the country. I just do not understand this. Does the HSE think it is acceptable to not have new funding in 2023 for such a serious issue?
Mr. Bernard Gloster:
It is a very serious challenge and it is a dreadful experience for a family who struggle with trying to support a family member with an eating disorder. I will not try to dress it up any other way than to say that we have a long way to go to do justice to what the need is and what the potential response is to that.
Mark Ward (Dublin Mid West, Sinn Fein)
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Was there any rationale as to why no funding was allocated in 2023? The Minister of State, Deputy Butler, has stated during debates in the Chamber that eating disorders is one of her key priorities and we come here and get the information from the HSE that there is no new funding.
Mr. Bernard Gloster:
To be fair to the Ministers and to the people in the HSE who draft the service plan and the bids, it is not that a deliberate attempt is made to exclude it. The range of specific and responses we are responsible for can be seen from the service plan. They are quite vast. Does Dr. Henry have something to add to that?
Dr. Colm Henry:
We have significantly expanded the number of teams and the members of teams across the country. I recently attended the first face-to-face meeting of these teams in the Ashling Hotel, which was led by the national clinical lead. Yes, there are deficits across the country and some of the teams are small but they are making a real impact. As I understand it, the expanded, dedicated posts have gone from a single figure sum in 2015 or 2016 to more than 70. I cannot remember the exact figure but I will come back to the Deputy with a detailed report on that.
Mark Ward (Dublin Mid West, Sinn Fein)
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I have a last point to make regarding CAMHS. I am paraphrasing Mr. Gloster regarding the Minister saying that we need to move away from CAMHS. It is all well and good and easy to say but at the moment 4,490 children or young people are waiting for a first-time appointment with CAMHS. Some 752 of these children are waiting for more than a year for appointment. It was mentioned that 95% should be seen in three days but there are 752 children. When this Government came into office, 200 children were waiting for more than one year for an appointment and it is up to 752 now. I always talk about early intervention and the connection between Jigsaw and other primary care services like primary care psychology. If a child or young person gets the service at an early age, he or she is less likely to need the services or CAMHS as they progress. Is any work being done to resource primary care or work between CAMHS and primary care psychology? There are 11,000 children waiting for an appointment with primary care psychology at the moment. Is any work being done to connect both of these services?
Mr. Bernard Gloster:
Primary care psychology itself is challenged because of the availability of qualified clinical psychologists and the demand for them. We are trying improvement initiatives specifically within CAMHS itself. The demand and the referral rates are very high. I made the comment before Deputy Ward came in that I think we have a serious question to ask. I would not answer it immediately but we do have a serious question to ask as to whether we continue to maintain more than 70 partially staffed teams or reduce them to 55 or 50 full teams with likely better effectiveness. We certainly continue to invest in those wider primary care well-being supports like Jigsaw and other interventions and we will continue to do that. The Mental Health Commission is due to report shortly in respect of a range of assessments of our CAMHS service. I do not wish to pre-empt what the commission will say. I have spoken to the chief inspector there in the past few days. I expect that will tell us a very challenging story and my focus is how our whole system, rather than just the expectation of CAMHS, responds to that. We have just appointed a national clinical lead for CAMHS specifically. A consultant psychiatrist will take that role. We have also just appointed a dedicate national lead, assistant national director for CAMHS, whereas before it was all merged with adult mental health. That itself is no silver bullet. We will continue to make progress. We have waiting list interventions and so on. For young people and their families, be it across CAMHS or across disability services, we are very challenged in our ability as a State to respond to children presenting with very complex needs.
Róisín Shortall (Dublin North West, Social Democrats)
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There have obviously been a lot of questions about the neurorehabilitation teams and they are critically important. A time-limited intervention is required and that is critical but we also have to consider what happens after that. There is undoubtedly a post-rehabilitation void at the moment and so many people do not have access to the kinds of therapies they require. That limits their lives so much and also puts an additional burden on the health service. There is the issue of the potential for falls and that kind of thing. Will Mr. Gloster to clarify precisely what is happening regarding the MS Ireland proposal for a national physiotherapy service? It submitted the business case for that and is strongly supported by other patient groups in this area. What consideration has been given to this because it has a proposal for a national physiotherapy programme?
Mr. Bernard Gloster:
It would be extremely unfair of me to say I know what the response is. I do not. I need to look into it and see who in our system has it or has reach into it. I absolutely promise the Deputy I will come back to her with a very clear answer. It would be wrong of me to say that I know as I am not familiar with the proposal.
Róisín Shortall (Dublin North West, Social Democrats)
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That is fine. I thank Mr. Gloster and I appreciate that very much.
I will move on to the issue of the serious shortage of GPs. There is an initiative but it is not clear exactly how it stacks up as regards the shortage of rural GPs. It would be good to get further information on that, albeit not today. The dire shortage of GPs in urban disadvantaged areas is equally pressing. We see the inverse care law apply in many urban areas, including in my own constituency. At one stage with a previous Minister it had been Government policy to introduce salaried GPs. I know from my engagement with graduate doctors that there is a huge level of interest in GPs being able to take a well-paid job. In the main, graduates want to practise as a doctor; they do not want to be businesspeople and do not have the capital behind them to get their own premises. They frequently said we would never expect school principals to provide their own school buildings. Why are we not addressing this issue by way of salaried GPs? The model that is there is 40 years old and based on contracts.
Róisín Shortall (Dublin North West, Social Democrats)
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It works for some people and those people are already there and have invested in their premises.
There is no reason they cannot continue with that. However, it is not a model that suits all circumstances. It is a model also that prevents many enthusiastic young GPs from practising in this country. That is my first question.
My second question is in relation to a not-for-profit charity that has been in existence for some time and was referred to earlier, GP Care for All. It is operating successfully in the north inner city out of the Summerhill Primary Care Centre. It is reaching hard-to-reach excluded and disadvantaged groups. It has a proposal to do something similar in the Finglas area. Finglas is in my constituency. There is a vast area of Finglas - all of Finglas west and south - that has no GP practice. It has been top of the list for a primary care centre for 12 years. There are various reasons that primary care centre is not yet in place but there are no GPs in that area. I am happy to speak to Mr. Gloster privately afterwards.
Róisín Shortall (Dublin North West, Social Democrats)
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I want to ask Mr. Gloster about that principle of salaried GPs and why we are not availing of that. There are many GPs who would be interested in staying here if they could be employed as a GP and earn a very good salary, as they deserve to. Why are we not using that alternative or additional model?
Dr. Colm Henry:
It is absolutely worthy of doing in parallel. In our discussions to date with the GP representative bodies, the Irish College of General Practitioners, ICGP, and the Irish Medical Organisation, IMO, the priority they have identified for general practice has been in supporting existing practices and the additional personnel following the O'Dowd report which identified the poor supports which GP practices have throughout the country, and clearly our attempts at increasing the trainees to 285 - up to 350 in a few years - per year and bringing in non-EU GPs.
Róisín Shortall (Dublin North West, Social Democrats)
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I recognise we are increasing the number of trainees but the number of people who are emigrating is increasing as well. That does not make any sense. We need to address the issue at its core, as we need to in relation to consultants and those who are fleeing these shores.
Róisín Shortall (Dublin North West, Social Democrats)
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In the main, it is existing people with the existing model who are dictating what the model should be for younger people.
Róisín Shortall (Dublin North West, Social Democrats)
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Why are we allowing that situation to continue?
Róisín Shortall (Dublin North West, Social Democrats)
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Does Dr. Henry accept there is a problem with that principle? It is fine to support existing practices but we need new models that recognise the needs of doctors.
Mr. Bernard Gloster:
Fundamentally, the alterations we have seen to general practice in recent years around additional eligibility, etc., have been add-ons to a very old contract frame. There is no point in saying anything different. We have now had two iterations of a revised consultant contract since that original GP contract and there is a fundamental question of revisiting the base contract. In revisiting the base contract, the question arises as to direct employed versus self-employed GPs. It is not all duck or no dinner. It is a mix of both.
Róisín Shortall (Dublin North West, Social Democrats)
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Absolutely.
Mr. Bernard Gloster:
I would certainly be supportive of that. However, I would not mislead the Deputy and say that I, right now, today, have any tangible steps to achieving that soon. There is a discussion and a negotiation to be had about it.
In relation to GP Care for All, I am intrigued by it. I am not familiar with it and I would like to talk to the Deputy offline about it. Perhaps Mr. McCallion and I will go and see it for ourselves. If there is a solid proposal to expand anything that improves access to general practice in any other part of the inner city where it is challenged, the Deputy will not find anything other than an open door with me.
Róisín Shortall (Dublin North West, Social Democrats)
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The outer city, in Finglas.
Mr. Damien McCallion:
I have seen Summerhill. I have been in it. It is impressive. As Mr. Gloster said, we can look at it in terms of whether there is potential around wider application.
That GP strategic review is also due to commence soon. That is the place for something like the salaried GP. That, as the Deputy knows, has not happened for quite some time but there is momentum now to do that. Hopefully, that is something that we just need to address.
Róisín Shortall (Dublin North West, Social Democrats)
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Sure, and that is a ministerial initiative. The research is all there. There have been umpteen questionnaires sent out to graduates answering the question-----
Róisín Shortall (Dublin North West, Social Democrats)
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I thank Mr. McCallion.
Seán Crowe (Dublin South West, Sinn Fein)
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I have a couple of questions.
First of all, I welcome the plan. It is a huge amount of money. For the plan to work, there are a lot of moving parts. Clearly, the beds issue is one that has to be addressed. I welcome the HSE statement this morning about moving ahead with the 1,500 suggestion. For example, and I accept these are always local issues, etc., I was looking back in relation to the 72-bed unit in Tallaght hospital. It was announced six years ago by the previous CEO. I asked a question last year about this capital building project of 72 beds and it was not even on the system. I merely give that as an example of the slowness, some of the road blocks and the blockages that were in the system. When we discussed this previously, we were talking in terms of planning. We asked whether that would interfere with hospitals, etc. My understanding with this particular build is it does not, and I am merely giving that as an example. We agreed on the previous occasion the HSE attended that there are other examples that we can move ahead in other hospital groups and other hospitals around the State. I wish the HSE well in progressing that.
The pathway initiative is really promising. That is the way forward. The HSE stated previously that it would bring in CEOs of hospitals, etc., and maybe at some stage in the future, it would give us a report on it outlining what works in one area and what does not work in another. Another example, from Tallaght hospital, was that day surgery stayed open during the worst of the challenges in accident and emergency.
We also talked about accident and emergency and the challenges there. Mr. Gloster stated the viral surges were a big challenge there. There was one virus, in particular, that was impacting on babies and children, that is, strep 1. There was another one as well.
Seán Crowe (Dublin South West, Sinn Fein)
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Looking at the challenges that we faced last year as part of the plan, are there proposals in relation to what we could do differently? I am thinking in terms of supports for those young mothers who were in that situation out of hours, such as the ability to telephone someone to ask if something is normal, not normal or whatever. Maybe there is something that could be done in that regard.
Lastly, on accident and emergency, we talked about people arriving at accident and emergency and the reasons for that, etc. One can give various reasons. The HSE spoke about the age profile. I will give an example of one challenging accident and emergency situation, that is, the eye and ear hospital. Someone mentioned earlier the case of an elderly person. I know of a case of a 96-year-old woman who arrived at that hospital. Earlier that day, she had got two injections in her eye due to a macular problem with the possibility of losing her eye. She had a bad reaction to it and her family rang up the hospital. There is a triage system within the hospital. It finishes at 5 p.m. You cannot walk into the hospital and that is why I want to address it. That is a challenge in itself. Where do people go if they have that difficulty? That woman was in the hospital system, within the eye and ear hospital, that morning but she had a bad reaction with pus coming out of the eyes. She was in incredible pain. The woman has a high tolerance of pain. The family brought her in. They were literally parked outside the hospital. You cannot get in because the triage stops at 5 p.m. The accident and emergency still works within the system. It is still dealing with patients inside. I am wondering about challenges such as I outline. That 96-year-old woman had her daughter with her and the daughter was there to advocate on behalf of her mother. Her mother was sitting on the bench, crying and in a lot of pain. The good news is that she was eventually seen.
There are challenges within the system in that regard and I am just highlighting the one I am aware of.
The witnesses might outline some of their ideas regarding the capital programme for building more beds into the system, or if they have anything to say in respect of the viruses.
Mr. Bernard Gloster:
Regarding beds, the Minister has been very supportive of advancing a proposal for 1,500 beds in addition to what Mr. McCallion outlined in respect of the finishing-out of the previous plans this year with the 200-odd figure and so on. An expansive range of building of community beds is going on. A significant number of them are replacements, to meet regulatory compliance, and there are also new beds within that.
As for the 1,500 beds, rather than wait for the funding to come, an expression of interest has gone out to the market with a view to their being built in 100-block units with modern-build technology, which would greatly shorten the timeframe. The expression of interest has an indicative frame cost of about €1 billion, so that is the scale of what we are talking about.
I will ask Dr. Henry to address the issue of viruses in a moment. In the context of the overall health of the child population, he and his team have led our public health restructuring. We all now know the importance and value of public health and of having public health specialties. In the context of the overall health of the population and subsets thereof such as children, one issue we have to target, as I saw recently in the north west, relates to the variable uptake of aspects of the primary childhood immunisation programme and in vaccinations as they emerge in response to various viruses. There is vaccine hesitancy and a great of deal of what we could call false narrative around immunisation programmes and so on. Overall, we need to continue to improve the health of the child population as part of health resilience for when viruses and so on emerge.
In respect of the question on chief executives of hospitals and community services, I have had three of those management team engagements and they are held every three weeks. I am not sure they are all delighted with the engagements, but we have had three. The first one focused on the performance of the CHOs on delayed transfers of care because, in my view, delayed transfer of care is owned by the community, not by the hospital. The second engagement related to the performance of hospitals against the waiting list action plan, while the third one, held last week, concerned hospitals in the community working together. Each of the six hospital groups and their associated CHOs had to present me with plans last week for how they are going to contribute to managing capacity and urgent care for the rest of the year. That will now go into the in-year plan Mr. McCallion and his team are finalising for me. That has been quite a productive, if challenging, process. I will not ask my colleagues to comment on it because they might say something different, but it is part of the direction of travel with a view to performance-managing an entire system.
Dr. Henry might wish to comment on the virus question.
Dr. Colm Henry:
There is not much. As the Chairman will be aware, in January we had a confluence of three viruses, including RSV, to which he referred. For the second year running, it hit much higher levels than it had done in the previous five or six years. There were also influenza and, of course, Covid-19, and all three peaked around the same time for a two- or three-week period, which caused significant pressure. As for what we can do about it, as the CEO mentioned, it is about our public health capacity, the Health Protection Surveillance Centre and our vaccination programme. I mentioned earlier in response to one of the Chairman's colleagues the disappointment we experienced regarding the childhood uptake of flu vaccination. While serious influenza is, thankfully, a rare illness in children, they are a reservoir for influenza affecting older, more vulnerable people, so we want to see big improvements in that regard. We cannot predict when viruses will come together, but we can certainly work hard on a vaccination programme and improve general, overall health to protect those who are vulnerable.
Seán Crowe (Dublin South West, Sinn Fein)
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We now have to bring the meeting to an end. The witnesses might revert to us with any views they may have regarding those challenges regarding the eye and ear hospital. I am not being critical of the system, but it clearly needs tweaking.
I thank the HSE for assisting the committee in its consideration of the HSE national service plan for 2023. The committee will continue its ongoing attention to the public health service generally and looks forward to further engagement with the HSE.