Alison Comyn (Fianna Fail)
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Before we begin, I welcome the students from St. Mary's National School. They are guests of Senator Cathal Byrne. It is lovely to see them. I hope they enjoy the rest of the day. There has been a long-standing tradition that any schools visiting the Seanad or Leinster House have no homework for the rest of the week. I am not sure whether that can stand or how the teachers will fare with it.

Victor Boyhan (Independent)
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And it is only Thursday.

Alison Comyn (Fianna Fail)
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I hope the students enjoy the rest of their stay. I thank them for coming in. I welcome the Minister, Deputy Jennifer Carroll MacNeill. She will have ten minutes, group spokespersons will have six minutes and all other Senators will have four minutes.

Jennifer Carroll MacNeill (Dún Laoghaire, Fine Gael)
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I thank Senators for the opportunity to discuss the HIQA review of urgent and emergency healthcare services in the mid-west. We continue to be fully committed to deliver the highest quality healthcare services nationwide, including at University Hospital Limerick and across the mid-west region.

I take this opportunity to acknowledge the hard work, expertise and consideration that HIQA invested in producing its recent review and the advice it gave me.I also acknowledge the significant work undertaken by the ESRI, which contributed important research relating to the future bed requirements for the mid-west, which greatly informed HIQA's advice.

We can all agree without hesitation that the people of the mid-west deserve access to responsive, safe, urgent and emergency care in a safe and timely way. Much has improved in Limerick over the past 12 months. To add to that, I was delighted to open the first of two new 96-bed blocks at UHL last month. Those beds were very much needed. The opening was important not just for Limerick but for the entire mid-west region. The bed block has already had a positive impact on capacity and reducing overcrowding. Since its opening, we have seen days this month such as last weekend where UHL reported on the HSE figures, which are our standard for measuring, nine, five and seven people on trolleys. On the same day last year, those numbers were 80, 75 and 59, respectively. The 96-bed block has had a major impact on trolleys in Limerick. It is not a universally perfect picture by any means but the difference in what is experienced in Limerick in the past number of weeks since the bed block opened is considerable. The average trolley number in the two weeks before the bed block opened was 54, while the average trolley figure for the two weeks after that was 20. As I look at the difference at random between my first pages of trolley figures and my most recent pages of trolley figures from January, we are looking at figures in Limerick of 72, 77, 57, 88, 91 and 69. If I look over the past number of days, the numbers are seven, six, 13, 30, 27 and 28. A figure of 28 people is too many but it is a very considerable difference and improvement and it reflects the trajectory we know we need to see. When I look at all the hospital trolley figures every day, there was a lot of red in January while there was far less red in the past seven or eight days. In Limerick, it really does come down to beds because it has made extraordinary improvements in all its processes, particularly in the emergency department.

We know that in large part this is because of the implementation of the excellent report of the independent investigation by retired Chief Justice Frank Clarke into the tragic death of Aoife Johnston at UHL in December 2022. It identified several factors that contributed to delaying treatment and to Aoife's death. My thoughts continue to be with her family. I was so grateful to have the opportunity to meet with them this year. The report highlighted particularly severe pressures that night in the emergency department and the HSE established a structure to oversee the implementation of the 17 recommendations made by the report immediately after it was published in September 2024. Work to close out that implementation has concluded and was shared with the Department last month. The outcomes from the report contribute to an improved patient safety situation in the HSE mid-west region and across the healthcare system in Ireland generally because other departments are learning from the experience in Limerick. It has transformed their processes generally in the emergency department but also in other parts of the hospital since December 2024.

Regarding the HIQA review, in 2024, my predecessor Stephen Donnelly requested HIQA to conduct a review of urgent and emergency care in the mid-west with the primary objective of ensuring safe, quality acute care. As part of that review, HIQA was asked to consider the case for a second emergency department in the context of population changes in recent years and ongoing pressures across the mid-west. That final report was submitted by HIQA and published at the end of September 2025. As Senators are aware, the report presents three options and advices for me as to how best to address the capacity gap. They include the expansion of capacity at UHL on the Dooradoyle site, option A; the extension of the UHL hospital campus to include a second site in close proximity under a shared governance and resourcing model, option B; and the development of a model 3 hospital in HSE mid-west providing a second emergency department for the region, option C. More than anything else, as Senators are aware, the report clearly identifies that the lack of sufficient acute inpatient beds in UHL and the mid-west region is the core issue that needs to be addressed urgently, and that is my priority.

In addressing the issue, we continue to increase capacity as we try to increase capacity generally. A total of 278 beds have opened in acute hospitals since January 2020, including two 16-bed rapid-build units delivered in December 2024 and June 2025 and the 96-bed block, which I opened last month. A total of 236 of those 278 beds are in UHL. We can see the impact on patients waiting on trolleys.

On enabling works, I have seen it myself in the second 96-bed block at UHL and a further 84 inpatient beds planned at UHL are under way. Those projects, including the 32 rapid-build beds and the first 96-bed block, will increase the bed capacity by up to 308 beds by 2028. Since 2020, we will have had 572 new inpatient beds across the region to 2031. I know these are lots of numbers and it is hard to imagine but the most striking thing for me was to stand in the soon-to-be-opened 96-bed block and look down and see the second 96-bed block about to be developed. The reason it did not happen at the same time was related to some of our outdated rules regarding procurement and infrastructure guidelines, which the Minister, Deputy Chambers, will be bringing measures to Cabinet next week to change.

Other really important initiatives include the acute virtual ward for 25 patients, which went live last year. We want to extend that to 40 patients. That is like 40 beds. It is 40 people who can be at home under the care of Limerick in the bed or on the couch, properly monitored remotely. It is working well in Limerick and St. Vincent's and we are expanding that across five more hospitals. It really works well. We have had very good outcomes and would like to see more of that. The Limerick surgical hub will open in the summer of 2026. We will begin recruitment for that in advance. It is very important. The idea is to pull out as much work that does not have to be in the hospital, such as elective and other day case procedures, to free up capacity for other things.

Staffing has grown by 53% since 2019, including 300 more whole-time doctors, including consultants, 571 more nurses and midwives and 163 more health and social care professionals. All of those improvements show our commitment to increasing capacity and de-escalating the pressure experienced in the UHL emergency department more broadly.

I compliment the work of the regional clinical director Dr. Catherine Peters, the overall regional executive officer Sandra Broderick and the patient council, all of whom have done extraordinary work on changing processes in Limerick. Limerick has the lowest proportion of public-only consultant contracts and is working with the 2008 contract holders in an excellent way to ensure there are more people working at weekends. They are discharging better at the weekends, have the highest presentations and are discharging and rostering the best at the weekend. They really have taken every possible step and what they need are more beds and more acute capacity. That is very clear.

I have met with the patient council and will meet it again. Last night, I met a cross-party group of Senators and Deputies to discuss the next steps of the review and outline my thinking for them. I thank them sincerely for their collaborative work. Everybody here simply wants to improve services for the people of the mid-west, whom they represent and to whom I have a major obligation. My intent, as I said to Senators and Deputies last night, is to bring a memo to the Government before Christmas to do a number of different things. One is to show how we are going to bring forth options A and B, particularly in the context of the new infrastructure guidelines that I hope will be approved by Cabinet next week. That is a really important enabler for us. The reason we did not do two 96-bed blocks at the same time related to the infrastructure guidelines and how difficult and slow they have been in the past, so this is an important enabling change and I need to see how that intersects with our plan for option A in particular. We need to get as much out of the Dooradoyle site as we can while exploring and delivering the other options. My intent is that the memo before Christmas will deal with options A and B together and set out a really substantial plan for how we can increase not just infrastructure capacity in Ennis and Nenagh, recognising that there are many more beds. I have should have spoken to that earlier. There are an additional 48 beds that are going into Ennis on top of the 81 that are there. That is a very considerable expansion. There will be something of a similar order in Nenagh. There will also be more radiology and other medical facilities such as disinfection facilities.

What we have not fully explored, and what I have asked the HSE to give me, is a plan for how we can deliver more services from Ennis. I am talking about cancer treatments that can be delivered closer to home after the patient has had the major diagnosis and the treatment plan in the acute hospital. What more can we do to deliver services? My intent is to bring forward a memo dealing with those three things in particular and to agree a process for how we will address option C, which needs to take a longer term approach to and analysis of what the perfect size for a hospital is and how that is best governed. We have a genuinely clean slate here and we are learning so much about the perfect hospital size in terms of efficiency, governance and clinical integration. The mid-west is a big opportunity for genuinely good thinking on that, bearing in mind what we have learned from the very important work of the infrastructure accelerator task force, which has been working with the Department of public expenditure and reform for the past six months or so.We have a major project of work. In my mind, I divide it into two sections: prior to Christmas dealing with the priority area of delivering acute capacity, which is what HIQA has said is necessary, so that must be our priority, and then the in the early part of 2026 having a proper structure that enables us to consider all of the factors about how we will deliver capacity for the longer term in the mid-west.

Alison Comyn (Fianna Fail)
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Before I call on the next speaker, I welcome more guests to the Visitors Gallery, two of whom I feel should be in our Distinguished Visitors Gallery. Please welcome Dr. Fiona Nic Fhionnlaoich from Shankill, County Dublin, granddaughter of former Senator, Peadar Toner Mac Fhionnlaoich, known as An Cú Uladh, the Ulster Hound. He was a Senator in the second and third Seanaid. I hope you can feel the presence of your grandfather in the great Chamber. I also welcome Julie O'Shea from Ardmore, County Waterford, guest of the usher, Paul Smith. I am sure you are being very well looked after. We have other guests of Deputy Séamus Healy. I hope you have a very enjoyable day today.

Maria Byrne (Fine Gael)
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I thank the Minister for coming to discuss this all-important issue. This is my ninth year in the Oireachtas, and I would not like to count how many times I, and many others in the Chamber from Limerick, raised the issue of UHL. I thank the Minister for her openness and transparency in terms of her thoughts and whole process, but also the fact she is taking the report from HIQA into account. It is very clear this is about capacity. I would like to compliment Catherine Peters and Sandra Broderick as well. It has been a breath of fresh air. The Oireachtas briefings have been very open and forward thinking in terms of what their thoughts are and how we can solve the issue. It is very clear that it is about capacity. When the Minister took over the brief, she put in greater efficiencies and put emphasis on the fact that consultants were not working on the weekend, people were not being discharged and there was bed-blocking. A lot of those practices have changed and that is down to the staff in the hospital and to the Minister's thoughts on how it should operate differently. It took buy-in from the staff to achieve that so that has certainly helped an awful lot.

The impact of the new 96-bed block has been shown in terms of trolley numbers, but some days it does shoot back up again and comes down. However, the staff have worked there under horrific circumstances as have the patients attending the hospital over many years. Some people were afraid to go in there. I really hated to hear that being said because if somebody is sick, he or she needs to go to the hospital. I would like to pay compliments to the other hospitals in the region, namely, St. John's Hospital, Nenagh Hospital, Ennis Hospital and Croom Hospital because they are all part of that UHL configuration. There are extra beds going into some of those hospitals, like St. John's Hospital, which is a Nightingale hospital. Many older people feel so comfortable going there, with the care and attention they get there. I compliment the staff in all those other hospitals. It has been about greater efficiency and greater use. I recall raising a Commencement matter about the blood clinic closing at 12 p.m. on a Friday, so if somebody went to the doctor after that, they were sent to UHL and spent the weekend waiting to have their bloods taken, whereas all those practices have changed and that is leading to greater efficiencies.

From the very beginning I have been very clear that options A and B need to happen in unison, which will eventually lead to option C. I compliment all my colleagues across all parties and none who came together as a unified voice right across the mid-west. This is the first time all voices have come together because they are so concerned about the future for the mid-west and the safety of patients and staff. It is great we have a unified voice from most parties on the future of what should happen at UHL. The buy-in from the staff has been really important. There are many volunteers working in the hospital. It is good to see they are delivering above their weight in terms of discharges and other issues that are happening at the hospital. We have the surgical hub coming on board. I understand that is opening in the middle of next year. That will help. Option A has to progress as quickly as possible. The foundations have started and it has gone out to tender. I hope with the memo from Minister for Public Expenditure, Infrastructure, Public Service Reform and Digitalisation, Deputy Chambers, that things will be able to happen in a more proactive manner. We might be able to provide more beds. We cannot pre-empt what is going to be in the memo, but it is about doing things more efficiently. The private hospital in Limerick went up in 18 months. The public hospital has ties to the Department. Hopefully that will help and the Minister will take that into account. As far as I am concerned, options A and B have to happen as quickly as possible.

I was in HSE West for a number of years and I listened to colleagues in Galway talk about University Hospital Galway and Merlin Park University Hospital, and how they were working so well in tandem. That is what I envisage for Limerick hopefully. The more acute patients will be in the main hospital and the less acute patients in the new section. It will mean greater efficiencies, but safety for all and people experiencing better healthcare. I acknowledge the people who have died in the hospital system. Sometimes, we do not know the circumstances. I also acknowledge the hardworking staff and everybody who is helping to bring this together, including consultant Terry Hennessy, who sat on the HIQA report team locally. I am looking forward to working with the Minister for greater delivery for the mid-west.

Victor Boyhan (Independent)
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I welcome the Minister to the House and thank her for giving her time. It is important that when we discuss this that we set the scene, because I am always conscious there are people outside of here looking in who will be looking at the Oireachtas report later on. We know HIQA publishes terms of reference. In a press release issued on 21 August 2024 the authority: "The HIQA has published its terms of reference for an independent statutory review to inform the delivery of safe quality urgent and emergency care in the mid-west region of Ireland."

We also know that through an examination of Oireachtas parliamentary questions, hundreds and hundreds of questions, motions and matters of discussion were raised with various Ministers for health. We have had the parties in Government in some form or shape for many years. I acknowledge the new Minister has clearly demonstrated a capacity to focus and a determination and emphasis on this particular issue, and on other issues. I acknowledge that and pay tribute to her for that.

The terms of reference were, of course, developed following a request by the then Minister, Stephen Donnolly, for HIQA, as the independent health and social care regulator, to conduct this review. It is important to stress this review was conducted under section 8(1)(e) of the Health Act 2007. I understand the review sought an evaluation of evidence-based and key factors to inform decision-making around the design and delivery of urgent and emergency healthcare services, including the case for a secondary emergency department within the region. Following completion of the review, the report ultimately landed on the Minister's desk and was published.

Before I go into some key questions to ask or points I wish to raise with the Minister, it is important we acknowledge the many patients that suffered within this region. Their cases were articulated well in this House by a number of my colleagues. That is important. In addition, what the key health workers, medical workers, front-line workers or any workers or service supports and anybody within the health service in this region had to tolerate for years was totally unacceptable. It has taken so long, and it is a pity it has taken so long, but we are now clearly on a trajectory for something new, which is important. The Minister mentioned the ERSI. I studied some of its documentation relating to this report and it is important we acknowledge that independent thought process feeding into it.I thank all stakeholders engaged in the process. Let us now move on. Enough of the old history listen, let us look at the key asks today.

We have three options. Option A talks about expanding. The three key issues are expand, extend and develop. Option A is to expand capacity at University Hospital Limerick, UHL, on the Dooradoyle site. Option B is to extend the UHL campus to comprise a new second site in close proximity under a shared governance and resourcing model. Option C is to develop a model three hospital in the HSE mid-west region, providing a second emergency department for the region.

The Minister has to put in place timelines. Clearly we cannot wait. There are issues, let us be honest, about resources that have to be secured. There is planning. There is a whole range of issues as consultation with all stakeholders. It is also important to acknowledge that HIQA completed this extensive research. We know that there were 17 in-person meetings with the stakeholders and that there were 1,121 public consultation submissions. I have looked at some of the correspondence that supports all of this. We know that an expert advisory group was convened to consult the independent review. Of course, then we need to go back to the core issues here. What was the core recommendation? The core issue of this was that there were not enough inpatient beds. Keep it simple. There were not enough inpatient beds in the HSE mid-west region capable of treating the sickest patients who presented for urgent or emergency care. This is a summary of HIQA's own report to the Minister. HIQA recommended "immediate action and investment to address current risks to patient safety in the shortest time frame and safest way possible". That is the kernel of what the Minister is saying. Therefore, we now have to go back to the options.

The time for deferral is over. There are three key options. What is HIQA saying about some conglomeration of option A or B? HIQA's view is that options A and B are most likely to increase the number of available inpatient beds of the required type in the shortest timeframe, addressing the immediate risk to patient safety. It acknowledges this risk. I suggest that this is the focus. This is what the ask is. I would be interested to hear what the Minister is proposing or planning. When will she have a timeframe in terms of kickstarting the recommendations? I presume she will have talks internally with her own officials and with the Government as well. We need to know today or certainly in the next few weeks, and the people in this region want to know, what is happening.

We have identified the problem and the weaknesses. We have acknowledged that people suffered. We acknowledged that patients and their safety were put at risk. We acknowledge that staff had to tolerate dreadful conditions. People were embarrassed. The medics and politicians who represent the region were embarrassed. Loads of parliamentary questions were asked and there were debates and motions. What do we need to do today? The heavy lifting is done. The Minister is committed to focusing on getting things done. What I would like to hear in the short term, for the people of this region, is what options she is recommending, what options she is going to fund and what timelines are involved for delivery. This will be progress and action, which is the key ask here.

Dee Ryan (Fianna Fail)
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Cuirim fáilte roimh an Aire. As the Minister knows, the people of Limerick, Clare and Tipperary have lived with crisis conditions in our acute hospital system for more than a decade. What the HIQA review has done, bluntly and unmistakably, is confirm in black and white what patients, families, clinicians and communities have been saying for years - that the mid-west’s acute hospital infrastructure is not fit for purpose, not matched to the population we serve and not resourced in line with national norms.

Last night, along with Oireachtas colleagues from across the region, I met with her to discuss the report and the action required in its aftermath. I acknowledge at the outset her engagement, her openness and her commitment to progressing solutions. Acknowledgment of the problem alone will not rebuild public trust in the mid-west. We now need decisive and visible action to restore public confidence - action that shows the people of the mid-west that this Government will deliver the acute hospital capacity that our region critically needs.

The figures are stark. UHL remains the busiest emergency department in the country, with 83,000 attendances up to 16 November, a 10% increase on the same period last year. It also has the highest acuity of any model 4 hospital in the country. This means that patients attending UHL are sicker and more unwell than those attending other hospitals. As a result, UHL has recorded the highest number of admissions nationally to date - 25,915 admissions nationally to date. Behind these statistics are real people and real suffering. The memory of Aoife Johnston and Eve Cleary and the testimony of families like that of Niamh McNally just yesterday must be front and centre in our minds. Their experiences and those of so many others are a constant reminder that delays in procuring hospital beds at UHL are not abstract problems; they are matters of life and death. Every day that we fail to deliver meaningful solutions increases the risk to people right across our region.

The geographical realities make the challenge even sharper. Over 40% of Clare's population lives more than an hour from an emergency department. The west Clare municipal district, the largest municipal district in Clare by population, is also the furthest from an emergency department. It is not just inconvenient; it is dangerous. I recognise and thank the staff - our nurses, doctors, hospital staff and management who continue to work tirelessly to provide safe care in difficult conditions. Their commitment is extraordinary. We have seen improvements. I acknowledge the impact that the new 96-bed block has had on trolley numbers since the Minister opened it last month. Indeed, for the first time in recent memory, Limerick was designated green last weekend, as the Minister stated, because the trolley numbers have fallen so low. We are, however, at 35 today on the HSE trolley watch and at 98 on INMO, which is more than double any other hospital in the country, even with those improvements. We must be honest - the new block has not ended corridor care. It is not capable of addressing the scale of the crisis before us alone.

The problem is bigger and deeper than that single block. That is why the HIQA report matters. It is why the decisions that the Minister takes now will shape healthcare for the mid-west for a generation. We urge the Minister to place herself in our shoes and imagine that she, her family and all her loved ones are in the catchment area for UHL and be ambitious for us. I welcome her commitment to option A, maximising capacity at the existing Dooradoyle site, and option B, identifying a site for a co-located acute bed facility. They must progress urgently and in parallel. I also welcome the Minister's confirmation that she will be bringing a detailed and fully costed report on those options to Cabinet prior to Christmas. That is the seriousness that this moment requires. I appreciate too that she is examining option C and looking at what the long-term sustainable hospital capacity for the mid-west may look like. I appreciate that this requires further time and consideration. That is prudent and necessary. At the same time, as I raised with her last night, we cannot simply wait for medium-term and long-term solutions. That is why I asked her last night for a UHL site-specific winter plan, as I had previously done in this Chamber over many months before the summer.

As I referenced last night, the HSE mid-west region has implemented a seasonal adjustment plan, postponing non-essential procedures. This is normally implemented in November and December and it is to keep the hospital beds free for the emergency department, but it was brought into force in October of this year. That means we have had a reduction in non-essential procedures from a maximum of 20 cases admitted per day to a maximum of ten admitted per day and the majority of those ten are reserved for oncology and in line with cancer treatment protocols. I ask the Minister, in advance of next winter, if we could have a site-specific UHL winter plan. I acknowledge that her plans, which we look forward to hearing next week, on localising services across the region will indeed help us to manage those challenges. The public needs to see movement. We need to see that the Government understands the scale of the crisis and that this Government is willing to match the investment with action. Let this moment be the turning point. Let it be the moment we acknowledge past failings, face the realities outlined by HIQA, and commit fully, visibly and without delay to delivering a modern acute hospital system worthy of the people in the mid-west it serves.

Martin Conway (Fine Gael)
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The Minister is welcome to the House.The meeting the Minister had with representatives from the mid-west yesterday and her opening statement here today show that she understands the urgency and purpose of the work she is doing, that she gets how important it is and that it is receiving the detailed attention at the highest level it deserves. I pay tribute to HIQA. It produced a very good report, which is informing the Minister. Many of us in the mid-west would have been able to summarise the recommendations ourselves from our ongoing engagements and experience over the years.

I have been a Member of this House since 2011. UHL is the one issue I have spoken about more than any other, both here in the House and at the Joint Committee on Health. It has been utterly frustrating to hear, week in, week out, month in, month out for year and years, the stories of people who have had negative experiences in the emergency department at UHL through no fault of the staff but because the accommodation and bed capacity was not there, leading to backlogs in the emergency department. We saw the tragic consequences of that when a citizen from my county lost her life unnecessarily. As a result of what happened, a lot of good is now happening. The new 96-bed block has made a significant difference. The facts and figures speak for themselves. As the Minister correctly said, it is still too many people. We still have not hit peak flu season. I take this opportunity to encourage everyone who has not got the flu vaccine to do so because it is the one way we can help to deal with the numbers in our emergency departments. The 96-bed block is up and running and making a difference.

I am very pleased that it is hoped that the accelerated critical infrastructure will include health infrastructure. I have no doubt the Minister has articulated that point loudly and clearly in the necessary corners of Government. With that memo on accelerated critical infrastructure protocols and so on being brought to Cabinet next week, I hope the Minister will be in a position to bring a memo to cabinet about options A and B the following week. I hope she will be able to refer to a process for examining option C as well. However, the critical thing at this moment in time is options A and B because they will eventually lead to option C. I know the Minister has committed to all three options. I am interested in hearing how we are going to develop both option A and option B. I believe that more can be achieved on the site at Dooradoyle. There is talk of a 96-bed block. It is my understanding that the history behind the number 96 is that the pocket of funding for the block had to be kept at €200 million. Perhaps that can now be scaled up. Perhaps the next 96-bed block could have another floor or two, adding another 15 or 20 beds. That is the type of outside-the-box thinking the Minister is very open to. There is this whole idea of capping funding at €200 million when we all know that bed capacity is needed and that funding is available for it. It is just about the process. Beds cannot be magically delivered overnight. There has to be a process. However, we can accelerate the implementation of option B. I know the Minister is fully committed to that. Again, on behalf of the people of the mid-west, I thank the Minister for her urgency and commitment in this regard.

Alison Comyn (Fianna Fail)
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I apologise for my error in having passed over the next spokesperson, an Seanadóir Nicole Ryan.

Nicole Ryan (Sinn Fein)
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I will share time with Senator Collins. I welcome the Minister and thank her for being here. What is happening in the mid-west is not a stand-alone issue. It is a symptom of a health system that is stretched to its limits and a government that has failed to match population growth with the necessary investment in critical infrastructure. For years now, the mid-west has had one of the most overcrowded emergency departments in the entire country. UHL has broken trolley records time and again. Staff are exhausted, patients are frightened and families are left in corridors for days. Communities across the mid-west have been raising the same alarm again and again. No other region in Ireland is operating under that kind of pressure. No other region has been expected to absorb the closure of multiple emergency departments without a corresponding investment in beds, staffing, diagnostics and community services. The result is predictable. We see overcrowding, dangerously long waiting lists and a level of strain that undermines the safety of patients every single day.

Of course, this not about blaming front-line workers. They are performing miracles in impossible conditions. The issue is political will and planning. It is about the refusal of successive governments to accept what every clinician and every community in the mid-west has been saying, which is that the system just cannot cope. We need a fundamental shift. We need capacity and more beds, staff and diagnostics. We need real investment in step-down and community care. We need resilience and a system that is flexible enough to ensure that one overcrowded emergency department does not bring the entire region to its knees. Ultimately and inevitably, the region needs another hospital. I know that is option C but it is needed, especially in light of current population growth. This is essentially about fairness and equality in services for people. A person's chance to get timely life-saving care should not depend on their postcode but, time and time again, we see that it does. The people in the mid-west deserve a health system that works and a Government that sees this not just as a regional problem, but as a national responsibility.

Joanne Collins (Sinn Fein)
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My thoughts go out to all the families in the mid-west who have unnecessarily lost loved ones due to the clear failures of our health service in the region. I commend the staff of UHL. They get up every day and go to work in what can sometimes only be considered a warzone. They have talked about the stress they are under and about feeling that staff in the mid-west are not being seen. I thank the Minister for giving up her time for that meeting yesterday. I apologise that I had to leave early but I did catch up with my colleagues afterwards. I was a bit confused when I saw some of the headlines coming out reporting that some of our colleagues in the Dáil were saying that we were going to get a second hospital in the mid-west. What I got from the meeting was that we were getting options A and B and that, after Christmas, the Minister might look at option C. I just do not think she gets how serious this is. I could be wrong.

I will go into some of the history, as my colleague did before me. Nearly 16 years ago, Fianna Fáil shut down three emergency departments in the area, those in Ennis and Nenagh and the one at St. John's Hospital. That Government promised we would get a centre of excellence. Between them, Fine Gael and Fianna Fáil have been in power, on and off, for the past 15 years and nothing has happened. We are getting 96-bed blocks and 16 beds here and there, but it is not good enough. The next 96-bed block is not going to be built until 2029. That is another three years. How many more lives do we have to lose in the mid-west before something is done to move this on a little bit more quickly?

Jennifer Carroll MacNeill (Dún Laoghaire, Fine Gael)
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That is not the case.

Joanne Collins (Sinn Fein)
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The plan we have been given says it will be 2029. The winter plan that comes out every year is great but it is a piece of paper and nothing ever seems to change. The hospital is still overrun with patients. It is constantly at capacity. It is great idea on paper to try to bring in GPs but we do not have GPs to put in there in the first place. People cannot get appointments with their GPs.

Trolley numbers went down a little but they are jumping back up. Yesterday, they were at 75. Today, they are at 93. That is not good enough considering 96 beds just opened up. There was a study done that suggested that you will get one death for every 67 people who wait on trolleys in emergency departments for longer than eight hours. It is not good enough that the number has already gone back up to 93. Where is that going to leave us?

I really welcome the HIQA report but it was done as the result of pressure from the families of those who died and for no other reason. It was not the result of political will. I have a little show and tell. Sinn Féin wrote a plan two years ago. It mirrors the HIQA report. Is there something wrong with the Sinn Féin plan that meant nobody wanted to look at it to see what we actually need? That is two more years of waiting and of constant reports and plans but nothing is changing.I am sorry if I sound really cross today but I am cross because I have elderly parents who refuse to go to UHL. One of my parents refused to get into an ambulance because he would have had to go to UHL. He made me put him in the car and take him to Galway. There is crippling fear in the mid-west and it is time now to do A, B and C. We cannot wait any longer.

Jennifer Carroll MacNeill (Dún Laoghaire, Fine Gael)
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The whole purpose of this is a patient safety issue. I have to correct a few things. Let me go through the patient safety issues. The whole approach is to try to make Limerick have enough capacity to have the same flow as other well-run hospitals like Waterford. Limerick is now an extremely well-run hospital. In the last 12 months, Ian Carter, Catherine Peters and Sandra Broderick have brought in really meaningful changes. All of the teams working there, all the consultants and all of the nurses deserve credit. The hospital is a different place in terms of how it is run and it is having a major impact on patient safety.

What do we do? We do a range of different things all the time and not just at Limerick. We are trying to decant as much as possible from the acute hospital so that people who are acutely unwell can get the best care there. So, we are doing a couple of different things. We are moving as many outpatient appointments as we can to primary care facilities. I met one of the ENT consultants, Joe Hughes, who is now running his clinics in the primary care centre in Newcastle West. That is exactly the sort of commitment to Sláintecare that we are seeing from consultants there. He does not need to do his surgery in the hospital, requiring people to incur parking costs and other different challenges. He can do that in Newcastle West. That is one of the many things we are asking people to do differently that is happening in the mid-west.

We do have an elective flex, not just in Limerick but in every hospital in every season not just in the winter season. We do that to account for a couple of different things. There is always a Christmas-winter flex and then we have to intersect when the flu season will hit; it changes every year. This year the flu season is likely to hit really hard in the two weeks over Christmas; normally it is a little bit later. We need to adjust and adapt to that. For anyone who has not yet got their flu vaccine, I encourage them to please do that. Even if they are not going to get the flu, even if they are not at risk, they can stop its transmission. From the experience of the southern hemisphere, we know that this will be a hard flu and an early flu. I am asking people to get the flu vaccine because that is the single biggest thing people can do to contribute to their loved ones' well-being and help the healthcare staff in Limerick. There are opportunities there.

We always flex. There has been a change in October and November this year. They do it all the time, but there is no change to the electives in St. John's. The electives are still continuing at St. John's and that is the model we have in Limerick to enable continuing elective procedures. We are also opening a surgical hub there to do elective procedures and take away the pressure, again to take away a thing that should not be happening in acute hospitals but can happen elsewhere.

Why do we do it? Why do we have an elective flex? I hope there is not a single person in this room who would think it is acceptable to bring in an elective surgery into an overcrowded hospital thereby creating danger to the people already there and to the person who is coming in potentially for very sensitive surgery. We need to try to do it somewhere else or at a different time. We should not bring people into an already overcrowded hospital. Our first priority has to be patient safety and the well-being of the hospital.

That is why it is so important that all the reforms I have been trying to push through since January in terms of weekend work, weekend rostering and weekend discharging are to make sure that we have a safe patient flow and that we do not have people backed up on trolleys on Mondays and Tuesdays. That is not just in Limerick but in every part of the country. All those reforms need to sit together to have a hospital that has a good flow all the time. Is it possible? Yes. The hospital in Waterford has had no people on trolleys in the last five years and it does not cancel elective surgeries. Why? It is because it has its patient flow absolutely tip top. When I look at the trolley numbers every day, Limerick is the only place that I will give a pass to in terms of being in the red because I know it has an acute bed capacity issue. It is not down to its processes. It is an acute bed capacity issue.

It is absolutely clear that Limerick is persistently better on trolley numbers, whether it is counted on the INMO figures or the HSE figures. I might get this slightly wrong but they are two very different things. The INMO figures count the people who are in the emergency room generally. The HSE figures count the people on trolleys. They are slightly different ways of counting. More people are self-referring to the hospital in Limerick than in any other region and so those numbers will always be much higher. However, we need to look at the trend regardless of which one we count by. The trend is persistently lower. I have to end this idea that Limerick is the worst hospital in terms of its emergency department.

Throughout November - I will happily call it out - Galway, St. Vincent's at the edge of my constituency in Dublin, and Cork have been persistently worse in their hospital trolley figures than Limerick and they do not have the same bed issues that Limerick has. For the benefit of Senators from the region I will outline the figures. Yesterday, Wednesday, at 8 a.m. there were 28 people on trolleys in Limerick on the HSE figure. There were 42 in Galway. On Tuesday, there were 27 in Limerick, 50 in Galway and 35 in St. Vincent's. It is persistently worse in other hospitals. We have to get away from the idea that Limerick is the most dangerous place and the most under pressure; it is not actually. This is as a consequence of two things. First is the greatly improved processes and second is the new bed block. We need more beds, there is no question about that. However, the other hospitals have more to do and they do not have the same presentation pressures, demographic pressures or capacity pressures. It is important to put that in context. In particular, I compliment the management there on the extraordinary work they do.

Am I committed to it? Every morning at 11 o'clock, there is a trolley call with the CEO and other senior management of the HSE, the regional executive officers and hospital managers - it depends on who is there. Owing to Cabinet meetings and everything else, just twice this week I joined the call in the background and listened to the specific nuances going on in each hospital. I do that because I recognise that there are some hospitals like St. Vincent's and Cork which have had an up-and-down experience over the last month where they are just not landing it and just not getting it right persistently. Some other hospitals might be under a flu pressure or an RSV pressure for a day or two and then recover. They are all slightly different issues. It helps me track the delayed transfers of care. It helps me track what is happening in the community and the beds the patients are going to.

One of the really important investments we are making is the additional investment in Ennis and Nenagh. We have 81 beds in Ennis and our plan is to put in another 48, a 50% capacity increase. We have 62 in Nenagh and an additional 27 coming. I think St. John's has 95 with an additional 42 coming. It is as much about the service delivery in those different hospitals to try to do everything we can to avoid the need for people to come to UHL unless they are seriously unwell or have been in a trauma situation. However, for routine treatment, for outpatient appointments, for elective processes, we do not want them to be in Limerick in the same way that we do not want them to be in other acute hospitals. We are across this.

We have an urgent bed capacity issue. I ask for all Senators' support that when we put in planning applications they do their best to make sure we minimise objections to those applications so that we can get the best out of the site that we can, that we push as hard as we can on that site, that we deliver an option B as close as possible to that and that we look intelligently with all of the best information we have about how to approach the option C construct and how we do that with optimal site location, optimal clinical location and optimal hospital size, recognising that we are learning more and more about better hospital efficiency over time from our international experience and from our own learning here.

There is a real commitment to the people of the mid-west from the hospital management, from the people who are working there, from everybody here and from me. I am invested in this on a day-to-day basis. Over the weekend, I get a text at 8 a.m., 2 p.m. and 8 p.m. every single day of my weekend every single weekend so that I can track exactly where every hospital is and so I can see if a hospital is going into difficulty. Am I committed? I promise Senators that I am. I know exactly what is going on to the best that I can in the 29 hospitals at any given time.

Last weekend, at one point I think there were 57 people on trolleys in 29 hospitals and that increased over Sunday night into Monday and Monday night into Tuesday. So, I really do know. Limerick is doing really comparatively well. It might not feel like that for people who are in Limerick today. It has the seventh longest wait times of all the hospitals but not the longest wait time. It does not have the worst hospital trolley presentations and that is because of the work of the people in Limerick and because of the 96 beds. My priority is to deliver more beds as quickly as possible and to put in all the supporting architecture to make sure we can bring people out of Limerick. We are genuinely committed to this.

We will prioritise A and B coming up to Christmas and we will all look together at the opportunities for option C in the new year. The Senator is right that I did not say those things at the meeting yesterday; I was not correctly quoted. We will look at option C intelligently and in a paced way in the new year when we have done what HIQA has asked us to do for the people of the mid-west, our commitment being in respect of option A and B and putting real teeth to that.

Alison Comyn (Fianna Fail)
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Before I conclude business today, I welcome the guests of Deputy Brian Brennan to the Seanad. They are just catching the very tail end of a very busy morning's work. I hope they enjoy their stay here.