Martin Daly on Model 2 hospitals, Limerick capacity and reform

Thanks very much, Angela, and your team for coming in, and for the report as well. I suppose it could make the reflection that people in the Midwest would quite rightly question the views of experts when they were ridiculed in 2008 when they opposed the downgrading of Nina and Dennis hospitals and were told that they were going to get a centre of excellence in Limerick, and that didn't happen. And, I mean, it has caused a huge loss of confidence, I would say, not just in the Midwest, but in other areas when we're planning our health services, because at the time the experts and considerable political capital was spent on making those changes and convincing people that they were wrong and that the experts were right. And it pains me to say that, and that's why this report is so welcome, because it's based on data and proper projections from the SRI's report as well, and so I welcome that. Following on from the Coherlux question around, you were making some comments around the Model 2 hospitals, because I think that has been one of the really untold stories of reconfiguration, because with a growing older population, a lot of our admissions, and this is my question, has there been any question around the type of admissions that are going to Limerick? So, for example, we know that a lot of the people who are being admitted, a lot of patients who are being admitted now are older patients with complex chronic illness, and many of their cases can be dealt with adequately in a Model 2 hospital. Is there capacity in the short term to develop further Model 2 capacity in there, pending the outcome of what's going to happen here? I might take that question, Deputy. So, you're quite right. We need to look at the way that services are configured in the round, and in the context of the Model 2 hospitals, as our CEO has said, that they are working very well, very efficiently, and they actually provide a good template for other Model 2 hospitals within the region. In our evaluation of the data around where patients present, we can see that, as Angela has outlined, the model of distribution of where a patient present differs within the region because the configuration differs. And if you look at the kind of triage score of patients who present to Limerick, it's actually much lower, meaning that the level of acuity of patients who actually present to Limerick is higher than it would be in a lot of the other emergency departments around the country. And what that means, essentially, is that Model 2s are carrying a lot of the heavy weight that's required around patients who do not need to go to an emergency department and can be very safely and effectively managed in the local injury units, the medical assessment units, and so on. Recently, we've seen a significant additional investment within the region in the medical assessment units. As part of our assessment approach, we would have visited those units, and we can see that they're providing a really vital service, particularly for those kind of older patients that you mentioned. You've got a myriad of conditions that need to be managed in an appropriate setting. And so really, I think the model, it does work insofar as the way that it is configured, but what doesn't work is the fact that the capacity within Limerick isn't enough to deal with those patients who rightly present to that. So would it be right, then, to say that the real weakness is that there isn't a Model 3 hospital in the region? Because in any other region, you'll have Model 3 hospitals as the intermediate piece between a Model 4 and a Model 2 hospital. Is that where the weakness lies? And, I mean, I take the recommendation that to produce a Model 3 hospital is going to take time, and that's something that I think the government and we as a whole here need to address, is the delivery of critical infrastructure, not just housing, not just wastewater treatment, but critical infrastructure like health care. There's such a long lead in time, but that's for another day. But the AB model seems to be the model that will deliver capacity more quickly. I think the other thing, Deputy, is that in the current plan by government, there are 114 additional beds planned for the Model 2s, and we've recommended in the advice that we should look very closely at the best use of those beds. We have seen that step-down beds can support earlier discharge, and I think Limerick of necessity was one of the early adopters of people having, and we can see that, they have the shortest length of stay, they move people on. We see that if you look at other countries, that's what they do. So that was of necessity there, but I think it's a good model. I think the other thing is that government has supported elective hubs, and we know that Nina has very good minor injury capacity, and again, minor surgical capacity. That also should be leveraged. So I think in terms of looking at option A, it is also looking at what is the potential to further develop what is a good model, because actually, if you look at the UK and other countries, they leverage smaller hospitals in the way that we don't maybe do as well. So I think it would be a mistake to lose that. I also think that, I know it's early days, and it's 96 beds, but the early signs are very good in terms of the impact of that investment to date. And one point that was made earlier on by one of the deputies, and I think was picked up by Sean, is the other critical ingredient here is capability, management capability. And I think it is important to recognise that in recent years, the capability and capacity, the capacity of the region has been leveraged by strong internal processes. Sean's reviews show that Limerick is using what it has very well. It's also adopting new interventions in line with best practice. So I think it is, the ingredients are about having the right capacity in the right place, about leveraging model twos. It's about leveraging egress capacity, such as delayed, just for delay discharges. And then it's about using what you have very effectively. So all of those things are critical. I think going back to giving acknowledgement to staff over the last number of years, I think the review shows that the staff in Limerick have been doing the best with what they can. And it's about trying to protect that going forward as well. That's a really important statement by yourself, because, you know, if you were to read media and to read reports, there was a lot of blame being laid at the feet of staff two, three, four years ago. And they were doing their jobs in an almost impossible situation. And I would say they were being set up to fail. There was no possible way that there couldn't have been adverse outcomes. In a system that was under so much pressure. I think the power of evidence, I think you made the point yourself. I think an objective assessment, such as Sean's team do through regulation and Maureen's evidence, and also what's coming through from the ESRI, allows us to look at whether, you know, whether the capacity is adequate or not. And I think that's an important lesson learned in terms of how we go forward. And I suppose this is more philosophical. I mean, we need level four capacity. Of course we need that. But we also need to avoid just a narrow drive towards specialisation with an ageing population. We need more generalists in the system. One of the problems we have as a GP is to find a general medical opinion. And the only place we can get those general medical opinions are in places like Wisconsin University Hospital, Clare and the Ennis Hospitals. We're not even getting them in level three hospitals anymore, medical personnel. And this is not what they're deciding. They're a specialist, not just in one area of endocrinology. But I'm only doing diabetes. I don't do anything else in endocrinology. We really do need to have to protect ourselves against this drive for this complete specialisation because what we need is more generalists in the system. Yeah, I think with chronic disease management and older persons, I think you're absolutely right. I think the ICPOP model that's in an early stage development is designed to put that clinical lens around people in the community. But I do agree that, I mean, Roscommon is a very good example. I think the Louds in the Louds Mead group, as it was, has also tried to leverage that. And people in the areas then have a sense of connection with that service in terms of meeting a lot of their needs. Especially older people. Thanks very much, Mr. George.