Opening statement to Joint Committee on Health by Prof Colette Cowan Chief Executive Officer UL Hospitals Group

September 21 2022

Introduction

Good morning Chairman and members. Thank you for the invitation to meet with the Joint Committee. I am joined by my colleague(s):

Ms Mary Day, National Director, Acute Operations

Dr Mike O Connor, National Clinical Advisor, Acute Operations

Prof Brian Lenehan, Chief Clinical Director, UL Hospital Group

Ms Maria Bridgeman, Chief Officer, Midwest Community Healthcare

I am sorry we were unable to attend this hearing in July as Prof Lenehan and I were on sick leave. We thank you for your understanding as we both felt it was important that we should make ourselves personally available to the committee.

At the outset, I wish to acknowledge the main findings of the HIQA report. I apologise for the distress and the lack of dignity and privacy experienced by far too many patients seeking to access care in UHL over several years and in particular over the last 18 months when we have seen further growth in demand for healthcare following the Covid-19 pandemic.

This is not the kind of care environment we wish to provide for the people of the MidWest. It is not for want of effort on the part of the management team or commitment on the part of our staff.

This is not the kind of report any hospital manager wishes to read but we must respond to it. And we are responding to it.

A detailed compliance plan developed in the wake of the HIQA Report includes actions to be taken in the short, medium and long term. The success of this plan hinges on the efforts of all stakeholders, locally and nationally, inside and outside of the hospital system.

We are working with the HSE National Support Team and with Mid West Community Healthcare to do just that, building on existing work and finding new ways to meet growing demand.

We are improving internal processes and we are implementing new hospital avoidance initiatives. The solutions also require closer integration with community services as set out in Sláintecare; and, more fundamentally, resourcing the heath service in the MidWest in line with the size and the health needs of the population it serves.

Note on reconfiguration:

We can discuss the way forward in greater detail with you this morning but it is important we acknowledge the recent past and the local and national factors behind the extraordinary growth in demand on UHL.

The MidWest was an early mover on the reconfiguration of acute hospital services from 2009 on. The Teamwork Report on which that reorganisation was based recommended that UHL should have 642 inpatient beds to manage the additional acute and emergency medical and surgical patients arising from the changes in Ennis, Nenagh and St John’s Hospitals. This did not happen, chiefly because of the global financial crisis and the collapse of our public finances.

Today, our inpatient bed capacity is 530, far short of the recommendation and making no allowance for the increase in and rapid ageing of our population in the intervening 13 years.

It is important that I acknowledge the support we have received in developing services, expanding our workforce and strengthening diagnostic capacity, for example through the addition of a second MRI scanner.

I want to acknowledge in particular the support of government and of the HSE in increasing our bed capacity in UHL by 98 since the start of the pandemic. We are moving ahead with our next 96 bed block but we remain far short of where we need to be. We are still playing catch-up. Until our under-capacity is addressed, we will not eliminate hospital overcrowding in Limerick.

Demand Since Start of Pandemic

There has been extraordinary demand on our health services over the course of the pandemic and an extraordinary response to same.

In 2021, the ED at UHL saw a record 76,473 attendances. In the first eight months of this year, we have seen a further increase of ED attendances of 7% and ED admissions of 25%. The number of over 75s attending our ED has risen by an even greater proportion. Hospitals around the country are seeing an increase in demand for unscheduled care but the numbers for UHL are exceptional.

Between 2019 and 2021, we have seen an increase of 20% of inpatient admissions at UHL and an increase of 15% in bed nights.

In 2021 we recruited over 1,200 staff across UL Hospitals Group, increasing headcount by 12%. And we have hired over 900 additional staff to date this year.

Since the start of the pandemic, we have opened 98 new single room inpatient beds and 10 new critical care beds. We have opened new theatres and a new 24-bed block at Croom Orthopaedic Hospital. We have run three Covid-19 mass vaccination centres and the country’s only operating field hospital during the course of the pandemic – the Intermediate Care Facility at UL Arena.

Resources:

We hope the publication of the HIQA report will be the catalyst to address the fundamental mismatch between demand and resources that is particular to the MidWest. We have communicated this in parliamentary replies to committee members over the years and this mismatch is underlined in the findings of an external review on UHL I commissioned Deloitte to undertake prior to the recent ministerial intervention and which we will shortly publish.

Nothing in this review alters the arithmetic and we estimate that we are currently short of inpatient beds to meet demand.

Next month, construction of a much anticipated 96 bed block will commence in UHL and this will go some way towards alleviating existing bed pressures. This will include 48 new beds and 48 replacement beds. Based on HSE guidance on hospital occupancy of between 80-85%, and AMIRC recommendations on multi-occupancy rooms, UHL will continue to have a shortfall of 87 beds. This does not take into account current unmet demand or projected future healthcare needs up to 2036. Based on our benchmarking with comparable hospitals, we have a shortage in NCHDs with at least an additional 68 required.

Reform:

We recognise that with any increase in resources must come a capacity to adapt and reform. Our region has not been found wanting in this regard.

The decision to reconfigure how care was delivered in our hospitals was difficult for our community and for our staff but it was taken in line with national policy and in response to another HIQA report which raised questions of patient safety.

Today, our model 2 hospitals at Ennis, Nenagh and St John’s are seeing significant increases in activity at their Injury Units and at their Medical Assessment Units. There has been an increase of 63% in attendances at Ennis MAU since 2019 and a 47% increase in St John’s MAU. These alternatives to ED provide safe and efficient services that are highly valued by our community and by our GP colleagues.

We are also working closely with colleagues in the community to provide alternatives to ED.

Integrated Care Programme for Older Persons (ICPOP) is a Community-based specialist service that provides rapid access to a multidisciplinary-delivered comprehensive geriatric assessment (CGA) for older adults living with frailty or at risk of developing frailty. To date this year, ICPOP teams in Clare, Limerick and North Tipperary have received over 600 referrals. There is currently no waiting list for this service, and service users are typically seen within seven days of a referral.

Almost 10,000 radiology tests completed up to the end of August 2022 under the direct GP access Community Diagnostics Programme. Community Intervention Teams (CIT) based in Clare, Limerick and North Tipperary focus on hospital avoidance and early supported discharge to the person’s home. Across Clare, Limerick and North Tipperary, these teams are currently supporting an average of approximately 760 people each month.

Working with the HSE Support Team, we have refocused on internal processes and on closer integration with the community in recent weeks, resulting in a reduction in the number of admitted patients waiting for a bed and the removal of patients on trolleys on our wards.

This has been achieved through the appointment of additional staff, including a head of operational services for UHL and 10 patient flow co-ordinators, of whom six are in post. In preparation for a challenging winter, we are working with the support team to put in additional medical and allied health professionals in the coming weeks, focused on our ED and on an Older Persons Assessment Centre.

Quality and Patient Safety:

All of these initiatives reduce demand on acute services and mitigate the risks cited in the HIQA report and which we ourselves have identified and escalated.

Because the HIQA Report has caused such concern in our region, I would like to address patient safety and outcomes more generally.

The annual audits of hospital mortality published by the National Office of Clinical Audit demonstrate that University Hospital Limerick continues to provide safe, quality services for its patients. Similarly, national audits on stroke, heart attack and so on confirm that outcomes for patients in UHL are in line with hospitals around the country and are on a par with if not better than other OECD countries. These audits are published and available for all to read.

These outcomes show that for all the challenges we face in UHL, we provide safe specialist care and that our staff are deeply committed to their patients and to quality improvement.

I again apologise to each and every patient who has experienced excessive wait times or a poor care environment in UHL. We will do all in our power address the shortcomings identified in the HIQA Report and we welcome the support of the national team and the wider recognition that significant resources are required to meet the exceptional health demands in the MidWest.

This concludes my Opening Statement.

Thank you.