At the end of last year, a national strategy for genetic and genomic medicine was finally launched. David Lynch examines the potential that the strategy offers to improve clinical care and research, as well as the likely challenges in implementation

“When I just think back at my time as a junior doctor, there are things done now that nobody would have believed back then,” according to Dr Colm Henry, HSE Chief Clinical Officer (CCO).

Dr Henry believes that genetic and genomic medicine has “revolutionised treatment”.

“When I was a junior doctor, I wouldn’t have dreamed about the way personalised medicine can be delivered now,” the HSE CCO told the Medical Independent (MI). “For example, cancer treatments were delivered in a very ‘one-size-fits-all’ manner. There were many conditions we thought were sporadic and random – we now know them to have a genetic foundation. It has revolutionised treatment.”

However, until now, much of this revolution has not been experienced in Ireland.

The new National Strategy for Accelerating Genetic and Genomic Medicine in Ireland, published in December 2022, aims to change this situation (see panel).

According to the HSE’s website, there is “room for improvement” in the medical genetics and genomics services offered in Ireland when compared to other European countries.

The strategy states: “To date, Ireland has made some progress in developing its genetic and genomic services, with pockets of excellence evident throughout the country. However, to fully realise the benefits of genetics and genomics, there is an urgent need to mainstream them so that they can become an integral part of our routine care delivery.”

Dr Henry said: “We wanted to make sure this country was better placed, not just in addressing existing structural and manpower problems, but [to] have a clear sense of direction of where we are going.”

In terms of recruitment in genetics, he added that Ireland wants to be a “place where we can attract the brightest and the best to work here”.

The Review of the Clinical Genetics Medical Workforce in Ireland 2019, produced by HSE National Doctors Training and Planning, found that only four clinical genetics specialists worked in the health service nationally at the time. Of these specialists, three were over the age of 55. This was against a backdrop of demand for at least 15 consultants. Irish patients were without access to genetic counselling and faced waiting times of between 15 and 18 months for priority cases and over two years for routine referrals.

In August last year, MI reported that the absence of a genomics strategy and multi-annual budget led to a “world-leading expert in genomics” declining the role of director of the planned national genetics and genomics medicine network.

However, Dr Henry is confident the new plans for the creation of a national office of genetics and a specific workforce plan will have a galvanising impact.

“We had difficulties recruiting before, it’s absolutely true,” he said, referring to MI’s August 2022 story.

“The reason is that we didn’t have a strategy for that person to implement and now, of course, not only do we have a strategy, we have €2.7 million from the Department of Health to kickstart some of this, including establishing the national office.”

He said the new positions in the national office will include a national director and clinical lead, a laboratory director, a bioinformatics director and support staff. “We need these staff to singularly focus on the priorities of year one, such as producing a workforce plan and also to look at current training, not just in genetics, but in other medical disciplines.”

“Strategies are very helpful in healthcare because a strategy gives you a sense of direction,” said Dr Henry. “We have a trauma strategy as you know, we have a cancer strategy, all of which have really improved the care in their particular domains…. We found that in the absence of a strategy, while we had areas of brilliance [in genetics], pockets of expertise, it was not tied together in a cohesive way. Also, in the absence of a strategy, you cannot guide multi-annual investment and address the areas of weakness in a very structured way.”

Recruitment

Dr Henry said six genetic counsellors and two consultant geneticists would be recruited prior to the creation of a new workforce plan. Beyond this, he has high hopes the strategy’s very existence will prove to be an attraction to doctors living abroad, while also impacting the training decisions of medical graduates.

“First thing is, we already have some excellent people… lots of clinicians working here would have brought their expertise back from training abroad,” Dr Henry said.

“But what I have found is when there are national strategies, such as cancer, it tends to attract staff. It tends to attract people home, it gives an incentive to people to study a particular area.

“If you are a medical graduate, for example, considering a career in the core discipline of medical genetics, or developing a specialist interest as part of another specialty, we find that [the existence of a strategy] tends to have a positive contagion effect on the healthcare system. It tends to have a snowball effect in interest in training and also attracting people home.”

On the impact of the national office, Dr Henry predicted there will be a high level of activity “in year one, and the office will drive it”. He said it will “become the engine of what happens in year two, three, four, and later”.

Also, the office will “advocate” and “compete for funding each year”.

Potential

MI has attended two major conferences on genetic and genomic medicine in recent years. At both events clinicians raised the lack of a national plan as a serious hurdle for progress. Now the strategy is published, how significant will it really prove?

“I think this is vitally important,” Prof Orla Hardiman, Clinical Lead, HSE National Clinical Programme for Neurology, and Consultant Neurologist at the National Neuroscience Centre of Ireland, Beaumont Hospital, Dublin, told MI.

Prof Hardiman described the new strategy as a “consensus document” generated “by all relevant stakeholders”. She added that it was a ‘roadmap’ that covers the perspectives of all involved, and such buy-in “will enable early implementation”.

“It is also very important that there is a very strong user perspective, which is essential,” she said, stating the “patient voice” was particularly important.

“The strategy also recognises the necessary interplay between clinical and research work in genomics, as the two are intimately linked.”

Prof Hardiman said the “next steps will now be very important”. 

“As our understanding of disease evolves, it is very clear that genomics will inform much of our decision-making.”

She noted that in the past, the concept of genomics was confined to conditions for which there is a defined chromosomal abnormality or conditions with a clear inherited component that can be mapped across families. However, currently “genomics have the potential to inform decision-making across a wide range of disciplines”, she said. 

“This is very much the case now in oncology, but it is also in evolution in all specialties as a precision medicine approach helps us to target individual pathogenic pathways, many of which are modified by genomic variation. And we also have early genomic therapies that are likely to expand over the coming years.”

Concerns

Prof Hardiman also highlighted potential challenges with implementation.

“The next step will be [to] ensure that there is adequate funding to implement a state-of-the-art programme,” said Prof Hardiman. 

“I am concerned that the budget allocated for this may not be sufficient. A joint professorship in genomics [between University College Dublin and Trinity College Dublin] has been advertised to move the field forward, but the programme will require a very significant investment in infrastructure and personnel.”

She added that consideration would need to be given to whether the programme will be centralised, or whether each of the major teaching hospitals will be encouraged to develop a genomics department, with an appropriately funded cohort of clinical and laboratory personnel.

“As a neurologist with a specialty interest in the genomics of neurodegenerative diseases, my strong preference would be to have genetic counsellors linked to the service that I and my colleagues provide, rather than a centralised service with genetic counsellors that cater for the entire range of genetic disorders. However, this remains to be fully discussed.”

Prof Hardiman said discussion would also need to take place on the funding and access to a new genome biobank “and whether this should be funded out of the public purse, or in collaboration with private entities”.  

“The latter consideration has been subject to much discussion over the years and from my understanding has not been fully resolved.”

Ethics

In May 2021, an online Royal Irish Academy conference focused on the lack of a national genomics policy and bioethical issues. Dr Oliver Feeney (PhD) is an Associate Researcher with the Centre of Bioethical Research and Analysis, Discipline of Philosophy, University of Galway, and was organiser of that event.

“Given the developments in genomic technology since the turn of the century, from whole genome sequencing to CRISPR gene editing, such a strategy is long overdue,” Dr Feeney told MI. Noting concerns over the “unregulated environment”, he said the strategy should not be considered a “finished product”, but something that has to continue to develop further in the coming years.

Dr Feeney said he believed “national coordination” would be pivotal for the strategy to prove successful. He said the strategy “emphasises public and patient involvement and genetic literacy to a great degree”.

“It also highlights the importance of ethical safeguards, particularly in terms of consent and data protection. These are all positive steps. But this is just the beginning of the ethical discussions that need to be much more developed and elaborated in the forthcoming months.”

Dr Feeney said “the strategy touches upon some ethical issues, and gestures towards the importance of ethics in general, but little more”.

“A number of issues face genomics as opposed to earlier forms of genetic research and other non-genomic forms of research,” he added. “For one thing, the reality or rhetoric of genuine informed consent with the individual keeping control over their data may be increasingly strained in a context where research is large-scale, international, and where secondary use of such data may elude such control.”

He pointed out “transparency is needed” regarding promises in the strategy to be able to refuse consent in the future and the right to withdraw your data from research.

The strategy notes that guidance on consent for genetic and genomic clinical and research purposes will be developed in line with the HSE national consent policy and the national consent for research policy, which is currently in development.

“The clinical application of whole-genome sequencing can also potentially identify variants in genes for unknown functions or where uncertainty exists over the relation to disease,” he said. “Such incidental findings, which are unrelated to the goals of the test or study, and are discovered unintentionally, raise questions on what to do with such discoveries in a clinical context.”

Dr Feeney added that other ethical questions arise including those “regarding the risk of genetic discrimination and stigmatisation”; how it will affect persons with disabilities that may have a genetic component; and how this information may contribute to increased abilities in predictive decision-making in the context of assisted reproduction.

“These are only the tip of the ethical or bioethical issues involved. Minister for Health Stephen Donnelly, in his foreword to the strategy, said that it ‘lays out a wider vision for Ireland’s future genetic and genomic service’. Insofar as it does, this vision needs a stronger bioethical lens than currently is the case.”

He noted that there has been “some movement” in terms of national ethics or bioethics infrastructure (“For instance, the national office for research ethics committees has national coordination at its core”). However, Dr Feeney argued that “in terms of broader bioethical questions, we are still in a largely ad hoc situation”.

As our understanding of disease evolves,
it is very clear
that genomics will inform much of
our decision-making

Literacy

Improving genetic literacy is a major aim of the strategy, Dr Henry told MI, not only among the general public, “but also among healthcare workers.”

For doctors, the aim is to raise “awareness of genomic medicine for all medicine disciplines, not just those training to
be geneticists”.

“I don’t want to be critical, there is a high level of awareness among medical graduates who have a very high education from our medical schools, about the power of this,” said Dr Henry. “But we want to make sure that we avoid what somebody called the ‘ghettoisation of genetics’ into a core specialty. There needs to be a heightened sense of awareness of its power and its role and application across all disciplines, not just the core discipline of genetics.”

Is there sufficient information technology (IT) infrastructure underpinning the health service to carry this strategy?

“Yes, of course, that is absolutely huge, no doubt about it,” Dr Henry replied. He said that while IT is not something the strategy is focused on over the first year, “once we get to a higher level” it will be crucial.

“The creation of an individual health identifier will produce more efficient and safer care not just for genetics, but right across our health system. It has to a priority when you consider not just the safety issue, the information issue, but also the waste issue that goes along with not having a single identifier for patients that can be used at all points of presentation in the healthcare system.”

The HSE has changed the reporting line of the Confidential Recipient despite the former post holder warning the board that this would damage the role’s “independence”.

Up to late 2022, the Confidential Recipient had a direct reporting line to the HSE CEO. However, the post now reports to the National Clinical Director of Quality and Patient Safety. According to the HSE, the Confidential Recipient acts as an “independent” advocate for adults with a disability and older persons receiving services in residential care, day services or any community service from the HSE and HSE-funded organisations. The role was created in 2014 after the Áras Attracta scandal.

“In the period 2014 to 2022 the Confidential Recipient reported to the CEO of the HSE,” an Executive spokesperson told the Medical Independent (MI). With the appointment of a new Confidential Recipient in late 2022, “it was decided
that this reporting relationship would change in line with service synergies.”

The spokesperson said the “confidentiality and independence” of the role is “respected and maintained”.  The Confidential Recipient will have access to the HSE’s safety and quality committee meetings “on an as needed basis and at a minimum once a year”. They will also “still have access” to the CEO “if and when the need arises”.

In September 2022 the then Confidential Recipient, Ms Leigh Gath, attended a HSE board meeting prior to stepping down from the role. According to minutes, a discussion took place on the “recommendation by the current CR [Confidential Recipient] to the board for their consideration in relation to the relocation of the reporting line of the CR from directly to the CEO to the National Clinical Director of Patient Safety be reconsidered to maintain independence of the role”.

“The board agreed and it was noted that the CR will continue to have access to the safety and quality committee.”

The HSE informed MI that the board had agreed with the change in reporting line.

Commenting last year on the independence of the role, Ms Gath told MI the then CEO Mr Paul Reid was the only person in the HSE to whom she was answerable, and Mr Reid “never” interfered with her work.

In November, the HSE announced the appointment of Ms Gráinne Cunningham-O’Brien as the new Confidential Recipient.

The Royal College of Surgeons in Ireland (RCSI) has proposed a new networked approach for emergency surgery.

The Surgery for Ireland report, which will be launched at the College’s annual Charter Day meeting, sets out a series of recommendations including that new emergency surgery networks should include injury units, emergency surgery units and emergency surgical centres, with each network supported by access to an elective hospital.

The RCSI report proposes that acute surgical assessment units should be available in every hospital receiving surgical emergencies to streamline surgical assessment and treatment and to allow a reduction in the number of hospitals providing out-of-hours emergency general surgery.

 “Access to high quality emergency surgical care is lifesaving and must be available to everyone,” said RCSI Vice-President Professor Deborah McNamara.

“Emergency surgery is safest when performed during normal working hours by fully- trained staff and where sufficient volumes of surgery are performed to maintain the expertise of the multidisciplinary emergency surgery team. A networked system of emergency surgical care enables most emergency surgical care to be delivered as near as possible to the patient’s home while ensuring equitable access to complex care when required,” added Professor McNamara.

The new RCSI report also recommends that geographically-based surgery networks are developed with agreed pathways to allow “safe and efficient escalation of care” in situations where a patient’s needs exceed the services available locally and to support repatriation when patients needs can be met closer to home.

The HSE has launched a new set of clinical practice guidelines in obstetrics and gynaecology.

The areas covered by the 12 guidelines include post-menopausal bleeding, stillbirth, vaginal birth after caesarean section, and post-partum haemorrhage.

“Clinical guidelines are an important resource for doctors, midwives and allied health professionals who are committed to delivering safe and respectful quality care,” said Dr Cliona Murphy, Clinical Director at the National Women and Infants Health Programme.  

“The National Women and Infants Health Programme is committed to improvements in women’s and infants health, and with the support of the Women’s Health Task Force, has developed initiatives in ambulatory gynaecology, endometriosis and menopause – all of which will be strengthened by national guidance.”

Prof Keelin O’Donoghue, Clinical Lead for the National Clinical Practice Guidelines, said the “Clinical practice guidelines assist healthcare practitioners, service users, policymakers and other stakeholders to make informed decisions about health practice, public health and health policy.”

“Clinicians also need up-to-date and reliable resources to keep up their knowledge, and guidelines are important to address this need,” added Prof O’Donoghue.

The first suite of guidelines will be followed with over 30 updated clinical practice guidelines during 2023 and 2024.

The updated guidelines can be found at www.hse.ie/eng/about/who/acute-hospitals-division/woman-infants/clinical-guidelines/national-clinical-guidelines.html

The Medical Council has today launched a public consultation on new draft maintenance of professional competence rules and accompanying guidelines.

Maintenance of professional competence is the formal way by which doctors record their continuing professional development throughout their medical career.

The current maintenance of professional competence framework model has been in operation since 2011. Over the last number of years, several processes pointed to the need to strengthen the framework to increase its “relevance and usefulness for doctors”, according to the Council.

The Medical Council has developed new draft rules which provide information on doctors’ and scheme operators’ obligations under a new “strengthened” framework. Alongside this, a set of draft guidelines were developed to further expand on the obligations contained in the draft rules and to act as an accompanying document.

The public consultation will enable the Medical Council to obtain a broad range of feedback from individuals and organisations which will inform the finalised versions of the documents.

Dr Suzanne Crowe, President of the Council said: “The Medical Council, as the regulatory body for doctors, has a statutory role in protecting the public by promoting the highest professional standards amongst doctors practising in Ireland. The path to lifelong learning starts for a doctor in medical school, and continues until they retire, all part of the continuum of medical education.”

“Engaging in lifelong learning helps improve the safety and quality of care provided for patients and the public. Ensuring doctors maintain their professional competence is an essential element in allowing the Medical Council to safeguard the public, by verifying the quality of the doctor’s competence through the new draft rules and guidelines.”

Ms Jantze Cotter, Director of Professional Competence, Research and Ethics in the Medical Council, said: “The new draft maintenance of professional competence requirements are not entirely different to what is already in place. However changes made to the maintenance of professional competence rules and associated guidelines will now bring these in line with best practice.”

“This consultation will be an important process to collect feedback provided by stakeholders, grounding the framework in experience and practice. Stakeholder input and collaboration is an important aspect in developing new draft maintenance of professional competence rules and guidelines, taking into consideration the impacts on the wider health ecosystem.”

The documents are available at  https://www.medicalcouncil.ie/public-information/public-consultations/ . This consultation closes on Thursday 16 February.

The Medical Council today announced the procedures for the election of the six directly elected members of the Council.

The body has a statutory role in protecting the public by promoting the highest professional standards amongst doctors practising in Ireland, and is made up of 25 members, with a majority of 13 non-medical members and 12 medical members. Members are appointed through a mixture of elections, nominations by several bodies and through the public appointments system.

In order to be eligible for nomination for election to the Medical Council, a medical professional must be on the register of medical practitioners and must be practising medicine in the State (but excluding any visiting EEA practitioner) on 15 February 2023, the day before nominations close. They must be nominated for election by 10 registered medical practitioners practising medicine in the State.

An independent Returning Officer has been appointed and in accordance with the provisions of section 17(1) and (8) of the Medical Practitioners Act 2007, will conduct the election process.

The six members appointed following the election process must fall under the following categories:

• One medical practitioner registered or able to be registered in the Specialist Division in relation to Obstetrics and Gynaecology
• One medical practitioner registered or able to be registered in the Specialist Division in relation to Anaesthesia
• One medical practitioner registered or able to be registered in the Specialist Division in relation to Public Health Medicine
• One medical practitioner registered or able to be registered in the Specialist Division in relation to Pathology or Radiology
• One registered medical practitioner, practising medicine in a hospital but not a consultant
• One registered medical practitioner who does not fall into the categories above

Candidates nominated should demonstrate relevant experience or skills in at least one of the following areas: corporate governance, risk management, strategy development, change management, regulation, and health sector knowledge. They should also show effective judgement, have effective communication skills, and be improvement focused.

The Medical Council is encouraging all interested and eligible doctors to consider running for election.

Mr Leo Kearns, Chief Executive of the Medical Council, said “The Medical Council is keen to promote equality, diversity and inclusion at board level, as ideally, a board should reflect the stakeholders its decisions impact. We would encourage all eligible doctors to consider putting themselves forward, and in particular those who have moved to Ireland and now work in the Irish healthcare system. The impact of the Council and its committees reflects the input from its members, and a diverse Council can only positively impact those we support.”

The closing date for receipt of nomination papers is Thursday 16 February 2023 at 1pm. The independent Returning Officer will attend at the offices of the Medical Council to receive nomination papers, which can be submitted via post or in person on 16 February 2023 between the hours of 10am – 1pm.

If there is more than one nominated candidate an electronic poll shall be taken. Voting opens from 12pm on 1 March 2023 and closes at 12pm on 21 March 2023.

The 25-member Council consists of 13 non-medical members and 12 medical members. Of these, six members are elected by registered medical practitioners, five are appointed by the Minister for Health, one is nominated by the Minister for Further and Higher Education, Research, Innovation and Science and the remaining 13 are nominated by a number of nominating bodies.

Since the last elections in 2018, the Council has introduced a ‘rolling term’, whereby some Council members sign up for either a three-year term or a term of up to five years. This ensures efficient functioning of Council by minimising loss of experience, skill and corporate knowledge associated with a change of all Council members every five years.

The newly appointed Council members will begin their term on 1 June 2023, and all those appointed following the election process will serve a term of up to five years.

Nomination papers and other information is available on the Medical Council website www.medicalcouncil.ie/elections

The College of Psychiatrists of Ireland has stated the new Mental Health Commission (MHC) interim report on child and adolescent mental health services (CAMHS) has failed to take adequate account “of poor governance structures and support systems”.

While welcoming and supporting the publication of the interim report, the College said it has also not sufficiently addressed “the significant doctor recruitment and retention crisis in our mental health services at present”.

The MHC interim report arising from an independent review of the provision of CAMHS in the State, found that children and young people accessing mental health services with open cases have been “lost” to follow-up care.

The interim report found that in one Community Healthcare Organisation (CHO) alone, there were 140 “lost” cases within the CAMHS team. These children and young adults “lost” within the system did not have an appointment, in some cases for up to two years.

According to the College’s statement in response to the report: “Despite the College calling for inspection of community mental health services, including CAMHS, this has not occurred as it has for approved centres.  Regrettably, had the necessary inspections and reviews taken place years before now, the distressing and upsetting situation for all those waiting for and in CAMHS, including serious shortfalls identified by the Maskey Report into South Kerry CAMHS, would have been uncovered and highlighted for action before now.”

 “The service provided by CAMHS is equivalent to hospital level, consultant-led and multi-disciplinary team care in the community for children and adolescents with moderate to severe mental illnesses. Consultant CAMHS psychiatrists are central to this. The same support structures, and patient/ family -friendly appropriate clinic buildings, are needed for consultants and multidisciplinary teams practicing in both these service locations. This would ensure that best evidenced practice, driven by appropriate expertise, is the foundation of the patient-centred care provided.”

The IHCA said the report has shown health service management’s failure to adequately and safely staff the mental health service or provide the capacity needed to ensure that patients receive essential care.

Commenting on the interim report, IHCA Vice-President and Consultant Liaison Psychiatrist, Prof Anne Doherty said: “The consequences of failing to have the necessary level of staffing and required frontline supports across our health service have once again been cruelly exposed, this time by the Mental Health Commission who deemed the risk to patients within the child and adolescent mental health service so serious that a decision was made to publish an interim report while vital investigations are still ongoing.”

“The failings identified in the interim report unfortunately come as little surprise to consultants working in frontline Mental Health Services on a daily basis and who have been desperately highlighting the need for more specialists and greater capacity across the board for years.”

The HSE has also issued a response to the interim report.

Commenting, Mr Damien McCallion, HSE Chief Operations Officer, said: “This Mental Health Commission report comes at a time when we have a major CAMHS improvement process underway, and we will be putting a senior clinical/operational team in place to drive and support that process. This interim report, as well as the current prescribing review and other ongoing HSE audits in CAMHS, combined with the service improvement work underway, will all contribute to this process.”

“The report makes systemic findings and conclusions, as well as highlighting concerns about the specific care provided to some children. The HSE engaged with the Inspector of Mental Health Services in the course of her work and where specific concerns were identified, we immediately put in place targeted actions plans to address them. In the case of all children where concerns have been raised by the MHC in their report, these have been managed directly by the service caring for them.”

At this stage in the review of the provision of CAMHS, five out of nine Community Healthcare Organisations have been completed. These are CHO 3 (Clare, Limerick, North Tipperary/East Limerick) CHO 4 (Kerry, North Cork, North Lee, South Lee, West Cork) CHO 5 (South Tipperary, Carlow Kilkenny, Waterford, Wexford) CHO 6 (Wicklow, Dun Laoghaire, Dublin Southeast) and CHO 7 (Kildare/West Wicklow, Dublin West, Dublin South City, Dublin Southwest.)

The Inspector of Mental Health Services’ review is continuing with the remaining four CHO CAMHS, and this will involve further meetings with young people, parents, and stakeholders. These areas CHO 1 (Donegal, Sligo/Leitrim/West Cavan, Cavan/Monaghan) CHO 2 (Galway, Roscommon, Mayo) CHO 8 (Laois/Offaly, Longford/West Meath, Louth/Meath), and CHO 9 (Dublin North, Dublin North Central, Dublin Northwest).

The Inspector’s final Report is due for publication later this year.

Medical News for the 24th January 2023. The Medical Independent. Read the current issues affecting healthcare and the medical industry in Ireland.

The Medical Council will spend approximately €2.6 million on renovations at its rented headquarters, Kingram House, a spokesperson has informed the Medical Independent.

Under the existing long-term lease on Kingram House in Dublin, the Council is “required” to maintain the building. “The approximate total cost for the project is €2.6 million. The majority of the costs relate to mechanical, electrical, furniture, and fit out requirements to ensure the building is compliant with building, fire and health and safety legislation requirements, and to maximise building use with [an] increase in staffing numbers. Existing furniture is also being reused,” said the Council spokesperson.

All options were considered in advance of the renovation works, stated the spokesperson. An expert group was convened and “this course of action was recommended as the best financial solution. Considerations took place over several years before this decision was reached.”

The refurbishments had to be carried out to ensure the building was compliant with health and safety legislation.

“As the lease holder we are responsible for ensuring the building remains fully functional, compliant with building and fire regulations, and meets the legislative requirements, which Medical Council staff will benefit from,” the spokesperson said.

“By completing the renovation at this point, we can capitalise on our investment through the greater use of the building, as increased numbers of staff can be accommodated, while more versatile use of space will allow for other events including fitness to practise hearings and Council meetings to be held on-site.”

Kingram House was vacated when the refurbishment process began in 2021. Office space in Dublin has been rented in the interim. Since mid-2022, all staff have returned to the office one day a week under a blended working policy.

It is expected staff will return to Kingram House in April. Under “normal circumstances” no other office space is required, added the spokesperson.

According to the Council’s 2021 annual report, operating lease payments recognised as an expense were €827,500 (2020: €827,500). In September 2018, the Council entered into a contract for additional office space due to limited space at Kingram House. The cost for 2021 included in the rent and rates expense was €111,776. In November 2021, the Council entered into an additional 12-month lease for additional office space due to refurbishment works at Kingram House. The cost for 2021 was €70,186.

In 2008, the Council entered into arrangements whereby it was tied into a 20-year lease at Kingram House from 2013 at a cost far above recent market rates. The tenancy terms were subject to litigation and the judgement was in favour of Kingram House’s owner Tanat Ltd. The Council appealed this decision and a confidential settlement was reached in 2015.

The IMO has proposed tax relief for trainees required to ‘double rent’ or pay concurrent mortgage and rent payments due to their rotations, the Medical Independent (MI) understands.

The union also supports greater regionalisation of training to minimise the need for trainees to uproot from their accommodation. However, regionalisation has not yet been systematically implemented by the training bodies. Rotations are driven by specialty-specific requirements and the service provision needs of the health system. 

The recent NCHD agreement between the IMO, Department of Health, and the HSE acknowledged “a particular issue for NCHDs who rotate and have to rent a second residence”. The parties recognised “measures are required to address this specific issue” and would be agreed as a priority.

NCHD committee member Dr Brian Doyle told MI that in many other employment sectors, employers cover the costs borne by employees who are required to move locations as part of their role.

“But NCHDs fully bear that cost themselves at the moment and it is grossly unfair. I think regionalising training will remove some of that [expense]. The HSE have recognised this is a particular issue in the latest industrial relations agreement… but no solutions have been found to help alleviate it at the moment.”

Dr Doyle said if the HSE was not going to cover the additional accommodation costs borne by their employee NCHDs, measures such as tax relief needed to be considered by the State. The tax relief measure has been put forward by the union.

A spokesperson for the Department of Finance stated: “Any proposals for tax-related measures are considered in the context of the annual Budget and Finance Bill cycle.”

The HSE is seeking to hire a consultancy service to aid the implementation of its new capital strategy.

The HSE Capital and Estates Strategy 2022-2050 sets the direction for the future management, development, and investment of the healthcare estate in Ireland.

In a recently published tender document, the HSE said implementation planning in relation to the strategy has commenced.

The HSE is seeking to appoint a consultancy service in relation to financial modelling and investment planning, asset management, and digital systems development.

The consultancy service would also be expected to provide business intelligence, innovative design advice, and procurement and construction expertise.

“The SME [small and medium-sized enterprise] consultant will co-develop and deliver a clear pathway to achieve these goals within national constraints and policy, and deliver solutions for the future management, development, and investment of the healthcare estate in Ireland,” according to the tender.

“The strategy’s implementation will be iterative, and the implementation approach will be continuously updated as workstreams are established, subject matter expertise on boarded, and detailed programme plans developed.”

One of the main objectives of the strategy is to “develop an estate that is net carbon zero no later than 2050”.

Other key workstreams relate to strategic investment, the development of “data-driven” asset management, and progressing digital technologies to support capital investment; “innovative approaches” to design, procurement, and construction; and workforce planning.

In order to develop “a prioritised approach” on capital investment, as well as developing an appropriate maintenance budget for the HSE’s built portfolio, the Executive requires the condition of the estate to be accurately assessed to ensure a healthcare environment that is safe and fit-for-purpose.

“The HSE faces considerable challenges to ensure properties are fit-for-purpose, comply with statutory legislation, are of the required size, type, and location and are maintained in good order to ensure that capital and revenue budgets are spent wisely to achieve value for money,” according to the tender.

The HSE recently completed a survey of the acute service estate. A similar survey of the remaining community, primary, and administration accommodation buildings will be required.

In 2023, the consultancy service will deliver defined outputs in “the commissioning of the specific workstreams” in the implementation plan.

The implementation of the strategy will be a multi-year programme that requires “significant investment in time and resources”, according to the HSE.

The strategy and implementation plan will be reviewed annually and updated on a five-yearly basis to ensure continued alignment with HSE requirements.

The deadline for the tender is Friday 3 February.

Nobody who follows the Irish health service can say that the record levels of overcrowding in emergency departments (EDs) earlier this month came as a big surprise.

The total of 931 patients waiting for beds on 3 January was the highest since the Irish Nurses and Midwives Organisation’s Trolley Watch figures began.

Only in December, HIQA had warned the health service was under “unprecedented strain” with increasing number of patients presenting to EDs. The number of presentations was “significantly” higher than in previous years, the Authority pointed out.

HIQA made the announcement to coincide with the publication of an overview report of its monitoring programme against the national standards in seven EDs in 2022.

Throughout 2022, HIQA commenced a new monitoring programme of inspections in healthcare services against The National Standards for Safer Better Healthcare. As part of the initial phase, HIQA’s core assessment in EDs focused on key standards.

HIQA’s Director of Healthcare Mr Sean Egan said findings from this new programme of inspections continued to highlight that “overcrowding in emergency departments compromises the dignity and respect of patients and poses a risk to health and safety of patients”.

He continued: “…. The Irish healthcare system remains challenged by bed capacity and workforce shortages and access and capacity issues in primary care. Emergency department overcrowding and insufficient access to acute and primary services will continue to occur unless a system-wide approach is taken to address major structural concerns and respond to, rather than continuing to tolerate or normalise, this problem.”

The problem has been normalised for some time. In 2006, the then Minister for Health Mary Harney described the levels of overcrowding, which were occurring in Irish hospitals, as a national crisis.

This description has been used by politicians, doctors, and commentators whenever the situation gets particularly bad. And the situation is rarely particularly good.

In essence, this is a crisis that has been unresolved for over fifteen years. There have been positive developments over this period, such as the establishment of the national emergency medicine programme. Over the last year there has been an increase in capacity, and a political commitment to recruit an additional 50 emergency medicine consultants.

But more ambition is required, especially given the continued additional strain that Covid-19 infections are placing on the health service.

The interim CEO of the HSE, Mr Stephen Mulvany, recently told the joint Oireachtas committee on health that the levels of infectious respiratory diseases were “at exceptional levels, with sustained peaks when compared to the past five seasons”.

The HSE’s emergency response to the current crisis is welcome. However, without the type of “systems-wide” reform referenced by HIQA, we can expect pretty much the same story next January, and the one after that.