Vol. 1070 No. 1
1. Deputy David Cullinane asked the Minister for Health the steps she has taken to ensure that Health Service Executive and National Treatment Purchase Fund spending on insourcing initiatives is transparent and accountable; and if she will make a statement on the matter. [34742/25]
Deputy Clarke is asking this question on behalf of Deputy Cullinane.
I thank the Cathaoirleach Gníomhach for facilitating us.
The Government remains committed to increasing capacity in the public system. The commitment is underpinned by unparalleled levels of investment as we move to universal access to health care. However, until the capacity is in place to meet the increased levels of demand, it is necessary in the interim to make use of all available capacity in the public and private systems to ensure that patients have access to the care they need.
The waiting list action plan 2025 includes targeting the delivery of additional capacity in the public and private systems through a co-ordinated approach by the HSE and the National Treatment Purchase Fund, NTPF. NTPF insourcing initiatives are governed by a memorandum of understanding, MOU, between the NTPF and the relevant public hospital. Under the MOU, the public hospital confirms that any such work is additional work over and above core hospital activity and is specifically carried out to reduce waiting lists.
In early April I requested that the HSE CEO initiate a detailed survey of all insourcing activity within the HSE to include activity funded directly by the hospital concerned and by the NTPF. The review is being co-ordinated through his office, assisted by finance, internal audit, HR and access and integration functions. The outcome of this review is expected shortly and will determine the appropriate next steps. We need to move away from this model by maximising internal underutilised capacity, while at the same time not negatively impacting on patient waiting times and outcomes.
I want to begin by acknowledging the great work done by staff in Children's Health Ireland, CHI. However, in the past month details of an unpublished report conducted on the clinical department of CHI at Crumlin hospital has been put into the public domain. One of the revelations in the report was a finding of several inappropriate and unnecessary NTPF-funded Saturday clinics conducted by a consultant. The report details how a consultant was facilitated to set up hundreds of appointments for patients who did not need to see him. He then placed these patients on his own waiting lists, which resulted in patients waiting twice as long as they would have otherwise. The report states that 95% of those patients could have been accommodated during normal working hours, that is Monday to Friday, without the need for NTPF funding. How confident is Minister that the audit will be able to identify this type of misuse of funds?
It is an excellent question. It is exactly what I have asked Bernard Gloster to do. Of course, I have to wait for the report to be able to express my confidence in the quality of the work that has come back. The Deputy may take that as a reference example. As I said in my opening reply, if there was underutilised capacity, that is, as the report states, other people in the hospital could have held surgeries at an earlier period but did not due to the waiting list management process, that is very serious.
In advance of receiving the insourcing report, we have mandated a centralised referral mechanism so that if someone is referred to surgery, they are not referred to Jennifer, Sorca or whoever. Rather, patients are referred to the system and will then be allocated an appointment according to capacity rather than an individual consultant having the capacity to manage their lists or patients in a way that is unhelpful.
I thank the Minister. There has been a significant increase in Saturday clinics over the past years. An example of this concerns scopes. More than 10% of scopes are now done on a Saturday but the distribution is very uneven across hospitals. Of the scopes carried out in Cavan hospital, one third are now done on a Saturday, that is 900 out of a total of 2,700. However, hospitals are still conducting fewer scopes than they were in 2019 when all services were provided between Monday and Friday. Waiting lists did not reduce during 2024 but they have reduced this year.
The system may be working and I do not doubt Cavan hospital in that regard. However, the CHI revelations are startling and there is real concern that this may be the tip of the iceberg. There is also concern that the quality might be suffering in some of the Saturday clinics or productivity could be higher during Monday to Friday. How is the Minister ensuring that hospitals are preventing the misuse of public funds and controlling spending and waiting lists initiatives? What is the breakdown of weekend hospital activity between the new public consulting contract and the fee paying service clinics? What action does Minister intend to take if she is not happy or there are unanswered questions when Bernard Gloster and the HSE bring forward the audit report?
The Deputy raised the issue I am concerned about, namely that there are incentives to be under productive during the working week with a view to, or which have the outcome of, very busy clinics on Saturdays or bank holiday Mondays. That is exactly the sort of incentive I need to see stop.
I cannot speak to the relative activity because I do not have that data. The Deputy's example is precisely the sort of example that prompted me to conduct the work on insourcing. I wish I was a couple of weeks ahead and had the data and could give her a better answer, but I will have the information during the next Priority Questions session. The Deputy is highlighting exactly what I might be concerned about.
To be fair, Saturday clinics and the NTPF meet those who have waited the longest and there is a need for that work, as she acknowledged. These sorts of incentives or opportunities are precisely what I am trying to identify, along with variations across hospitals or specialisms within hospitals, which is also important. I want to find ways to make sure that we are not permitting those incentives and there is a standardised approach that we can stand over and thereby reduce our dependence on such a system.
2. Deputy Pádraig Rice asked the Minister for Health if her attention has been drawn to the failure of a number of symptomatic breast disease clinics to see newly referred patients within ten working days (details supplied); the steps being taken to ensure that these clinics meet their targets; if the required resources will be allocated to these clinics to ensure there is adequate staffing; to provide an update on the programme for Government commitment to ‘protect diagnostic pathways and invest in infrastructure and equipment to meet target treatment times outlined in the national cancer strategy; and if she will make a statement on the matter. [35169/25]
Access to symptomatic breast disease clinics has become a postcode lottery. Following an urgent GP referral, a person should be seen by a clinic within two weeks. However, timely access to these clinics varies widely. Last year, only four out of nine hospitals met the target of seeing 95% of urgent referrals within two weeks. The other five failed. The Mater Hospital only reached 29%, St. James's Hospital 51% and Letterkenny 58%. Some of these are shocking failures. It should not matter where one lives; no person should have to wait more than two weeks. These are urgent referrals. Where is the sense of urgency?
There are nine HSE rapid access symptomatic breast disease clinics nationally, as the Deputy knows. The HSE has set a target of 95% of urgent referrals being seen within ten working days. Non-urgent referrals should be seen within 12 weeks. The HSE national cancer control programme monitors the performance of these clinics. Last year, national compliance with targets was 76% for urgent and non-urgent referrals but I recognise the variations the Deputy described. While five centres generally met or exceeded the targets during the year, four did not. This is often caused by staff shortages or problems in accessing diagnostics or radiology services.
These clinics consistently operate at full capacity. Unfortunately, any disruption to services can lead to a backlog, which can take time to clear. Where a performance issue arises, the HSE implements site-specific measures, but it may also need to implement regional measures, which we can discuss further. These can include funding additional clinics or providing locum cover where necessary.
The national cancer control programme is also developing new or modified pathways for certain patient cohorts. These aim to make better use of available capacity and provide appropriate access for high-risk patients such as those with a family history of breast cancer. My Department is also reviewing diagnostic services to ensure that capacity is fully maximised. The Government's commitment to cancer services is reflected in significant investment, with more than €105 million provided for cancer services under the national cancer strategy, including €23 million in 2025. Nevertheless, there is a great deal more I would like to say about it. Perhaps I can do so in a supplementary reply.
One report states that one in four people waited longer than recommended for an appointment at these urgent clinics. I would like to share with the Minister the experiences of two women from north Dublin. They had to wait for in excess of the two-week period to be seen by the Mater's symptomatic breast clinic. In February, one woman was referred by GP due to the presence of two lumps in her breast. However, when the Mater Hospital received the referral, she was told the waiting time to be seen had risen to three months.
Let us imagine receiving this news at a time of extreme uncertainty and fear. It was May before she received her appointment at the Mater. Another symptomatic patient in the Mater who had been waiting for an appointment since April was seen last Monday, two months later. During these agonising two months all these women were told was that the Mater's BreastCheck clinic was understaffed and there was no estimated appointment date to be provided. In what world is this acceptable? What has happened to this country's cancer services? Cancer care used to be regarded as the jewel in the crown of our health services.
The Deputy is right. Yesterday I was at St. James's Hospital and it and Trinity College have become one of the accredited cancer centres of the Organisation of European Cancer Institutes. There are many accredited centres but this is at a different level. It is the most prestigious award for cancer control. The Deputy is correct that we have very good services. He asked in what world is this acceptable. There is no world in which it is acceptable and there is no world in which the Mater's figures are remotely acceptable.
Let me also say that like the Deputy I have correspondence from the breast health unit in the Mater and I am deeply disappointed with the content and the tone of the letter being sent to women who are not just going for BreastCheck but who are going because there is a problem. I have written to the CEO of the Mater hospital to express my concern about this and to ask for the number of people waiting on it. I have also asked the regional executive officers for that area and the adjoining area, which includes St. Vincent's University Hospital and Tallaght University Hospital, to come up with a regional solution that meets the needs because this is absolutely unacceptable.
We absolutely need better planning here. A lot of this comes back to staffing. Greater resources must be allocated specifically to breast clinics to ensure adequate staffing throughout the country, regardless of where people live. To secure cancer care pathways greater workforce planning is required but this cannot be siloed in the Department of Health. We need joined-up thinking. The Departments of Health and higher education must work together to ensure people are able to access places on various healthcare courses, especially radiology given its key role in diagnostics. The HSE also has a role as it must ensure there are enough clinical placements for trainees. Crucially, we need to ensure people can stay in Ireland to work in our healthcare system after qualification. As the Minister has said, these are very concerning findings. These are women who have symptoms and who are waiting for too long to be seen. It needs to be addressed urgently.
I thank the Deputy and I agree with him on all of these points. Yesterday at the health committee we covered some of the workforce planning issues and the expansion of training places. It is also a workforce management issue and the variation between hospitals is well noted. I am told that in the Mater there have been long-standing recruitment challenges but they have been stabilised. There has been a consistently high volume of urgent referrals with difficulty in accessing radiology in St. James's Hospital. A lean project is under way to improve efficiencies. In Letterkenny the hospital has met the urgent KPI targets for the past three months, although the figure for the year to date is 85% following a poor performance in January. St. Vincent's Hospital has been meeting the urgent KPI since last September and it is at 99%. Cork University Hospital remains in the 80% to 90% range for urgent referrals.
I know the Deputy did not raise this necessarily in the parliamentary question but Galway University Hospital's performance this year has averaged 33% but it is expected to show improvement in May because of the appointment of a replacement breast surgeon. He and I are having to discuss this on a hospital-by-hospital basis and we have to make sure the system is across itself.
3. Deputy David Cullinane asked the Minister for Health the steps she has taken to improve governance and accountability at Children's Health Ireland, CHI; if she will publish the unpublished review of a department at CHI at Crumlin; the steps she has taken to address issues highlighted in that report; and if she will make a statement on the matter. [34743/25]
Will the Minister detail the steps she has taken to improve governance and accountability at Children's Health Ireland and will she publish the unpublished review of a department at CHI at Crumlin? Will she outline the steps she has taken to address the issues highlighted in the report?
In response to a series of reviews which raised corporate and clinical governance concerns at CHI, I have moved to strengthen governance and oversight structures at CHI in a range of different ways. This was done via the appointment of two members of the HSE board to the board of CHI on 28 May. There are more board appointments to be made. This means that all but one members of the board have been appointed since 2024. This is a different reference period to some of these activities.
The service level agreement between CHI and the HSE has been strengthened, and there is significantly increased involvement from the Dublin and midlands regional executive officer. Recognising the need to co-ordinate oversight of the range of matters of focus in CHI in a cohesive fashion, the HSE CEO has established the HSE CHI improvement steering group. These actions are designed to support the new CEO in CHI and enable her to continue with the transformation programme she has started.
Regarding the 2022 internal examination referenced by the Deputy, I have been advised by the Attorney General that I do not have the legal basis to publish this report. I sought that legal advice with a view to trying to put it into the public domain correctly. I received it correctly but it is the property of CHI and I do not have the power myself to publish it. Any publication must be made by CHI. On 16 June, CHI published a summary of the report. Subsequent to my letter on 26 May requesting a response from the CHI board to the report, on 18 June I wrote to the CHI board requesting assurance that the recommendations have been addressed in full. I also emphasised the priority I place on child patient safety issues and asked the board to report directly to me on the status of the children that may have been impacted.
There has been scandal after scandal at CHI. There were inappropriate spring implants, possibly hundreds of unnecessary hip surgeries and now a scathing leaked report of an examination of a clinical department at Crumlin hospital. The report has raised exceptionally serious concerns and it follows the Boston review, the HIQA review into unauthorised springs and the hip dysplasia audit. We would not know about the first two reports if it were not for whistleblowers who came forward, and the third report was released by HIQA. The approach from CHI has been unacceptable. It has stonewalled and refused to release the report in full. It has also refused to report the misuse of public funds to the Garda. The HSE took doing this into its own hands earlier this month. The HSE said CHI did not even share the report with it until after it was leaked. At a time when we hope to move into the new children's hospital in the coming two years, confidence and trust in CHI has never been lower. What steps is the Minister taking to address this? In terms of the new board members coming in, how does she intend to hold the previous board members to account?
The Deputy will note the number of resignations from the board. She has identified a series of important and serious issues, most of which we knew would be coming because of the concerns raised by whistleblowers and others. Reports were correctly commissioned with HIQA by the HSE and CHI. We knew they would come but, as she pointed out, the report that was not shared with either the HSE or the Department raises very serious concerns. It comes from 2022 when it should have been shared and addressed properly but it is today that we have to address it. I recognise that we have nearly a new board. We certainly have a new CEO who was appointed in February and is establishing an executive team around her, all of whom are new to the system. I will work directly with them to ensure this is taken forward. Of course I have stronger confidence because of the increased involvement of the HSE. There is ongoing reporting to me of what is happening about the implementation of the various issues. I am concerned in particular, of course, from a patient safety perspective.
There are still 226 children waiting on spinal surgery. Of these, 34 children have been waiting longer than six months. There are also many more who were removed from waiting lists because they were left for so long that they have become inoperable. One of these is a young lad called Mikey. He is from Mayo and is aged 16. He has severe scoliosis. Last September Mikey's parents were told by CHI that he is not fit for surgical intervention. The letter did not indicate any pathway for Mikey. His parents have asked many times for a second opinion abroad. Last month my colleague Deputy Conway-Walsh, who is from the county, raised this with the Taoiseach and he stated he was of the view that a second opinion should be facilitated. The family has had no update from CHI in this regard. Will the Minister make sure that Mikey and children like him get the second opinion they need?
I want to be very careful of the privacy of Mikey and his family but I have met him and I have met his family. I am aware of the various issues. On foot of meeting them, I put in train a process and perhaps I might speak to the Deputy about it privately rather than on the floor of the Dáil, recognising his privacy.
With regard to scoliosis and the issue of waiting times, it is a source of great frustration to me that there has been so much additional investment, both financial and personnel, into the system but we are not getting what I would regard as a commensurate increase in output or productivity. They sound like harsh words but I mean surgeries for children who need them. It is very important to look at the work the HSE internal auditor will do. The auditor will look at three specialisms, two of which will be surgical and one medical.
The auditor will examine the waiting list management within that, and I imagine that scoliosis will be one of those areas that will be examined. Again, I reiterate the importance of a central referral system, which manages it on behalf of the team, rather than individuals managing their own lists.
4. Deputy Marie Sherlock asked the Minister for Health if she will act to protect front-line healthcare workers impacted by long Covid and who are in receipt of the special scheme of paid leave; if she plans to extend this scheme or recognise long Covid as an occupational illness to quality for occupational injury benefit payments; and if she will make a statement on the matter. [34984/25]
As the Minister knows, the scheme for special leave for those who contracted long Covid is due to expire on in four days on 30 June. A total of 166 employees of section 38 organisations and the HSE are currently in receipt of this payment. To be frank, the response to date has been downright disrespectful and degrading to those who gave so much and risked so much at a time of such uncertainty and risk in this country. What plans has the Minister put in place and what actions has she taken to protect those health workers who have contracted long Covid?
I thank the Deputy.
The role our healthcare workers played during the pandemic cannot be overstated, particular at the very early stage of it. They went beyond the call of duty, working in front-line environments, treating Covid-19 positive patients, particularly in the early days when the control mechanisms were what they ultimately became and while the risk was extraordinarily great. In response to that, a temporary scheme was put in place for 12 months in July 2022 to support eligible staff who were impacted by long Covid in the public health sector. The intention of this scheme was to support those employees working in Covid-19 environments in the time before PPE and vaccinations were readily available. It is my understanding that approximately 159 employees are currently on the special scheme, the majority of whom have been supported on full pay for almost five years.
My Department has always worked hard to ensure supports have been in place for those workers impacted by long Covid. At the Department of Health's request, the now Department of Public Expenditure, Infrastructure, Public Service Reform and Digitalisation has agreed to extend the scheme on four occasions, most recently at the end of June 2024, when it was extended for a further 12 months for the existing group of employees being supported by it. However, I understand the Department of public expenditure was clear at the time that this was the final extension that would be granted. As such, the special scheme will conclude on 30 June 2025.
I reassure, to the extent that I can, those 159 employees who have been supported by the scheme for up to five years that they will continue to be supported. The full provisions of the public service sick leave scheme will apply for anyone who remains unable to return to work. The sick leave scheme provides full pay for three months and half pay for three months. This is followed by temporary rehabilitative remuneration, which can provide up to a further 547 days of paid leave. The critical illness protocol that forms part of the sick leave scheme may also provide additional supports for up to three years.
I am aware that concerns have been raised by a number of unions about the scheme ending, and I know that the matter was before the Labour Court on 11 June, the findings of which are currently awaited.
As the Minister knows, people's lives have been turned upside down by long Covid. This is not any ordinary type of illness. This was contracted in the workplace, yet there has been a persistent refusal by this State, in sharp contrast to the vast majority of EU member states, to recognise Covid as an occupational illness. The refusal to extend this scheme or to put in place a long-term framework for those who contracted Covid in the workplace reflects a shocking lack of empathy and respect for those workers. The reality is that the sick pay scheme currently in operation across the public service runs out after a period. As workers have described it to me, the special scheme has been a lifeline. There is a different pay calculation for that scheme relative to the ordinary sick pay scheme. The crucial point is that these workers have ultimately been told they are five years on and to get over it, but that is not their lived reality.
There is no intention not to recognise that or to not be empathetic, which is why the scheme for full pay was there for five years. I am aware that the Minister for Social Protection has reviewed the EU recommendation in respect of the recognition of Covid-19, not long Covid, for an occupational illness. Following that review, it was determined that Covid-19 did not meet the requirements to be recognised as an occupational illness in the context of the occupational injuries benefit scheme and the Social Welfare Consolidation Act 2005.
It is important to recognise that the EU advisory committee on health and safety recommended the recognition of Covid-19 and not long Covid as an occupational illness in health and social care settings. As I said, the Minister for Social Protection reviewed those recommendations and did not recognise it in the context of the occupational injuries benefit scheme. While many EU countries recognised Covid-19 as an occupational illness or injury, this related to Covid-19 and not long Covid. It is not clear that any country sustained full pay for workers suffering from long Covid in the same way Ireland has for its public health workers through the special scheme we have had to date.
With respect, the Government is splitting hairs in distinguishing between Covid-19 and long Covid. Clearly, long Covid resulted from Covid-19. The reality is that the request has been for a framework to be put in place to support these specific workers. We are only talking about health workers. We are not talking about gardaí or the many other front-line workers who went out to work during that period. The Government gave false hope last year that some sort of scheme would be put in place. Now those hopes have been dashed. It is shameful that people have had to go to the High Court and that unions have had to go to the Labour Court to try to get respect for those workers who contracted this illness in the workplace. My direct appeal to the Minister is that she ensures some sort of new scheme will be put in place in specific recognition of those workers, their experiences, their desire to get back to work and their need to be supported. The scheme should be separate from the sick pay scheme that exists in the health service.
Again, I recognise that the findings of the Labour Court are still awaited and I respect that. I will also reiterate the terms of the sick leave scheme. Having been on full pay for five years, the healthcare workers may receive further full pay for three months, half pay for three months, temporary rehabilitative remuneration for 547 days of paid leave and the critical illness protocol that forms part of the sick leave, which provides additional support for up to three years.
I appreciate the distinction, importantly, the Deputy has not made between Covid and long Covid. Nevertheless, when we look at the EU comparison, we are not aware of any case such as that. If the Deputy is aware of any case where any country sustained full pay for workers suffering from long Covid in the way Ireland did, I ask her to please bring it to me. We have tried to take an empathetic and supportive approach. The Minister for Social Protection has reviewed the EU position to determine how this works with the occupational injuries benefit scheme. The public service sick leave scheme is an important scheme in the context of supporting all people in the public service.
5. Deputy Charles Ward asked the Minister for Health the process she is currently undertaking in choosing a location for a surgical hub for the north west, as outlined in the programme for Government; the factors that will be considered in choosing the location; if this decision will be based solely on geography, population, demographics, day case numbers and staffing numbers; and if she will make a statement on the matter. [35141/25]
It will be no surprise to the Minister what I am asking her today. The decision of where to locate the surgical hub in the north west is an important one. Therefore, transparency in the decision-making process is vital. Will she outline, in detail, what factors will be considered when choosing the surgical hub for the north west?
I thank the Deputy.
As part of the Government’s ambulatory care policy and in advance of the new elective hospitals, the HSE is developing surgical hubs across the regions. They will play an important role in separating scheduled and unscheduled care, reducing waiting times, thereby improving access and care for patients. The programme for Government committed to delivering six new hubs and exploring the provision of an additional surgical hub for the north west. No decision has yet been made on a location for this hub and the business case has not yet been submitted to my Department. I visited Letterkenny on 1 May to better see and understand the hospital and the supporting environs, such as the 110-bed community nursing unit across the way that is under construction and the excellent Errigal hub, which is also across the way from Letterkenny Hospital.
On 11 June, I believe I met with all Oireachtas Members for Donegal. Last week, I also met with representatives of doctors and consultants in Letterkenny, who have engaged with me very constructively and positively on this issue. It was a wide-ranging discussion, and I have committed to meet with them again soon. I am open to listening to them and to understanding the issues, which I share, regarding surgical capacity in Letterkenny in the medium and long term. I look forward to my next engagement with them to best determine the way to deliver healthcare for the people of the north west.
I thank the Minister for outlining that. The location of the surgical hub has generated a lot of public interest. It has the potential to impact many people's lives across the north west. It is important we get it right. As I said to the Minister, this is not a Sligo versus Donegal issue. The north-west region alone is disadvantaged in many ways. We should not be forced to fight over squeezed resources. Ideally, to address the imbalance in healthcare and to meet the current demand, two surgical hubs should be established. All I can say, as someone who has worked on the ground in Donegal, is that the case for a surgical hub in Letterkenny is overwhelming. Donegal consultants and GPs who met with the Minister last week outlined this. I am asking her to take their experiences and all the data presented into account. The public needs reassurance that the decision will be data-driven and free from influence.
I thank Deputy Ward and I assure him, representatives from Donegal, the consultants and doctors in Letterkenny and the people of Donegal more broadly that I will do precisely that. I am committed to that region. That is why I visited it a number of weeks into becoming Minister for Health in order to understand for myself. I cannot look at it on a map or look at drawings. I have to be there to understand the dynamics and to listen to people, which is precisely why I went and have tried to engage in this way. No decision has been made yet. I ask Deputy Ward to give me a little bit more time to work out how to manage this.
I wish to update the House on the operation of the surgical hubs. I was in St. James's Hospital yesterday. To update the House, the surgical hub that has opened in Mount Carmel Community Hospital has seen 1,000 patients already. The CEO of St. James's Hospital informs me that its pain relief list is nearly clear because they are able to give pain injections. The surgical hubs are really important.
In respect of what Deputy Ward describes, I know and respect the geography of Donegal. It is important we have capacity there to deliver these different services. I ask Deputy Ward to allow me a little bit of time. I am trying to work on it.
I thank the Minister for her engagement on this matter. She has been proactive and committed to ensure that all the data and experiences are being taken into account. We appreciate this. In Donegal, we are grateful the Minister is listening to us. We are fighting our corner and are willing to listen. The Minister is taking all the situations into account. We appreciate and understand that.
All the TDs in Donegal are united on this matter. We are disappointed and honestly shocked that the HSE decided no consideration be given to Letterkenny for the surgical hub, despite overwhelming data presented to it, including the geographic population, demographics, day case numbers and staffing numbers of the hospital. It is hard not to feel a bit despondent when faced with this. I truly appreciate the Minister's consideration and I look forward to engaging with her in the future on this matter.
I thank Deputy Ward and I hear what he is saying about his experience of the HSE. That is important. It is also important to reflect on local hospital management and their responsibility to advance cases on behalf of the hospital. When I met Deputies from Donegal, I went through the projects that had been advanced and supported. I recognised there was, in my view, insufficient surgical ask by the local hospital management. While I am not trying to deflect from the surgical hub issue in any sense, it is also important there is a real development control plan for Letterkenny University Hospital for the medium and long term in the way that has been successful in Galway and other places. I strongly urge Deputies to pressure for and demand this sort of approach for Letterkenny. However, do not allow me in any way to attempt to confuse that with the specific surgical hub issue, which is more pressing and immediate.
