Dáil Éireann - Volume 618 - 26 April, 2006
Accident and Emergency Services: Motion.
Ms Harney Ms Harney
Ms Harney: I move:
That Dáil Éireann,
— commends the Government and the Tánaiste and Minister for Health and Children for their commitment to improving care for patients in our hospitals;
— recognises and supports the necessity for a substantial reform to accompany the unprecedented level of resources being invested in our health services and in hospitals in particular;
 — acknowledges and supports the commitment of the Government to providing increased resources to accompany reform; and
— supports the substantial actions being taken to address the problems in Accident and Emergency (A & E) Departments, including:
— the comprehensive range of initiatives under the 10-Point Action Plan to deal with the many factors impacting on Accident and Emergency Services;
— the introduction of new measures to build on the Action Plan, including the setting of performance targets for individual hospitals;
— the establishment of a dedicated A & E Task Force to advise on how further improvements can be made to the efficiency and effectiveness of A & E Departments;
— the opening of new A & E Departments in Cork University Hospital, Connolly Memorial Hospital and St. Vincent’s University Hospital;
— the provision of additional long-term care beds in private nursing homes and home care packages to facilitate the discharge of patients who have completed the acute phase of their care;
— the provision of admissions beds and appropriate facilities to ensure that patient privacy, dignity and comfort are preserved while awaiting admission to an acute bed; and
— the renewed emphasis on hygiene in our hospitals through the second national hygiene audit which is currently taking place.
I welcome the opportunity today to set out some facts about the actions under way to improve patients’ experience at the accident and emergency departments in the country where there are problems and delays.
I reiterate to the House the Government’s total commitment to achieve sustained results by working with the Health Service Executive to address all the issues that cause problems at certain accident and emergency departments. These are complex problems which require a full spectrum of actions to address them. The problems will be solved with a combination of reform, resources, management actions and improved efficiency, tailored to each individual hospital.
The Government takes the responsibility to lead reform for real improvements and we are giving this priority. We are providing all necessary funding. We have empowered HSE management to act and we will support and back up its actions.
 We plan to recruit many new consultants in the coming years. We are providing funding for new beds in hospital wards, in accident and emergency areas and in the community. We urge all concerned to contribute to solutions and we will continue to work to get this right.
Last year, more than 1.2 million people attended accident and emergency departments nationally, an average of nearly 3,300 a day. On average, 75% of these patients are treated and discharged without the need for admission to an acute hospital bed. Not every hospital has problems with its accident and emergency services; some of the accident and emergency departments function very well.
There are 53 acute public hospitals in the country; 35 of these have accident and emergency departments and a minority of these experience consistent problems. The problems are different in each hospital and this is the reason the solutions are hospital-by-hospital. The bottom line for all of us is that no old person should have to sleep overnight on a trolley in a corridor. This has to stop and I am determined that it will.
We also have to speed up our accident and emergency services for everybody. I said I wanted the accident and emergency situation to be treated as an emergency, so as to up the pace, so to speak, in achieving better outcomes for patients. It is entirely appropriate for the Minister for Health and Children to exhort maximum effort and speed from all concerned to improve care for patients.
The actions in the ten point plan which started in 2005 continue to be implemented. I will update the House later on each of them. This time last year, the HSE had no permanent CEO. Professor Brendan Drumm is now leading the management focus on accident and emergency solutions, hospital by hospital. This focused and consistent management action would never have been possible when we had the old health board system.
The HSE is setting targets for each hospital to drive continuous improvement in waiting times. Consistent with international standards, its ultimate objective is to ensure no patient will wait any longer than six hours to be admitted after the clinical decision to admit has been made. This will be a ceiling, not a floor. It is to be bettered and is currently bettered for many of the 1.2 million accident and emergency patients annually in our hospitals. Our challenge is to support these hospitals to ensure they maintain this standard and bring all hospitals up to the same level of performance.
The HSE is taking the following approach on a hospital by hospital basis. It is developing specific time-based targets in relation to accident and emergency and delayed discharges, it is putting in place financial and other incentives linked to performance which is a new development in accident and emergency in our health services and it is developing targeted initiatives aimed at  delivering immediate and sustained impact in attendances, delayed discharges, and efficiency.
The board and the management of the Health Service Executive are fully focused on accident and emergency improvements as their priority. The HSE board agreed that the allocation of hospital budgets for 2006 would include financial incentives linked to specific, time-based performance improvements. In addition, specific funding is being set aside for projects to advance innovation and reform in the areas of efficiency and throughput. This is a welcome and effective initiative in public hospital funding. Hospitals and organisations respond to positive incentives. Another result of having the HSE for the first time is that each hospital network manager has been instructed to treat accident and emergency as his or her top operational priority and to deliver a measurable improvement in accident and emergency services. It is intended that this will be reflected in the performance-related pay scheme. This is also new and welcome in our health service.
Responsibility for delivering measurable improvements in accident and emergency services has been assigned to each hospital CEO or a named senior alternative. The performance targets for individual hospitals relate to the numbers of patients on trolleys awaiting admission, and the time those patients spend waiting. The HSE will begin now to publish waiting times at accident and emergency units next week — another first in our health services — so that improvement can be monitored and encouraged by all concerned. The hospitals will be assisted in achieving their targets by the task force which has been established by the HSE.
I applaud the commitment of those who are voluntarily giving their expertise to the task force. They include emergency department consultants, a consultant geriatrician, a respiratory physician, a director of nursing, a hospital CEO and full-time representatives from the national hospitals office and primary, community and continuing care services. The task force will advise on how improvements can be made to the effectiveness of some emergency departments.
We will also free up hospital beds by helping people leave hospital as soon as they are medically ready. We are providing more care in the community, in step down beds and nursing home places. There is no question of discharging people who are not medically fit for discharge but people who are medically ready to leave hospital should be able to avail of appropriate care outside a hospital setting.
This year the Government is providing funding for the largest ever expansion of services for older people — €110 million in 2006 and €150 million in a full year. Under this funding, we will treble the number of home care packages, some of which will be used to assist older people who would otherwise have their discharge from hospital delayed.
 Care at home is still the preference of the vast majority of our older citizens. Long-term nursing home care is also necessary for some patients after their hospital treatment.
I have made it clear that the HSE should go ahead and use as many public and private nursing home beds as required to free up beds for patients awaiting admission. The acute beds that become available as a result of this initiative will be ring-fenced for those patients awaiting admission in accident and emergency departments.
It is important that patients’ comfort and dignity are fully safeguarded while they wait for admission to a ward bed. We are providing more appropriate facilities for patients awaiting admission. The 33-bed transit unit in the Mater Misericordiae Hospital has been operational since January last and is working well.
Transit units are being fast-tracked now with capital funding in Tallaght, where a 40-bed transit ward is being developed and is scheduled for commissioning by July of this year, in Cavan General Hospital, Wexford General Hospital, Our Lady of Lourdes Hospital in Drogheda and elsewhere. These initiatives are designed to provide immediate support to accident and emergency departments. However, it is essential that they are supported by significant changes within and outside the hospital system in capacity, the optimal use of capacity, practices and procedures and non-acute hospital services.
There are continual calls for more hospital beds as the solution to the accident and emergency problems and, it seems sometimes, to all problems. Let me state clearly to the House that we have provided more acute hospital beds, we are providing more acute hospital beds at present and we will provide more hospital beds in the future to cater for a growing and ageing population. There are now 13,255 beds in public acute hospitals and 1,800 in private hospitals. Since 1997, the number of public acute hospital beds has increased by 1,528, up from 11,727. Most of the increase — over 900 — comprised inpatient beds.
Our five year capital investment programme includes provision for 450 more acute beds. We also are encouraging the private sector to invest to create new public beds by moving 1,000 of the existing private beds out of public hospitals.
The HSE is reviewing the long-term acute bed requirement nationally. It is my view and that of the HSE that it would be an inefficient use of taxpayers’ money to put additional beds into an unreformed acute hospital system, effectively to compensate for inefficient processes. Therefore, as we plan for additional acute hospital beds, we intend to address the underlying processes and wider service issues that impact on the services provided in accident and emergency departments.
The HSE commissioned a process mapping exercise across ten acute hospitals. The project focused on the maximum utilisation of existing  acute capacity and, in particular, the blockages, causes and potential solutions in the patient’s journey through the hospital, from the decision to admit through to discharge.
The exercise has shown that a patient arriving in an accident and emergency department with a letter from a general practitioner can have up to five separate contacts with medical personnel before eventually being admitted to a bed. Some hospitals have simplified this process with very positive results. We need to examine the processes and procedures in other hospitals to make sure that they operate in the most efficient way to avoid wasting time and resources.
Difficulties in accessing diagnostic services outside normal working hours also contribute significantly to delays for patients. The HSE is clear that access to diagnostic facilities will be broadened so that they operate 12 to 15 hours a day as a rostered service. In addition, private sector diagnostics will continue to be used where they can contribute to faster patient services.
Consultants play a pivotal role in the efficiency of hospitals across virtually all departments. They are the senior decision makers, and the importance of their clinical decision-making skills in speeding up the patient’s journey through the hospital system cannot be overstated. We need to have far more consultants available at all times, both in accident and emergency departments and in hospital wards.
Consultants are very much part of the solution and I want to hear their ideas for practical measures that will help improve services to patients. I very much welcome the comments of Professor John Higgins of Cork at the IMO conference where he encouraged his colleagues to be innovators and problem solvers in the health service.
Hospitals cannot be the only setting for medical care. Many people with chronic illnesses such as diabetes or heart disease regularly attend hospitals but could, with a well developed community service, get most of the treatment they need from their general practitioner and primary care team. With enhanced primary care services, patients can get local care from health professionals such as physiotherapists, who otherwise would require hospital referrals.
The HSE is establishing community intervention teams in Cork city, west Dublin, north Dublin and Limerick. These teams will provide services to enable dependant people to remain at home rather than be admitted to hospitals or other care facilities. Nationally, all general practitioners have been invited to become involved with the HSE in the further development of primary care services and there has been a very positive response to this invitation.
I referred earlier to the ten-point action plan for accident and emergency and it would be useful to mention some of the measures taken under the plan. These actions continue. I have not heard  anyone argue that any of the actions in the ten-point plan are mistaken or should be abandoned.
A particular focus of the plan, which is continuing, is on those patients in acute hospitals who have completed the acute phase of their care and are awaiting discharge to a more appropriate setting. I want to outline some of the measures that have been taken under the ten-point plan.
A number of the new accident and emergency departments commissioned in 2005-06 provide for minor injury clinics, including Connolly Hospital, Blanchardstown, Cork University Hospital, St. Vincent’s hospital in Dublin and St. James’s Hospital. Outside of Dublin, funding was provided for the expansion of minor injuries services at St. John’s Hospital in Limerick, and the provision of a minor injuries unit at Waterford Regional Hospital.
A second MRI scanner is due to be commissioned in Beaumont Hospital by the end of 2006. Following a tendering process, interim arrangements with a private provider have been put in place. Additional capacity is also available at weekends to deal with urgent inpatients and 320 patients have benefited under this initiative since November last.
The planning for the provision of acute medical assessment units, AMAUs, in Beaumont Hospital and St. Vincent’s hospital is under way. In Beaumont Hospital, planning is under way for the development of a 29-bed AMAU, to be ready for commissioning by the end of the year. In St. Vincent’s hospital the unit is partially developed. The aim is to have 20 beds fully operational by the end of June next.
A number of patients with very demanding care needs have been discharged to high dependency beds contracted from private nursing homes.
Intermediate care beds were provided to allow the discharge of 560 patients from acute hospitals in 2005. Some 270 patients have been discharged to intermediate care beds so far this year.
Additional home care packages facilitated the discharge of 409 patients from acute hospitals in 2005. Some 182 patients have been discharged to date in 2006.
The HSE hopes to have an out-of-hours general practitioner service for north Dublin in place by the summer.
The first national hospital hygiene audit took place in all 54 acute hospital sites during July and August 2005. The audit was carried out by a UK based contractor. The report of the audit was published in November last. The second hospital hygiene audit is under way, using the same methodology as last year. The results of the audit will be available in June or July.
Palliative care services have been developed at Our Lady’s Hospice, Harold’s Cross, and have been in operation since October last.
Arrangements were put in place with private providers for the commissioning of CT scans and MRIs to facilitate direct access to diagnostics for  general practitioners. During 2005, more than 1,000 CT scans and 100 MRI scans were carried out under this initiative. Every piece of the jigsaw to address accident and emergency department problems is in place: the analysis, the resources, the reform programme, the management, the targets, and the incentives. Implementation at local level in each hospital and in the community services in its locality is the key to success, as there is no other way. I urge all involved in medical and other organisations to contribute to the implementation of ideas and actions to improve these services for all our families. The Government and the Health Service Executive will continue to give this top priority. I am confident the actions will result in the sustained improvements that patients and their families deserve.
Amendments Nos. 1 and 2 not moved.
Dr. Twomey Dr. Twomey
Dr. Twomey: I move amendment No. 3:
To delete all words after “Dáil Éireann” and substitute the following:
“— asks the Taoiseach, Tánaiste and Minister for Health and Children and former Minister for Health and Children, Micheál Martin, to apologise to the people of Ireland for their failure to ensure appropriate emergency medical services in hospital accident and emergency departments, despite being in Government for nine years;
— condemns the Government for its failure to deliver the following services as promised in the National Health Strategy and Primary Care Strategy 2001:
— 3,000 promised acute hospital beds;
— 200,000 full medical cards to families on low incomes;
— the 5,600 community nursing unit, community care, community support, extended care beds (800 promised each year over a seven-year period from 2001);
— 40-60 primary care teams by the end of 2005;
— condemns the Government’s further failure to deal with the accident and emergency crisis despite numerous public relations attempts such as the Tánaiste and Minister for Health and Children’s accident and emergency ten-point plan; and
— demands that:
— the Government’s commitment to deliver a “world class health service” as announced by the Taoiseach in 2001 is fulfilled;
 — the Tánaiste and Minister for Health and Children take appropriate measures to reduce the suffering of patients both young and the elderly who are regularly forced to endure unnecessary hardship when seeking medical attention due to the failures of the Fianna Fáil-Progressive Democrats Government; and
— the Tánaiste and Minister for Health and Children clearly outline the measures she intends to take to improve all aspects of acute hospital care that will allow patients to be treated in a dignified and respected manner.”
The Government parties have not that much to show after nine years in office in regard to improvements in the health services but it would be no harm to go back over the recent history of our health services to examine why we have arrived at the current crisis. In October 2001, the Government held a special Cabinet meeting, attended by the Tánaiste, in Ballymascanlon, County Louth, the purpose of which was to discuss only the health services. The then Minister for Health and Children, Deputy Martin, was confident that his day of publishing reports and doing little else was about to change as he was about to announce the health strategy, Quality and Fairness — A Health System for You. As he left that meeting, the ghost of former times, Mr. Charlie McCreevy, stated: “Putting money into the health services is like pouring money down a black hole.” On the same day the Taoiseach informed us the health services were well resourced and further stated we had a world class health service.
I am not sure what the Tánaiste’s views were at the time but, since she was at the Cabinet table and would have read these comments in the media reports and given that she did not announce a ten-point plan at the time, I assume she was in the Taoiseach’s corner and that she also thought the health services were well resourced and world class. However, what happened next was the greatest fraud ever perpetrated against the people of Ireland. The health strategy and the primary care strategy, which was published two months later, were announced as Government policy and they both found their way into the Fianna Fáil and Progressive Democrats manifestos for the 2002 general election. The Taoiseach, the Tánaiste and Mr. McCreevy never intended to fund these reports to the extent they proclaimed prior to the general election and that contributed greatly to the position we are in today.
At the same time, it is unbelievable that the Government parties have doubled health spending since their re-election but they have also managed to double the number of patients on trolleys waiting for an acute bed in our hospitals over the past 18 months. The Progressive Democrats  members consider themselves accountable and providers of value of money as they look after the taxpayer’s money but they should ask themselves where all the money has gone over the past four years. When €150 million went down the Swanee during the PPARS debacle, the Tánaiste informed the Oireachtas Joint Committee on Health and Children that maybe that was where all the money had gone. However, the taxpayer should receive improved accountability for what has gone wrong with the health service, given the amount invested.
Why was the accident and emergency department problem allowed to go so much out of control that at first it became a crisis and then was finally declared a national emergency by the Tánaiste last month? In October 2004 she stated it was unacceptable for people to spend up to 12 hours on a trolley while last month she stated it was unacceptable that the waiting period in accident and emergency departments had increased to 24 hours. She announced a six-hour waiting list earlier. This was an announcement for consumption by people who do not pay much attention and it sounded like spin. However, the position has deteriorated over the past four years, no matter which way one looks at it, and the Government should be more accountable.
The public will tolerate the arrogance of a number of Ministers but not when it is mixed with the incompetence and complacency we are witnessing. I have sympathy for the Tánaiste because she is trying to put a Band-Aid on a gaping wound in our health services so that the Progressive Democrats can limp past the post following the next general election. However, while I agree many of the problems she faces were developed by her predecessor, she bears collective responsibility as a Cabinet member for what has gone wrong in our health services.
During her 18 months in the portfolio, she has suffered a dose of “Micheálitis” as she publishes one report after another without making great improvements to the health services. She has taken to publishing reports with the same gusto as her predecessor, Deputy Martin. The Health Service Executive commissioned a report on acute hospitals.
The report on Wexford General Hospital was exactly the same as one commissioned by the hospital in 2001. The problems highlighted in both reports were the same, even though they were published five years apart. Both reports acknowledged that the accident and emergency department was too small to cater for the numbers attending, was not fit to provide modern day emergency health care, was cramped and offered little patient comfort, privacy or dignity. The same report on Wexford Hospital could apply to many other hospitals because it states the hospital has fewer beds and staff per capita than many other acute hospitals. However, I would like the Tánaiste to pay particular attention to the following statement in the report:  “That hospital’s medical admissions unit, which opened 18 months ago, is experiencing difficulties moving patients on to wards due to the lack of beds”. She is attempting to portray the medical admissions unit concept as the solution to the accident and emergency department problem but it is only part of the solution.
The Tánaiste referred to the accident and emergency departments in Kilkenny and Waterford hospitals as success stories. The reason the medical admissions unit in Kilkenny is successful is that consultants work well together and have equal responsibility for the unit. In addition, in 1997 a number of acute beds were opened in the hospital which allowed management to move patients ready for admission from the medical admissions unit to the hospital proper.
When Professor Drumm appeared before the Oireachtas joint committee, he stated Waterford Regional Hospital was a success story in terms of patients not waiting on trolleys. However, the reason for the success story is the accident and emergency department is located near the ENT ward, which holds 30 beds. Many patients who attend for ear, nose and throat procedures are told their appointments have been cancelled because accident and emergency department patients have taken their beds. ENT consultants are therefore attending the hospital with no work to do. The Tánaiste should be honest with the public. Waterford Regional Hospital has not resolved its accident and emergency department crisis because it is penalising ear, nose and throat patients.
Kilkenny hospital has succeeded because management secured additional acute beds while consultants are working well together. Wexford General Hospital is falling down in this regard. Accident and emergency departments represent a bottleneck in the system. Patients must queue to gain access to an acute bed in a hospital. The solution to this crisis is the proper delivery of acute beds. Many of the other solutions mentioned will have a varying impact on the crisis but the only solution that will make a difference is an increase in the number of acute beds. The Tánaiste is moving too slowly in this regard. The Government parties have only delivered 380 new inpatient beds since the previous general election, even though they published a report prior to it in which they stated they would deliver 3,000 new acute hospital beds. At that time, she did not describe them as day beds, acute beds, recliners or couches. She said that there would be new beds in the hospital system, but she has not delivered on that. That is why the crisis exists at the moment.
Fine Gael has put forward some solutions to the accident and emergency crisis. The solutions will not in themselves solve the problem, but they will help. To solve the hygiene problems, there is little point in auditing hospitals by informing them that they will be checked once or twice a year. Some form of flying squad must be set up  that can arrive at these hospitals unannounced. In her speech, the Tánaiste spoke about making someone responsible for accident and emergency departments, but she must do the same for hygiene. Patients should be able to contact someone to report that bathrooms or wards are filthy. That is the only way to improve standards. Security, alcohol abuse and the behaviour of drunks in accident and emergency departments has also been made a top priority by Fine Gael. It is not acceptable that staff and patients, particularly the young and the elderly, should put up with the behaviour that goes on in accident and emergency departments on weekend nights.
The Tánaiste again paid lip service to this problem. The Minister for Justice, Equality and Law Reform is trying to legislate for it, but we must ensure people’s experience of hospitals is more acceptable. People are afraid to enter hospitals as patients or visitors because they are afraid they will pick up something. That is a disgraceful standard for a country that has seen the best of times in the past nine years, but we have had the worst of Governments when it comes to delivering an acceptable health service.
We must examine the kind of patients that enter accident and emergency departments. Many of these patients could easily be treated in primary care by their general practitioners. Others have problems that could be dealt with by GPs, but they need access to diagnostic services, which are not being delivered. However, the real problem in accident and emergency departments is the number of patients lying on trolleys that need to be admitted to a bed. These are the most vulnerable.
There has been much commentary about what Derek Davis said at the IMO conference in Killarney. He is right in many respects. His comments may have been too general, but that can often be the case. There is a manpower crisis in general practice. GPs have done their best to cope with the pressures on them. There were about 50 practice nurses in Ireland 15 years ago, but now there are more than 800. GPs have invested in primary care centres, mainly because the Government has done nothing about it. The Government has provided tax concessions to build private hospitals, but there are no tax concessions for primary care. If a problem exists whereby patients cannot access general practice services, it is because such services are shrinking due to the lack of Government involvement in primary care. I fear for the future of general practice and primary care.
I know the patients who will be worst affected by the fact that the Government is doing nothing. The patients that are worst affected are those to whom the Government has most responsibility, that is, those who have medical cards. They will be squeezed out of the system because the Tánaiste is not taking control of the situation. GPs will provide the service and it is insulting that the Tánaiste can state that there is no GP  service out of hours. Does she know how much her Department pays out every year for out-of-hours services in this country? Either someone is carrying out massive fraud in the health service, or an out-of-hours service is being provided. North County Dublin is the one area over which she had control in terms of out-of-hours service, but she and the HSE did not seem to be committed to its delivery. It could have been easily provided over a year ago.
It has been stated that the lack of an out-of-hours service has contributed to the rise in numbers attending accident and emergency departments. I will be working in such a service next weekend in County Wexford, but 41% of patients will still go to accident and emergency departments. In some respects, it is the choice of the patient. Tourists, immigrants, young people who do not have a GP and others who do not understand how the system works will often attend the local accident and emergency department. They do not do this because they cannot access a GP service or because they think it is expensive. If one attends a GP out of hours and then attends an accident and emergency department with a letter from the GP, one will not be charged in the accident and emergency department. That should be highlighted a little more.
I do not accept the solutions proposed by the Tánaiste. Derek Davis stated that if his GP provided blood results and x-rays to patients on site, more patients would go to primary care, but I do not think that is true. There is only one place in which patients can receive a consultation, get a blood test and an x-ray carried out and have results given on site, that is the VHI Swiftcare clinic in Dundrum, opened by the Tánaiste. Not many patients in the country would pay the €200 demanded for such a service if we offered it to them. Only a small percentage of the population can pay such an amount of money for such a service. A service which involves access to diagnostics and blood tests must be provided in the public system. I am not interested in her comments about people making more money. People who are earning good incomes in this country do not have that kind of money to pay out on health care costs. That money is there to pay high mortgages and for a range of stealth taxes that have been brought in under this Government. Just because they have high incomes does not mean that they have the disposable income the Tánaiste imagines. We should still be providing these health services to people in the public system like before. The Tánaiste is privatising the health services and it is unacceptable.
People often pay these high costs in places like Dundrum out of fear, especially for their young children. That is why I am a strong advocate of providing medical cards for children under five years of age. People come to the doctor out of fear for their babies and young children. My wife and I are both doctors and we have often been  concerned about our own children at that age. The Tánaiste is disconnected from what is happening to the public. Many issues raised in her speech constitute a list of failures in the delivery of health services.
The role of consultants in the health service is very important. Some of the consultants feel hard done by as a result of some of the comments we have made. I have been critical of a number of consultants and the Lourdes report has confirmed many of the things about which I have spoken. The criticisms only relate to a small cohort of consultants. It is disappointing to see how little importance the Tánaiste put on the recommendations of Judge Harding Clark and that she is not moving on the issues that need to be addressed urgently. We only need to worry about a very small percentage of consultants in our health care service. The vast majority of them are doing a good job.
There are major industrial relations issues in the acute hospital sector, yet the Tánaiste talks about expanding the availability of diagnostic services for longer periods of time. She has been talking about this since the day she entered office and the Government is now nine years in power. Instead of talking about it, she should be telling us how she overcame these problems. It is an absolute disgrace that these diagnostic services are not available for longer periods of time in our acute hospitals. If one suffers a stroke in Carlow, Kilkenny, Waterford, Wexford or south Wicklow, one must go to Waterford to get a CT scan. The other acute hospitals in the south east go off-call at 5 p.m. That is a disgraceful use of an extremely valuable service.
Even CT scans are not considered as high-tech as before. There is now a whole range of diagnostic services such as MRIs and PET scanners. The fact that our CT scanners are not working 24 hours a day shows that Government has been paying lip service to the problems in our acute hospital sector.
Accident and emergency departments are in crisis but that is just the tip of the iceberg. They are problems patients do not understand and to which people do not pay much attention because they have not yet become crises. Problems are building in the HSE and in general practice. The day will soon come when GPs are not available and the crisis in accident and emergency units will become worse. Regardless of the spin put on cancelled elective procedures and patients who must wait forever for operations, patients have lost hope. These problems will become worse over the coming years, yet we will be able to do little about them because the Government has allowed them to build up over the past nine years.
Ms McManus Ms McManus
Ms McManus: The second anniversary is approaching of the publication by the Tánaiste and Minister for Health and Children of her ten point plan to resolve the accident and emergency  crisis. She promised real and measurable improvements within months, stating:
Accident and emergency is a litmus test for me, for the government and for the people of our country. By focussing our analysis, our funding and our energy on this area I believe we will achieve tangible improvements this year.
The year she referred to was 2005. We are now in the second quarter of 2006 and are still waiting for the colour of the litmus paper to change. There are no signs of the promised real and measurable improvements. This year, the situation has worsened and there is no relief for patients. When it comes to the Tánaiste’s solutions for the accident and emergency crisis, I am reminded of Estragon’s line in “Waiting for Godot”: “Nothing happens, nobody comes, nobody goes, it’s awful.”
Recently in the Coroners Court, a case was highlighted of a woman who died on a trolley in the nurses’ tea station after waiting four hours to see a doctor. The doctor giving evidence said: “it is inexcusable what happened”. A doctor in Letterkenny explained how hospital staff move heaven and earth to find beds for terminally ill patients on trolleys so that they can have a chance to die with dignity but noted: “the tragedy is we are not always successful...it’s awful, awful, awful.”
Yesterday, 198 patients were on trolleys in our accident and emergency departments. The winter is over, the seasonal pressures are off and there is no flu epidemic, yet 198 people were waiting, nothing happened and it was awful. Not as awful as last month, when the number of patients on trolleys nearly topped 500. In Wexford hospital, where 40 patients were waiting, staff ran out of trolleys and had to go as far as Tipperary to find more.
The ten point plan has been shelved alongside all the other plans to tackle the accident and emergency crisis. The ten point plan bears a close resemblance to plans that the former Minister for Health and Children, Deputy Martin, used to serve to us on a regular basis. The minor injury units and chest pain and respiratory clinics have not materialized. Unbelievably, the promised MRI scanner for Beaumont hospital still has not been provided. The word is now that it will not be in place until October or even April of next year. The acute medical units are still awaited and the promised provision of GP out of hours cover for north Dublin has become a farce. Less than 10% of our hospitals have proper hygiene standards and, every day, members of staff are put at risk because of insufficient security.
The record of the Tánaiste with regard to keeping her word is abysmal. She staked her reputation on the successful delivery of her ten point plan. The reality is she has performed so dismally that it is even beyond her to provide diagnostic equipment to Beaumont hospital to relieve the  pressure. It seems the central task of taking responsibility for the health service is also getting beyond her. Increasingly, she is off-loading her burden on to the HSE and, in particular, Professor Drumm. We no longer receive answers to parliamentary questions from the Tánaiste but referral letters to Professor Drumm, who then refers us to the parliamentary unit in the HSE. Then, like patients waiting for an appointment to see a specialist or for a bed in a hospital ward, we are left waiting weeks and sometimes months for a reply.
Meanwhile, the Tánaiste gives lectures to everyone else in the health service about how they should be more efficient and harder working. It is particularly risible that the Tánaiste ticked off doctors for not working 24 hours a day like her old GP, given that she was on a lengthy break from the Dáil herself. The hallmark of this Government is the extraordinarily low number of parliamentary working days it delegates to itself.
The Taoiseach does not lecture in the way his Tánaiste does but depends on plain old verbal abuse. When referring to the relatives of patients on trolleys he merely said:
People say “so what about Joe and Mary down in A and E; they shouldn’t be on a waiting list”. Now, I think it’s a pity that people are so unintelligent, really.
This Government considered us fools when we complained about patients on trolleys, until the actor Brendan Gleeson articulated on the “Late Late Show” the deep and widespread anger and dismay about what is happening in our hospitals. That caused the Tánaiste to snap to attention and declare an emergency in accident and emergency services. A declaration of national emergency demands rapid and significant action but, in this case, the Minister declared an emergency and disappeared to Limerick to address the party faithful. Nothing happened. Not one additional resource was provided or action taken as a result of her announcement. The task force in which she lays such store is not markedly different from what was previously in place and what should always be in place if the HSE is ever going to live up to its ambition to deliver a streamlined administration.
The single most important response to the emergency has been a one day debate around a smug, self-congratulatory and delusional motion which only proves to the public that this Government has lost touch with the people and is quickly losing its grasp on reality. That is why I proposed on behalf of the Labour Party an amendment which not only sets out the problem but outlines the solution.
On 1 November 2004, when the Tánaiste took over as Minister for Health and Children, 166 patients were on trolleys. On 8 March 2006, 495 patients were left on trolleys. The deterioration in the service has been real and measurable. This was foreseen by doctors working in accident and  emergency departments but their concerns were ignored. If a declaration of emergency is to have any meaning, the necessary changes must be fast and funded but that has not happened. We need a clear programme of capacity building and the provision of more beds must be central to that programme.
In 1980, 33% of acute bed capacity was removed from the system, yet our population has increased by almost that amount. Of the patients admitted through accident and emergency departments, 71% are elderly people. By 2026, our elderly population will have doubled and the Government’s own health strategy determined that 3,000 new acute beds are needed, yet all we have from the Government are muddled thinking and mixed messages. Professor Drumm does not agree to new beds, so the Government flip-flops on the issue. Yesterday, the Taoiseach said we do not need any new beds, yet three days earlier, the Minister for State at the Department of Health and Children, Deputy Seán Power informed the IMO conference that the Government planned to provide 450 beds over the next six years. That figure falls far short of what is required but does answer questions about the content of Government policy. We hear various declarations from Ministers and it is difficult to ascertain the proposals coming from the Government. It is clear, however, that the great capacity building project promised in the health strategy has stalled. The 900 beds the Minister of Health and Children has promised are too few, too late and hundreds of them are chairs and trolleys rather than beds. At least the Minister of State, Deputy Seán Power, had the grace to turn up. His senior Minister was too busy talking to the party faithful and Professor Brendan Drumm, the CEO of the HSE, made the extraordinarily shortsighted choice to attend the PD conference instead of meeting the organisation that represents 6,000 doctors. At a time of emergency, officers usually talk to the troops on the ground and by showing them leadership build up their morale, which needs to be done considering the state of the health service. In this emergency the officers absented themselves and went to Limerick instead of to the front line. Is it any wonder health professionals feel let down? This lack of leadership is at the core of the problem. Health professionals and their patients need strong and clear direction from the Taoiseach and the Tánaiste. They are not getting it and they will have to wait for a new Government before it happens.
Professor Drumm has argued for more beds for the elderly in the community and I agree with him. At least 1,500 new community long-stay beds must be provided by 2010, but he and the Minister are disingenuous when they talk about this issue. This week for the first time I was able to publish the truth of what is happening with community beds. Figures in the latest Labour policy document that  we launched this week record that the number of such beds is falling, not rising. The information was extracted from the Minister as if it were a State secret. I put in a parliamentary question on 29 November 2005 and did not receive a reply until 29 March 2006, and even then some of the data was blank. It is clear the Minister and the Government have presided over a significant reduction in the number of long-stay community beds for the elderly since taking office in 1997.
In Dublin south city there are 80 fewer beds for the elderly now than in 1996. In Limerick there are 60 fewer beds, in north Tipperary 43, in Meath 25, in Westmeath 28 and in Longford 16. Many of these are areas where the elderly population is higher than the national average. All her rhetoric about elder care is contradicted by the facts. Far from investing in new beds in the community, Deputy Harney and the HSE have closed beds and denied elderly people the chance of a bed in a community nursing environment close to their homes.
To solve the accident and emergency crisis a radical shift towards primary and community care is required. Labour will tackle the issue effectively and comprehensively by its commitment to the following proposals: to provide acute hospital beds to meet current and future needs; to ensure accident and emergency departments are dealing with accidents and emergencies and that direct referral by GPs of patients is facilitated and encouraged; to increase the percentage of those on medical cards to 40% of the population; to ensure high-class management of chronic illness in general practice; to implement a primary care preventative strategy; to increase the numbers of GP training places to approximately 160 annually and double undergraduate places for Irish and EU citizens; to integrate primary health care services at community level; to integrate primary and secondary care; to expand and support GP out of hours service, with particular encouragement of GP co-ops; to encourage GP-based audit and research and have universal patient registration and robust data collection systems; to ensure there is comprehensive legislation to allow for compulsory peer review by the Medical Council for standards of care; to ensure accountability by making the Minister for Health and Children answerable to parliamentary questions; to aim to have a hospice in every former health board area with a palliative care team in the local hospital or primary care centre; to increase the numbers of home care hours and ensure proper contracts; to expand community support services for elderly people to enable them to live independent lives as far as possible; to build at least 1,500 additional community beds by 2010 to meet current and future needs; and to ensure a comprehensive, integrated and well-funded range of mental health services at primary care level.
When the public began to protest at the way elderly and frail people were being marooned on trolleys in corridors without dignity or comfort  they were insulted by the Taoiseach and lectured by the Minister. People are entitled to a well planned, fair, well resourced and efficient health service to meet their needs. Like the patients on trolleys in accident and emergency the people are being forced to wait for this by an incompetent and bloated Government. Fortunately we live in a democracy and the people will have an opportunity to choose not just a new and different Government, but a better one.
When one speaks in a debate such as this there are many cases of people who are having difficulty accessing care one wants to bring forward. When we concentrate only on the accident and emergency department we do not give the full picture of people who are sick and suffering. I know a man who has an extreme case of psoriasis and who needs treatment to relieve the pain and suffering it causes. He wants to have that treatment in Hume Street hospital and will have to wait until December. I was contacted in the last few days by another patient who requires treatment for a dermatological condition but has been told she will not see a specialist for three years. That is the experience. These people are paying taxes and are entitled to expect a decent service in return. One of the reasons there are so many pressures on our accident and emergency departments is that the services and capacity are not there to meet people’s needs earlier. A condition becomes an emergency and people present at accident and emergency departments. Accident and emergency departments must deal with crisis cases while other people are admitted to hospitals via alternative routes to hospital care such as a GP’s referral or other means we see in a few isolated cases where hospitals such as St. Luke’s in Kilkenny operate different systems of admission. That must be developed but it requires capacity.
It is disingenuous on the part of the Minister and Professor Drumm to say we will not need extra capacity in our acute hospitals. Our population is growing rapidly and aging and we will have to provide the acute hospital beds to meet its needs. There is no other way to do it. Beds are not the sole solution but are part of it. When doctors complain and make that point we must listen to them. While the Minister says she wants to hear from consultants, she wants to hear only what she wants to hear. She does not absorb the message she is being given. The most startling event in recent times has been the public statement by neurosurgeons on the demands that they cannot meet. The fact that they, as professionals, are concerned about standards of care that are not being met for their patients, could be exposed to litigation and have been driven to the extreme measure of going public is telling. Hospital consultants are not known for their radicalism. If one was seeking an example of a non-radical group, hospital consultants would fit the bill. Yet, increasingly, when they are not being muzzled — I know of cases where attempts have been made — it is those like hospital consultants or nurses  who are on the front line speaking out on behalf of patients. The Government is not listening. The motion shows that it is disconnected from the reality of the health needs of our population. It is time for a complete change in the mindset that dominates a Government that is either incompetent, incapable or unwilling to meet the challenges that exist in the community and which desperately need to be addressed.
Mr. Gormley Mr. Gormley
Mr. Gormley: I wish to share time with Deputies Cowley and Connolly.
Mr. Sherlock Mr. Sherlock
Mr. Sherlock: Is that agreed? Agreed.
Mr. Gormley Mr. Gormley
Mr. Gormley: The Tánaiste stated in her address: “Every piece of the jigsaw to address accident and emergency department problems is in place: the analysis, the resources, the reform programme, the management, the targets, and the incentives”. As the father of two children under the age of eight, I have experience of jigsaws. When I look at the health service, I do not see a jigsaw puzzle that has its pieces in place but one which has its pieces all over the living room floor and which must be cleaned up and put in place, perhaps by the next Government. The Tánaiste described the situation as a crisis and a national emergency. However, what we got from her today was an exercise in spin. It was self-serving, self-congratulatory rhetoric. The previous Government spun its way out of this problem prior to the previous general election and got away with it.
I hope the Tánaiste is not about to leave the Chamber just as I am getting into my stride.
The Tánaiste Mary Harney
The Tánaiste: No, I am not. I look forward to the Deputy’s contribution. I think he will be doing his own spinning, given what I have heard.
Mr. Gormley Mr. Gormley
Mr. Gormley: The Tánaiste should hear me out. My contribution will not be over-complimentary.
The Tánaiste Mary Harney
The Tánaiste: I am surprised to hear that.
Mr. Gormley Mr. Gormley
Mr. Gormley: The Government got away with it at the previous general election but I do not believe it can pull off the same trick twice. The Tánaiste’s predecessors in office as Minister were Deputy Cowen, who kept his head down and described the Department as Angola, so full of landmines was it, and Deputy Martin, who was really the Minister for reports and who published document after document about the health service. He even established a commission on water fluoridation, which was a ridiculous exercise that cost a lot of money. All he needed to do was ask me and I could have told him about water fluoridation without costing him or the taxpayer a penny.
The Tánaiste took office like a sheriff coming into town on a horse. She was going to clean up  the Department of Health and Children and take no nonsense. The Tánaiste, like the Taoiseach, stated in this Chamber that she would deliver a world class health service. I said at the time: “Dream on”. The Tánaiste took umbrage at my comment but we are still far away from a world class health service. Instead of delivering such a service, the Tánaiste has begun to indulge in the blame game. She is dumping on the doctors and nurses who are apparently to blame for the crisis in accident and emergency. These are the staff on the front line who have contributed more to our health service than the Tánaiste ever has or will.
The Tánaiste has overseen the introduction of the Health Service Executive. My amendment to the Government motion states that the HSE has resulted in less accountability and transparency. Professor Brendan Drumm has effectively become a ventriloquist’s dummy. The Tánaiste is spinning a line which Professor Drumm takes up to propagate the same message, which is that lack of bed capacity is not the problem.
Some figures will help to encapsulate the problem. We have experienced a 25% increase in population since the 1980s but in that period there has been a 25% reduction in bed capacity. It does not take a rocket scientist to work out that there is a problem in this regard but, apparently, the Tánaiste has not worked it out yet.
The Tánaiste Mary Harney
The Tánaiste: There has been a 100% increase in day cases.
Mr. Gormley Mr. Gormley
Mr. Gormley: This problem applies across the board, not just in the health service. The Minister for Justice, Equality and Law Reform also must realise that we need more gardaí because our population has increased. Across the board, there is an infrastructural deficit and a problem with which the Government cannot cope which results from the growth in population caused by the growth in the economy. It is clear that the Government cannot manage growth in the economy.
Another problem the Tánaiste has failed to recognise is that 25% of those who present at accident and emergency units are intoxicated. The Tánaiste is not dealing with the unruly people who cause serious problems. The alcohol products Bill would have been a start but the Tánaiste shelved it and it mysteriously disappeared from the programme for Government.
The Tánaiste stated that this would be the litmus test. When I used litmus paper at school it was to judge the pH value of a substance. Someone would always mess about and put in a lump of potassium when we were trying to measure the pH values, which had severe consequences. The Tánaiste’s privatisation and Americanisation of the health service is similar. She is destroying the health service and making the accident and emergency crisis much worse through her actions. It is  time to discover that we want to be closer to Berlin than to Boston.
Caoimhghín Ó Caoláin Caoimhghín Ó Caoláin
Caoimhghín Ó Caoláin: We all knew that this Government was in disarray in its stewardship of the health services but this motion shows clearly that it has lost the plot altogether. Yesterday 331 patients were on trolleys and chairs in accident and emergency units in this State. That is the most telling answer to this bizarre, self-congratulatory motion from the Tánaiste and Minister for Health and Children, Deputy Harney. It would be laughable if we were not dealing with such a tragic situation for people who suffer daily in our hospitals. One must wonder at the real reason the Government decided to introduce the motion. It may well be the spin-off effect I highlighted earlier today in the course of the Order of Business.
The Tánaiste and her colleagues must take the people for fools. She recently described the situation in accident and emergency units as a national emergency. At the IMO conference last weekend the Minister of State, Deputy Seán Power, spoke of the “perceived flaws” in the health system and said that highlighting these “helped to create a false impression of a health system in crisis”. So, on the one hand, the Tánaiste states we have a national emergency while, on the other, the Minister State says there is no crisis.
The reality known only too well to people the length and breadth of this country is that we have had a crisis for years, not just this past winter or since the Minister, Deputy Harney, took up the health portfolio. This reality translates all too sadly into thousands of individual crises for patients and their families. People are being subjected to the dangers and indignities of overcrowded and often chaotic accident and emergency units year on year, with the situation worsening every winter. In the first three months of 2006 there has been a daily average of 300 patients on chairs and trolleys in accident and emergency units.
I commend the Irish Nurses Organisation on keeping the public informed of this through its Trolley Watch. This is in contrast to the HSE and the Minister’s office, which wish to conceal the real extent of suffering in our hospitals. In that regard, in certain hospitals patients on trolleys are now being accommodated in designated rooms or wards. They are still accident and emergency patients who are not admitted to a proper ward and still waiting for a proper bed, but patients in such rooms or wards are not included in daily figures for trolley-bound patients.
There is no mention of a national emergency in the Government motion, nor of one of the most essential measures needed to address the accident and emergency crisis, namely, a fully resourced plan to provide the 3,000 additional public hospital beds required in the system. That figure is not plucked from the sky but in the Government’s health strategy published in 2001, yet  there is no plan to provide those beds. There has not even been a proper audit of beds, an assessment of bed needs.
The Tánaiste’s solution to the bed shortage is one of the greatest frauds ever perpetrated on the Irish people. She quite rightly tells us that private beds are heavily subsidised by the State in the public hospital system and that those beds should be public beds. She is right about that, but her solution is to pour even more public money into the private health business through tax breaks for developers of private, profit-driven hospitals and gifts of land at public hospital sites. She claims that will free 1,000 beds in public hospitals, yet she does not tell us when or where we will see these beds. To achieve that alleged aim, the Fianna Fáil-Progressive Democrats Government reinforces the two-tier public private apartheid in our health services. The Tánaiste pursues a privatisation agenda, rewarding the greed of those who see the health service first and foremost as a profitable business rather than as a basic right to which all are equally entitled — I emphasise — on the basis of need alone.
As the Sinn Féin amendment to the Government motion states, all Government spending on health services should be on the public system only. The money spent on tax breaks for developers of private hospitals together with the money wasted on the HSE’s failed computer systems would already have funded 1,000 acute hospital beds in the public system.
The accident and emergency crisis has also been compounded by the closure of such units in smaller hospitals, including in Monaghan and Dundalk in my region. Those services should be restored as part of the overall measures needed to address both the immediate crisis and the longer-term reform of health services. On behalf of the Sinn Féin Deputies, I urge all Members to reject the Government motion and support the Sinn Féin amendment as the real alternative.
Dr. Cowley Dr. Cowley
Dr. Cowley: In three and a quarter minutes, it is very hard to make a major contribution to the debate, but I will mention a few points.
As someone who has worked in the accident and emergency department of Mayo General Hospital and in University College Hospital Galway, as well as having seen matters from the perspective of a GP over many years, I agree that it is a problem with many different causes. After our press conference, in which we outlined the case of a patient who died after having waited ten days to get into UCHG, the Tánaiste declared the accident and emergency situation a national emergency. However, it is not simply an accident and emergency crisis but one of the health service as a whole.
The man in question, who was in his mid-70s, died waiting for a bed that was simply not there for him. In a Republic where the citizen is king, we let him down. He was born around 1916 into a country where there was very little. However,  in this day and age, when we are supposed to be so rich, he died waiting for a bed.
Whether it is admitted, beds are a major part of the problem. It is a matter of simple mathematics that if an accident and emergency department is the portal of entry, once people are deemed in need of admission, they have no place to go. Two days before the man died, 12 people were waiting on trolleys in Mayo General Hospital and 20 at University College Hospital Galway. Before he could be admitted to a bed in UCHG, those 20 people would have had to be cleared from the trolleys.
It is not acceptable that this situation should continue. The neurosurgeons have said that they will all resign because of this. Hundreds are waiting for such services. I know that neurosurgeons have approximately 55 beds, with some for intensive care. That is very little for a country with such great needs. People are in acute hospitals who would not be there if there were adequate beds in neurosurgery, for example. Another example is the National Rehabilitation Centre, which has 200 people waiting for beds. There are 150 beds, 25 of which are for road traffic accident victims. People are occupying beds right across the board that they should not be occupying were there enough beds elsewhere.
I could continue, but my time is up. I have only begun to speak, and there are many other things that I could say, but beds are a very important part of the equation. We must ensure that numbers attending are reduced, but that cannot happen without investment in general practice. Some €1.3 billion has been promised, only approximately €14 million of which has gone into services to date. That tells its own story.
Mr. Connolly Mr. Connolly
Mr. Connolly: I too welcome the opportunity to speak in today’s debate. Problems regarding accident and emergency services have been aired daily for the past three years and I see no sign of debate having improved the situation. We should acknowledge that staff work very hard in what are often quite cramped conditions in accident and emergency departments. It is not a secure working environment and health and safety could be described as non-existent in what should be a rather safe place to be. That could lead to mistakes and it is not a safe environment for a patient.
Before today’s debate, I spoke to several staff in accident and emergency wards, asking for their opinions and assessment of the situation. It is very important to listen to what staff have to say. On several occasions, one of the first comments made has been that accident and emergency departments should be used for just that. Among problems described were admitted patients remaining in the department, which should not happen. A patient who has been admitted will receive no further active treatment there per se.
We should consider Nenagh, where GPs regularly contact accident and emergency admissions  officers and will only send the patient when they know that a bed has become available. That might mean holding the patient for an extra night at home, and GPs are often prepared to do that to offer the patient a service. GPs generally like to offer the best service, involving, for example, their sending the patient to hospital for a test. It is also wise for the patient to remain in the accident and emergency department for the result of the test.
If the GPs had the same access to diagnostic reporting as the hospital or could get it at the same speed, it would mean that the patient could go back under his or her care. Effectively, the patient is there waiting for the result of a test, and I have cited the example of a venogram. The patient would have to be treated for deep vein thrombosis for a period until a negative result was forthcoming. That is part of the problem.
Accident and emergency departments have been used by gardaí under section 12 as a place of safety for children. That too is inappropriate and unhelpful. Staff also cited the absence of social workers as a major problem, particularly when no social worker is available for young children or people who might need such a service. There is no weekend service and when it comes to 4 p.m. on a Friday, staff find that there is no social worker available, although many social problems present themselves at accident and emergency departments. Those are the matters that we should resource in the community and we should ensure that people are sent there.
Old people are sometimes sent to hospital despite the fact that appropriate treatment could be provided for them in a nursing home. Effectively, they find themselves there while they wait for a nursing home bed, again putting additional strain on hospital resources. The idea of a patient having to be seen by five people before admission is not safe. One goes to a GP and then has a sequence of people to see in the accident and emergency department, which is not the best use of resources. We should not second-guess GPs, who should know when someone requires elective admission to hospital. That person should be sent straight to a hospital bed.
In recent years, while problems have grown in accident and emergency departments, we have planned to close them in smaller hospitals. There were plans to close the surgical accident and emergency service in Monaghan General Hospital, as well as threats regarding Nenagh and Ennis. By now, we must have seen enough to shelve those plans and state publicly that such small hospitals play a major role in delivering accident and emergency care where allowed to do so. We have all sorts of ten-point plans, but I would like to see people listen to staff on the ground. I found that they had much to contribute, with many useful ideas.
 Sitting suspended at 1.30 p.m. and resumed at 2.30 p.m.
Dáil Éireann 618 Accident and Emergency Services: Motion.