Mr. Tony O'Brien:

I am grateful for the opportunity to address the committee. I am accompanied by Mr. Pat Healy, Ms Angela Fitzgerald and Dr. Colm Henry, all of whom are members of the emergency department taskforce in addition to their normal roles. The pressures on emergency departments over the past two weeks are not new or unexpected. As I have highlighted previously to this committee, the population over 65 years is growing by approximately 20,000 per year and the numbers of those aged over 80 years are increasing by 4% annually. Due to reduced budgets over the past number of years, the development of the required capacity within our community services to deliver home help, home care packages, and short and long stay residential care has not kept pace with this demographic growth. Furthermore, acute hospitals have experienced increased presentations and avoidable admissions, increased numbers of delayed discharges and unacceptable numbers of patients on trolleys in their emergency departments.

The data inform us that the numbers of emergency presentations in 2014 are up 2% on 2013 and emergency admissions are up by 8% over the same period. The main factor leading to the current emergency department pressures relates to higher numbers of delayed discharges in acute hospital beds when comparing this year to the same period last year. On 6 January, 745 delayed discharges were reported across the acute hospital services. This figure was approximately 150 more than at the same time last year and has led to a consequent increase in the numbers of patients on trolleys requiring admission, particularly in the first week of the year. This was despite hospital and community investments in transitional care beds during the course of 2014.

Winter planning is an embedded response within acute hospitals and community services. In order to manage increased demands, hospitals have been required to be at a state of escalation since autumn 2014. This is part of the normal planning in place to deal with the expected surge in demand in emergency departments whereby hospitals invoke escalation plans which include the opening of additional overflow areas, curtailing non-emergency surgery, providing additional diagnostics and working in an integrated way with their community service colleagues to strengthen discharge planning. Hospitals have continued to take these steps since September 2014, as required, so that patients who need to be admitted to hospital are admitted to a bed at the earliest opportunity. In preparation for the demands of the winter period, during the month of December the acute hospital system cancelled non-urgent elective activity to ensure maximum capacity to deal with emergency admissions. Primary and social care services in particular escalated their plans to facilitate discharges through the provision of home care, aids and appliances, access to community hospital beds where available, etc. In addition, the Minister for Health convened the emergency task force which supported the measures being undertaken by the hospital and community services to prepare for the anticipated additional demand for services during the key period post Christmas.

In recognition of the increase in delayed discharges and the fact that sufficient funding has not been available for the past six years during the recessionary period, the Minister has managed to secure a total of €25 million as part of the service plan for delayed discharge patients in 2015. Preparatory work for its implementation commenced in November 2014 and additional resources were allocated for delayed discharges in December. The full funding came on stream on 1 January 2015.

As delayed discharge figures reached their highest level by the end of November 2014, an additional allocation of €3 million was provided in December as an interim measure prior to the €25 million coming on stream to enable the early release of the additional 300 fair deal approvals immediately. This was in addition to the regular release of 700 places, bringing the overall allocation to 1,000 places for the full month of December 2014. Also in December, 165 additional transitional care beds were funded and targeted at hospitals in the greater Dublin area to facilitate speedy discharges.

Additional home supports were provided with a specific focus on supporting acute hospital discharge prior to the Christmas period. During Christmas week, 120 home care packages were provided in total, with 87 related to patients in the acute hospitals. The combined efforts of the above initiatives saw a net reduction of 109 delayed discharge patients with approximately 700 delayed discharges reported at the end of December 2014.

The full €25 million package is being implemented since January this year as follows. An additional €10 million for the nursing home support scheme will support in a full year the 300 extra places allocated in December 2014. This has had the impact of reducing the placement list to 1,160 in the first week in January and reducing the funding delay for fair deal from 15 weeks to the current 11 weeks. Short-stay residential care has been allocated €8 million to provide an additional 115 short stay beds, of which 50 of have been earmarked for provision in private nursing homes for the greater Dublin area. The remaining 65 beds will be opened in Mount Carmel on a phased basis commencing March or April 2015 as a dedicated community hospital for Dublin. Home care packages were allocated €5 million to provide 400 additional packages benefiting 600 discharges across targeted Dublin hospitals during the course of the year to facilitate patients to return to their own homes in the community. Community intervention teams were allocated €2 million to allow the service to expand its service levels in the greater Dublin region and deliver services to an additional 8,000 patient cases. In addition, new services are being established in Kildare, Louth and Waterford, servicing the main hospitals in these regions and providing direct access to GPs and nursing homes, thereby facilitating patients who would otherwise have to attend hospital unnecessarily.

In response to the continuing pressures in our emergency departments, all of the focus of our efforts during the month of January has been to maximise the discharge of patients from our acute hospitals who have completed their acute treatment either to home with home care supports where required or to more appropriate residential care. To achieve this we have sought to eliminate red tape as much as possible and during the month of January, as an exceptional measure, all patients who are clinically discharged but who require ongoing levels of residential care are being matched with suitable nursing home placements following clinical review. This will see a potential movement of 250 patients who are currently in acute hospitals to other suitable facilities.

While much of my previous commentary focused on delayed discharge as a factor, it is important to note that there are 28 emergency departments in Ireland and the challenges faced vary between each location. For example, in Beaumont where there has been a persistent level of delayed discharges and a number of people on trolleys, there is a direct relationship with the shortage of residential capacity in north Dublin. However, in Letterkenny, where over the weekend of the 3-5 January, 2015 there were over 31 people on trolleys, the problem was not related to delayed discharges but rather related to a particular spike in the number of unwell elderly presenting at the hospital. Another example is St. Luke’s in Kilkenny, which is a level three hospital with a very good reputation for integrated working across hospital and community and for maintaining low levels of delayed discharges and trolley waits. On Monday, 5 January there were 22 patients on trolleys in that hospital.

The current mainstream and integrated efforts at national level are enabling a cohesive and consistent response to cope with the demands. The leadership role of clinical directors, consultants and nursing management in carrying out additional ward rounds and discharge planning is also proving effective in alleviating the pressures in emergency departments. The role of primary care and social care in extending community intervention team coverage facilitates early discharge or hospital avoidance where possible and the use of public beds to decant patients from acute hospitals has contributed significantly in dealing with demand issues.

Early release of nursing home support scheme funding arrangements in December, coupled with the provision of additional transitional care beds and additional home care packages allowed discharge to continue throughout the month of December and the crucial Christmas period. At this point, nobody on the delayed discharge list is waiting for home care package funding.

Collaboration across hospitals in terms of enabling bed access has also assisted in reducing delayed discharges. Examples of this are the use of rehabilitation beds in Cappagh hospital by Connolly and Drogheda hospitals, the use of elective beds in Navan by Drogheda, and the optimisation of model 2 hospitals at Ennis, Nenagh, Bantry and Mallow, which contributes to alleviating waiting times for Limerick and the south west. The ongoing escalation of matching patients, numbering 250, who are medically discharged with nursing home care placements is proving beneficial in yielding capacity. There are recognised deficits in key service areas which support the discharge process, particularly of older people.

The level of home help service provision has decreased significantly over the past number of years, from €211 million to €185 million. Funding for home care packages has remained relatively static since 2008. Public residential care beds are a key component of service provision and must be maintained at existing levels, despite impending issues with compliance on infrastructure. Reliance on agency staff - medical and nursing - due to market conditions, together with associated challenges in terms of recruiting and retaining senior decision makers, is impacting on our ability to open additional capacity.

The review of the nursing home support scheme currently being undertaken by the Department will need to suggest longer-term solutions to place the scheme on a sustainable footing, recognising the demand-led nature of the scheme and an aging population. The development of the required capacity across primary and social care is essential to meet demographic growth in a predominantly elderly population. The challenge for re-registration of public long-stay beds with HIQA is a significant issue to be dealt with over the coming months, as there is insufficient capital funding available to meet all the requirements. There are over 30 large units providing in excess of 2,500 beds. There is currently insufficient funding in the capital plan to bring this infrastructure to the required standard.

I take this opportunity to acknowledge the discomfort and, in many cases, stress caused to patients and those who have experienced our accident and emergency departments over the past period and reassure them and the committee that we are doing everything possible to deal with the issue. I also thank the staff, including nurses, doctors and others, in the service for their diligence, patience and hard work amid such difficult circumstances.