Dr. Colm Henry:

Although we track junior doctors closely through each six-month cycle, one never knows exactly what the figures are until the day of change because people may withdraw their applications or move elsewhere. We have had additional junior doctors in the past year because of our duty to comply with the emergency working time directive, EWTD. Despite these difficulties, as of last Monday, the day of changeover, our outstanding vacancy rate was 170 out of a complement of almost 5,000 junior doctors. This figure has been remarkably consistent over recent years. It hardly changes and tends to be concentrated in the same specialties in the same hospitals. Although we have had worries at times about keeping certain services going, we have managed to maintain front-line services even in the hospitals which are particularly challenged in terms of recruitment.

The question on older people is interesting and is one about which we all need to be mindful. One could argue that by the time a frail older person arrives at an emergency department, it is almost too late to consider alternatives. Like other health care systems in the western world, we must consider alternative pathways for older people that are more sustainable, fairer, kinder and more appropriate to their needs. Older people can present to day hospitals. In Cork, where I work, geriatricians visit the community hospitals to avoid hospital referrals.

In Blanchardstown, we made an innovative appointment where a geriatrician works half time in the community and half time in the hospital. During her tenure, referrals from nursing homes have fallen by 20% to 30%, so simply by her crossing that interface and identifying elderly people, she has managed to avoid their referral to hospital and to treat them as day cases or in step-up beds in hospital. It is a much more humane and kinder approach to people who do not want to be on hospital trolleys. We must expand the idea of addressing the care of older people before they ever come to hospital, identify at risk cases, have case managers look at these people and work with hospitals to identify a menu of options other than referral to emergency departments, in particular in the Dublin area. This takes time and it is a cultural change which requires a change of mindset among all those engaged in health care. It is part of the initiative in which we are engaged. We will be developing such models in Dublin.