Mr. Tony O'Brien:

I appreciate the invitation to attend the joint committee to discuss the issue of overcrowding in hospital emergency departments. The issue of overcrowding in our emergency departments is not just a problem for the emergency departments alone to resolve, but rather requires the entire health system to work together in order to address the issue and, hence, a number of senior colleagues from across the health care divisions are here today. All of them participate in the emergency department task force.

Before I outline the improvement measures, I would like to provide some background context in terms of hospital emergency activity. There have been almost 900,000 emergency department, or ED, new patient attendances for the year to date, as of October 2015. Some 83% of patients are seen and either discharged or admitted in nine hours or less. New ED attendances for October 2015 were 3% up on October 2014 levels. This is shown in table 1, which provides a breakdown and comparator between the two October periods, broken out by each of the hospital groups. New registrations at emergency departments were at their highest, year to date, in November 2015 at 99,418. Figure 1 shows the plot line for national monthly registrations. That shows the relative consistency, but slight increase, that is occurring there.

The week ending 9 November 2015 showed the highest number of new registrations of any week, year to date, at 25,055. This is against a backdrop of a 3.5% improvement on the INMO trolley count 30-day moving average in 2015 compared to 2014. The HSE TrolleyGAR, which is a separate measure, shows an 8% improvement for the same period. We can see that in figure 2 which charts the INMO trolley report. The blue line relates to the previous year, and the red line relates to the current year. As members of the committee can see, throughout most of the year we were consistently significantly above the previous year, but have recently seen those lines cross over as various measures kicked in.

Figure 3 shows the TrolleyGAR totals. I emphasise that these are 30-day moving averages, as opposed to day-by-day counts. That evens out some of the variability from day to day. The INMO count is a five-day week count, while the TrolleyGAR one is a seven-day week count.

The emergency department task force agreed a set of recommendations to address the issue of overcrowding in emergency departments. The HSE is implementing those recommendations and is working to ensure safer and timelier access for patients to assessment, treatment and admission or discharge. The recent escalation directive, issued on 27 November 2015, will ensure that attention and efforts are focused on new procedures and processes to prevent patients waiting any longer than nine hours for a bed following a decision to admit. It is intended that this mandatory directive issued under the accountability framework, which is part of our service plan for the current year, will drive a focus on good internal practices within hospitals such as the appropriate streaming of patients through medical and surgical assessment units; care planning and setting an expected date of discharge for every patient; use of centralised bed management systems to direct access to beds and direct the further development of short-stay, cohorted and specialty wards; and multidisciplinary team meetings planning for complex discharges. I have asked that the special delivery unit take a key role in ensuring adherence to this directive.

Within our emergency departments and acute medical assessment units, focus is being maintained on continuing to improve efficiencies in the internal processes around assessment and treatment. An immediate priority has been to reduce the number of patients having prolonged waits on trolleys. Recent improvements in sites allow for further focus on improving processes such as triage, time to first clinical decision maker, access to diagnostics, and development of rapid access pathways, such as stroke, fractured hip,etc.We are continuing to remain vigilant of the challenges that always present at this time of the year in the context of winter planning. We conducted a series of meetings in October with all hospital groups and community health organisations, CHOs, around their integrated winter plans, reinforcing lessons learned from previous years around preparedness, especially as it relates to the first two weeks following the Christmas and new year holiday period.

We are seeking to create additional capacity within the system by agreeing delegation of skills and tasks to other disciplines, for example, nurses performing IV cannulation, delegated discharge, 8 a.m. to 8 p.m. opening of radiology departments to support access to diagnostic investigations and progressing the opening of up to 440 additional beds. We are recruiting additional staff in all professions both within and outside emergency departments, EDs, who will support patient access, assessment and flow-through the services, for example, consultant geriatrician and support teams, inclusive of nurses, occupational therapists and physiotherapists, to work in the community to provide alternative to ED presentation or to facilitate earlier discharge from hospital.

For example, in Beaumont Hospital we have placed a physiotherapist and occupational therapist in the ED to assess older people in the ED and the acute medical assessment unit, AMAU, for frailty. This service, while relatively new, beginning in September 2015, has proven to be effective in avoiding admission for some patients and reducing length of stay for others. A 10% reduction of medical inpatients greater than 75 years with an average length of stay of less than 30 days is a baseline measure which compares that to 287 admissions in October with 259 admissions in the same category. It also serves to fast-track appropriate patients for comprehensive geriatric assessments.

We continually monitor and seek improvements in length of stay, LOS, and due to a reduction in delayed discharges we have seen improvements in two to 14-day LOS which in turn improves throughput and patient flow through both the EDs and AMAUs.

We are also changing services to reshape and reduce demand on ED services by improving services in primary care.

For example, the primary care focus is on strengthening existing alternatives to hospital emergency departments and on creating new options for patients and referring clinicians which do not necessarily require attendance at hospital emergency departments. These include further development and expansion of the GP out-of-hours service to provide complete cover nationwide. This process will be complete in 2016, with activity levels expected to exceed 1 million patients per annum. There will be an expansion of the community intervention teams and out-patient parenteral antimicrobial therapy service, OPAT, which is now operational at 11 sites and has capacity to treat 24,000 patients per year. There will be increased diagnostic capacity to provide GP access to X-ray and ultrasound examinations without recourse to hospital radiology departments. This has meant 16,000 tests in 2015, which will expand in 2016. Minor surgery capacity in primary care will be developed, starting with 20 sites in 2015 and expanding to 80 sites in 2016. Palliative care capacity in the community will be expanded with additional specialist beds in Galway and Kerry and consultant and clinical nurse specialist appointments in under-serviced areas such as the midlands and the north east. An increased focus on flu vaccination for vulnerable groups in partnership with the health and wellbeing division is also a key part of the hospital avoidance strategy this year. This will help to prevent flu outbreaks and the ensuing pressure these give rise to on hospital emergency departments during the winter months.

In the context of the national service plan and the additional €74 million investment package provided during the year, the HSE has been in a position to reduce waiting times on the nursing home support scheme, or fair deal scheme , to no more than four weeks as well as providing 600 additional home care packages. The funding has also enabled the opening of 214 additional public short stay beds on a permanent basis, including 65 beds in a dedicated community hospital for Dublin at Mount Carmel. We have also provided approximately 240 transitional care beds which provide 83 transitional care places every week to 17 acute hospitals across the country. This amounted to approximately 3,600 places provided in 2015. The impact of all this work in collaboration with acute hospitals and our primary care colleagues saw a reduction in delayed discharges from a high of 830 in November 2014 to a current November average of 568. This represented a 32% reduction in the overall delayed discharge numbers as detailed in the graph in figure 4 in the document circulated to members. The blue line for 2014 and red line for 2015 show the crossover that occurred as a result of the additional funding. This is a matter we discussed here in the committee in February last year.

Following their highlighting here, decisions were made at governmental level to address the key issues. Members can see how direct an impact that has had on delayed discharges. This work has helped free up bed capacity in acute hospitals for more acutely ill patients and there is evidence that this is having an impact in a number of hospitals. There are now 16 hospitals showing trolley waits below the same time last year, including six of the eight focus hospitals as per table 2 in the document on screen now. It shows the movement and percentage improvements. Some improvements are greater than others and there are some disimprovements also. As we have previously discussed, this is not one single nationally defined problem; it is a whole series of locally defined problems. The solutions are tailored and the results are variable.

With that and the sharing of this information, I conclude my opening statement. My colleagues and I will do our best to answer any questions the committee may have.