Dr. Emily O'Conor:

May I begin with an apology? Despite the committee's invitation being dated 16 December, it got to me at 3 p.m. yesterday. The absence of a more prepared opening statement reflects no disrespect to this committee, but rather reflects the reality that the executive of the IAEM is a voluntary organisation with no administrative support and composed of consultants working full-time in emergency medicine. As I am sure that the committee is aware, it has been a busy few weeks.

I thank the committee for the invitation to speak. There are one or two factual inaccuracies in its draft of my opening statement, but I will submit a corrected version to the secretariat and this will be available to members.

Crowding in emergency departments is caused by the boarding of admitted inpatients on trolleys in those departments because there are no beds available on the wards. These patients have completed their emergency phase of care. They are not so-called inappropriate attenders, drunks or those with minor illnesses or injuries. That group of patients does not need hospital beds. Inpatients on emergency department trolleys cannot be diverted from needing a hospital bed by improving general practitioner, GP, care, at least not in the short or intermediate term. General practice needs investment in its own right and, in the long term, its role in preventative medicine and chronic disease care will reduce the need for hospital care. However, that is in the future. Patients boarding on emergency department trolleys are not victims of poor care from GP or emergency medicine. Mostly elderly, they are victims of a lack of capacity across the entire health care system. They need hospital beds.

Crowding in emergency departments - the boarding of admitted inpatients on trolleys in emergency departments - is the overflow valve of the Irish health care system. We do not say "No". We do not close our doors. We should not be allowed to become "full". Crowding in emergency departments is not caused by the departments themselves, but by a capacity deficit across the entire health system. Crowding in departments causes significant reputational damage to Irish health care and emergency medicine in particular.

Approximately 1.3 million citizens attended emergency departments in 2015. Last year, the number attending the emergency department that I work in, Connolly Hospital Blanchardstown in west Dublin, rose by 8.7%. That is likely reflected across the system and should come as no surprise. Our population has grown, our people's health care needs have become more complex, we are surviving for longer with conditions that previously would have killed us, and we expect and are told to expect timely care. Adding the 8.7% to which I referred to the 2015 figure of 1.3 million emergency department attendances means an extra 100,000 attendances last year. Approximately one quarter of people attending go on to need hospital beds. In broad terms and based on my calculations, an extra 20,000 to 30,000 patients needed admission from emergency departments to hospital beds last year. We need more beds.

This is not to say that crowding in emergency departments is new. Patients have suffered boarding or warehousing on emergency department trolleys for nearly two decades. I remember statements from Members of the Oireachtas in the past. I believed that the situation would improve. It did not. It is getting worse. There were 520 people on trolleys yesterday. One of the inaccuracies in my submission can be seen here. I wrote "286", but last year's target for the maximum number of patients to be boarded on trolleys during the winter initiative was actually 236. For those patients, even that target was unambitious and posed an unacceptable clinical risk, but did we ever have a hope of meeting it? The answer is not with current bed capacity. We lost so many beds from the acute hospital sector in the 1980s and 1990s that we are now down to 2.8 acute hospital beds per 1,000, which is well below the OECD norm of 4.3.

Over the decades, processes have improved across the system, even if that improvement has been patchy. We tried to cope and keep patients moving through the system, but we failed. We fail patients every day. The UK has approximately the same percentage of acute hospital beds per thousand. There was significant investment in process change in the UK. It started just after I left there in 2000 and saw the introduction of targets, leading to a reduction in trolley waits. However, that improvement has reversed because the UK has run out of bed capacity. The NHS is experiencing crowding in emergency departments because of inadequate bed capacity across its health care system. I have included in my submission a reference to the Royal College of Emergency Medicine, which has a great deal of information on this matter.

Ireland needs capacity built into general practice, community care and home care, but we will see headlines about the trolley crisis again next year unless acute hospital bed capacity is built or commissioned now. Hospital beds must be commissioned, built, opened and staffed. Crowding in emergency departments causes a greater risk of preventable deaths, poorer medical outcomes and longer lengths of stay and lessens the chances of those aged over 75 years returning to their pre-admission health levels. Evidence from high-quality international studies is freely available and widely accepted. I can supply references to committee members if necessary.

Overcrowding is also undignified and uncomfortable. It is noisy and always bright. In one's moment of crisis, imagine giving intimate details to a doctor - me - in a corridor where it is so noisy that one has to shout. Imagine having diarrhoea and queuing for a single toilet cubicle with 20 other admitted patients. This happens. Imagine having an ECG or heart trace done in a public corridor. Imagine being immunocompromised, perhaps post chemotherapy, and sharing a corridor with ten others all coughing loudly. Imagine shouting at the nurses and then feeling guilty because one knows it is not really their fault.

Imagine being a nurse coming onto a night shift to care for ten patients who are over 75 years of age and have all been on trolleys since one left the night before when one promised them that beds were coming. Imagine that feeling of hopelessness that they are still there. Imagine being an enthusiastic doctor who comes on shift every day knowing that there are lots of patients in the waiting room who have been waiting hours to be seen and there is no place to see them. The doctor takes a history in the corridor, but there is no place to lie the patient down for an abdominal exam. The doctor circles the department for any spot that will provide a bit of privacy. He or she finds a space, but before the doctor gets the patient there, another patient takes it, so the doctor starts again. Imagine how enthusiasm wanes. Imagine how relationships turn sour. Spend years doing this and understand how it breaks morale in a department and in a specialty. Are we surprised that recruitment is difficult?

We are again going abroad to recruit nurses while we export our own to countries with better resourced emergency medicine.

Ireland has excellent medical schools with large numbers of students interested in emergency medicine. We have excellent core and higher training in emergency medicine, delivered by consultants in emergency medicine, as well as producing high quality consultants in emergency medicine. However, they cannot work in our public system. The conditions for patients are too poor, the environment too hostile. There are more Irish consultant emergency physicians in the Australian state of Victoria than in Ireland. We produce five home-trained consultants in emergency medicine every year, I can only name one or two who have gone through a Public Appointments Service competition over the past several years and have been appointed to a permanent post. Instead, they are going into temporary locum posts, full-time private practice or leaving the country.

Ireland has 80 consultants in emergency medicine spread over 29 emergency departments. Some emergency departments do not have a consultant in emergency medicine on call out of hours. This is not acceptable. The Irish Association for Emergency Medicine, IAEM, has done work on a staffing document showing how appointing consultants in emergency medicine gives breadth and depth of care. With adequate numbers, we can look at extending hours of direct shop floor care and resuscitation. We can have consultant-delivered clinical decision units and ambulatory care to further deliver admission avoidance. Without more consultants in emergency medicine, we will continue to have a pyramidal system with most care delivered by doctors in training rather than fully trained consultants.

Consultants in emergency medicine, both in leadership and direct clinical care, are essential for the running of high-quality emergency medicine care. However, we do not work in isolation. On the shop floor seeing patients and supervising NCHDs, non-consultant hospital doctors, I need diagnostics and not just between nine and five. I need to be able to access community beds and services and not between nine and five, Monday to Friday. We need to move away from pretending that patients come for medical care just between nine o’clock and five o’clock. We must stop making them wait until the next day or the following Monday to get the diagnostics or services they need.

There is hope, if the Government can deliver bed capacity and conditions to allow trained staff to stay. Irish emergency physicians are trained to the highest standards. Irish emergency medicine is delivering on training. We know what good care looks like. Let us keep our doctors at home. Irish nurses are internationally sought after. Let us keep them at home. The Government needs to create capacity by building beds where needed, perhaps modular, and staffing beds where they already exist. We must allow people to get good emergency care, allow them to come in from the waiting room to a vacant cubicle to be seen and allow them flow through into a bed when they need one. We must also allow them home or into other care when they are ready.

Processes need to be efficient and we have done extensive work on this. In 2012, the National Emergency Medicine Clinical Programme published a model of care which describes in some detail the processes needed and our path forward such as trauma networks, emergency care networks, local injury units, clinical decision units, staffing levels and advanced nurse practice. We know where we need to go.

We have leadership in emergency medicine locally and nationally to show the way. The Government must give us space to do our job and allow patients to move on from trolleys in emergency departments so that the incoming patients can be seen. Access to public emergency care is a cornerstone of our society. How we treat our citizens in their moment of crisis marks us. It marks committee members and me. The Government must stop warehousing or boarding inpatients on trolleys in our emergency departments. It risks killing them.