Ms Brigid Doherty:

We thank the Chairman for the invitation to meet the joint committee. I also thank the staff of the committee who helped us to put this presentation together.

I will begin by telling the committee about Patient Focus. I will then discuss our perspective of overcrowding in emergency departments.

Patient Focus is a national patient advocacy service. It was set up in 1999 and established as a company with charitable status shortly afterwards. It has four staff and is funded by the HSE at the rate of €216,000 per annum. Last year we also received some funding from the national lottery. Each year we provide support for between 500 and 600 new clients who have been damaged in some way in the health care system. Most have suffered damage, much of which is very serious. Some have been damaged in emergency departments, as also happens in all other areas of hospital care.

Our approach to healing hurt caused in the health care system is by means of patient centred advocacy. It is not widely known that many people are hurt, injured or die each year because of the provision of inadequate care. We are best known for our work in supporting and advocating for patients on several major issues. They include baby deaths and injury in Portlaoise and elsewhere; miscarriage misdiagnosis; unnecessary caesarean hysterectomies and ovary removals at Our Lady of Lourdes Hospital; and symphysiotomy.

It seems to our clients and us in Patient Focus that much of the public discourse on emergency departments is about overcrowding and the dangers it undoubtedly creates, particularly at times of pressure during the winter months, at weekends and during bank holiday weekends. Our clients tell us of a service that is at skeleton levels at these times. They also tell us of a service in which adverse events occur during normal times all too frequently. The examples they have given us in recent years include problems with unborn infants not picked up at birth, despite the mother raising concerns, and with small children who were brought to emergency departments and whose mothers were not listened to when they raised concerns. Examples also include children not being transferred in a timely fashion to specialist centres; misdiagnoses of illnesses leading to a shortening of life and-or permanent injury;a man being found dead in a hospital corridor that was considered to be a "virtual ward"; no staff being available to assist in helping a patient from a trolley to meet their toilet needs, resulting in forced incontinence; and no proper meals. These events are not reported in the media unless they can be linked with a daily trolley count. In our view, this tends to set the media agenda in a way that is not helpful to patients. It is easy for the media to cover issues of quantity, but, in our view, it serves to put the resolution of issues of quality and safety even further down the line. It is our strong feeling that, for these issues to be resolved, every group must buy into the finding of long-term solutions. Problems in emergency department are related to problems in other parts of the system. The dignity and safety of patients are sometimes sacrificed. It is almost as if the system, with its competing vested interests, seeks to maximise the horror at critical periods.

Those who work within the system have a duty to ensure their individual professional approach is patient centred. They also have a duty to insist on their representatives not seeking to maximise the lack of dignity and safety in a way that is ultimately anti a systemic solution. It is hard at times to escape the impression that some interest groups like to use the chaos in unhelpful ways. This is easier than working with others to seek long-term solutions to the chaos.If there are groups within the system which are acting against the interests of patients, it needs to be said. Courage is needed, but sometimes it seems as if it is sadly absent. HIQA made several national recommendations about how emergency departments should be run to ensure the safety and dignity of patients. We believe that where there is a will, there is a way.

We have suggestions for improvements. Community services need to be developed and expanded on a statutory basis as a matter of urgency. Nursing care teams must be extended, including employing more advanced nurse practitioners. Public health nurses must be upskilled to carry out procedures in which some are not currently skilled or do not see as their role. GP services must be more effective such that sending a patient to an emergency department is seen as a last resort. GPs should be able to make direct referrals to the specific speciality and patients should be seen on arrival rather than having to sit for hours in an emergency department waiting for assessment and referral to the speciality. Good social care services independent of the health service need to be set up because there is duplication of assessment procedures. Palliative care services in the community need to be available nationally, including a 24-hour service supported by public health nurses.

Developing medical, nursing and social care services in the community is expensive. However, in the longer term it is cost effective and, most importantly, provides safer care for patients in their preferred place of care - their home.