Mr. Liam Doran:

And neither of us has enough. If an initiative might improve the patient flow and patient experience in one area but might incur cost in another area, it does not happen because it does not transfer. This touches on Senator Swanick's comment about properly using district and community hospitals. We have got to develop district and community hospitals in order that they can address a certain level of acute illness in their patient population. That means that they must grow their nursing staff, expand their roles and so on. We are on record of congress as wanting to do that since 2007. The then CEO of the health service called it elder abuse to transfer people from a continuing care setting to an acute hospital when their situation could be managed in that continuing care setting through the expansion of roles. We are still waiting to be engaged by the continuing care setting managers to deliver that, whether it is first-dose antibiotic, fluid balance, phlebotomy or whatever.

That has not happened and, recognising reality, it needs to happen. The sharing of budgets is very poor. It is very siloed and there is no integration. The one thing we have done, badly at that, is we were moving towards integrated care structures in the health system and we have gone backwards in the past two years and become more siloed.

A question was asked about special measures in respect of the labour market. Nurses and medical staff are no different to anybody else. They respond to labour market realities. When we talk about special measures, that includes monetary solutions but it is also about terms and conditions of employment and access to continuing education. I am very passionate about developing access to a buddy hospital system whereby if I am a nurse in an emergency department, ED, perhaps I could have a contract which would send me over to the United Kingdom to do a specialist programme in emergency nursing and come back to my permanent job. So it is about monetary compensation but it is also about issues of professional development, which are not available at the moment. I wonder why nursing staff and support staff go in every day to emergency departments. It is an absolute miracle that they go in every day to the same problem and try to cope with it when the situation around them has got worse. We need special measures.

In terms of the numbers presenting, for the record, the national figure for attendances is up by 5.3% year-on-year to the end of December, according to the latest figures from the task force. It is steadily increasing every year. The point is very well made about lack of consultant cover. As to whether the GP system is working, integrated care happens and then it does not happen in some spots.

In terms of causes of attendances, there is a problem undoubtedly about lifestyle. We will not comment on the whys and wherefores of it but in terms of whether emergency departments are staffed to deal with that presentation, I do not think that is the case. Thursday, Friday, Saturday and Sunday nights are very heavily influenced by alcohol and related issues and that presents huge challenges, not just for the staff but for the patients who are there for normal reasons and have to put up with the shouting and so on. Security is very poor.

Bed capacity and timeframe issues will not be solved without the nettle being grasped. We have not been invited to contribute to the bed capacity review from the point of view of either congress or my own house but I do not think it requires much science to work out that we need additional beds. The trick is – this is a political issue – that there are greater needs in some areas than others. The level of overcrowding has noticeably reduced in Dublin hospitals but outside of Dublin the situation has become significantly worse. I do not say the situation in Dublin is good but it is not as bad as it was, whereas outside of Dublin it is about 20% worse than it was two or three years ago. Hospitals are now experiencing overcrowding that never did before, for example, the level of overcrowding in Kilkenny and Tullamore is very bad. The patient experience time is also very bad and staff are completely overburdened.

We have discussed community district hospitals and we have touched on transitional care. The practice nurse is a vital cog in the wheel. The practice nurse is part of the nursing infrastructure for the community and we hear a lot about primary care and community nursing. For the record, at the end of December 2016, there were three more public health nurses employed than at the end of December 2015 but yet we speak about reorienting care into the community. I listened to the submission by Patient Focus on growing the role of public health nursing and I agree with what was said. A public health nurse is a highly educated professional and currently such nurses are not being properly utilised. We had 1,700 and now we have only 1,500 because of the recruitment moratorium in the past eight years. Only three have been added in the past 12 months. That is not a sign of a commitment to offering an alternative to hospital care and to give a safety valve to the emergency departments and keep the frail elderly in particular out of hospital. The Institute of Community Health Nursing does excellent work and we often work with it. Such entities have a role to play in trying to devise policy but ultimately this problem will not be solved without making the health service bigger.