Mr. Liam Doran:

I will try to be brief. There were a number of questions and some repetition. There are a number of reasons that the figures have improved in Dublin, as in not improved but stood still, as opposed to the country, where they have got really bad. The infrastructure in Dublin in terms of access to continuing care beds and so forth is better than in other parts of the country. There are improved process issues as well. There are a number of advanced nurse practitioners, ANPs, in a number of the Dublin hospitals, which also speeds patient flow. The group I spoke of that recommended the 107 staff for admitted patients also recommended that we should have 150 ANPs. We currently have 78 across the country. There is no funding for that. It is proven that ANPs greatly help in terms of minor injuries, patient flow and so forth. St. James's Hospital has six ANPs and has the lowest number of trolleys. It has high patient satisfaction rates. Advanced nurse practitioners work, but again there is no rush or stated intention to deliver them on the ground to meet and deal with the patients, which is all that matters in this situation. I do not wish to suggest that Dublin is good. It is just that the situation outside of Dublin has gone south so badly so quickly that it is truly alarming.

I must be very blunt. We reap the harvest of fundamentally flawed decisions taken within the last decade. Reconfiguration of acute hospital services was an unmitigated disaster. I will go toe to toe with anybody about that. When one talks about reconfiguration the two areas that come to mind are the north east and the mid-west. In the north east in 2007, appalling as it was, there were 2,800 people on trolleys. In the Lourdes hospital last year there were 5,600, and it was 7,000 in the year before that. That is when Navan, Louth and Monaghan were taken out. I am not saying they are perfect but one must give the alternatives that are there. Deputy Kelly spoke about minor injuries units and so forth. They must work on a 24-7 basis and be properly staffed. If those units and services are closed down and then only one door is provided, should anybody be surprised that the one door gets overcrowded?

If one wishes to see the total and utter madness of policy decisions taken ten years ago, look at the mid-west. In 2007, Limerick had 1,367 people on trolleys. Last year, it had 8,090. That is not the fault of the clinicians on the front line or the nursing staff. It is the fault of whoever made the decision to shut down services in Nenagh and Ennis without building up Limerick. On top of that, HIQA decided that the accident and emergency department in Limerick is unfit for purpose. Did that not dawn on somebody before they made the decision to put everybody into Limerick? It is the same in Galway. It is unfit for purpose. I accept that alternatives are being built, but it is building alternatives ten years after the fact. That is why one wonders at policy decisions. I am including political policy decisions as well. They have to be owned by people when we reap the harvest in terms of what has been done in various areas outside of Dublin.

There was a question about the impact of private hospitals. I have to concur. We do not measure so we do not know. However, at 5 p.m. or 6 p.m. anybody who needs care is transferred back to the nearest public hospital, because the staff are going home. No harm to them, but that is the position. I understand the rationale for pointing to their capacity but it would be an expensive alternative to be forced on the public health system.

Everybody must remember we have the fundamental problem that we have a two-tier health system which offers perverse incentives to certain key players in the system as to how they work and offers speedier access to care for those who can afford to pay for it. In fairness to emergency departments, they do not do that. In emergency departments, everybody is treated absolutely the same. They are triaged and the system responds. Our emergency department service is world class at consultant, nurse and support staff level, when one gets in there. They will not lose anybody who could be saved. However, they are just overrun. They are not inpatient wards. That is what is compromising care, particularly the care of admitted patients.

A question was asked about what was good or bad about the winter initiative. One always has to try to be balanced. This year's winter initiative was primarily aimed at transitional care, reducing delayed discharges and improving home help supports and home care packages. To a very significant extent, it achieved those targets and it did well with dedicated funding in those areas. As somebody said, the original provision was 55 acute beds with 17 opened. They then had the meltdown on the first Tuesday in the year. It was a crash course, and they said they had to do it better again. They came up with 63 beds. Some of it was regurgitating the 55 beds that had not opened in the first instance. They opened 25 beds in Galway. The only way they opened them was by cancelling the leave of the nursing staff. They cannot keep doing that. It is a Band-Aid over the problem. I remain unconvinced they will open those additional acute beds. There were aspects of the winter initiative that worked, and if they had not been there, the 612 people on trolleys would have been 800, in terms of delayed discharges and blocking up beds. I am using the wrong phrase, but the members know what I am saying.

Can we foresee the flu epidemic? We can never deal with anything like that, given that we have 95% to 100% occupancy in our acute hospitals week in, week out. We cannot deal with any extreme demand. The only way we deal with it is by cancelling elective procedures. That is all we do. We cancel planned operations. As Dr. O'Conor said, the bed managers have the job of ringing people once, twice or, on occasion, three times. On behalf of ICTU, I make the following point. Can anyone explain the policy that we admit every year that we cannot do elective work, and so we give money, through the NTPF, to private hospitals to do the operations the public system does not have the capacity to do, but we never tackle the capacity issue?