Mr. Liam Doran:

Correct. And it will get longer and longer as people's expectations and demand rises for interventionist care, preventative procedures and so on. This is right, fair and reasonable. However, I am not convinced it does the taxpayer any good to use that arm to spend €20 million.

We could not cope with a massive disaster. However, I never underestimate the ability of health service staff, whom I admire and represent, to move mountains in an exceptional situation. The chances are that mountains would be moved. However, they are moving mountains every day, not on exceptional days, and that is the problem.

Issues were raised about the correct care at the correct time, choice issue, acute beds and the nine to five issue. At the risk of irking people, acute hospitals still primarily function at an optimum level Monday to Friday, nine to five. It has not changed. The emergency department task force is good at measuring everything. The latest dashboard figure we saw was 12% discharge at weekends. That was the same 18 months ago as it was in November. In the emergency department task force there is a commitment to empower and enable delegated discharge in accordance with national agreements and cross-team discharge, having regard for the consultants' ongoing responsibility for their patients. There is another commitment to ensure an appropriate level of senior clinical decision-making in emergency departments. There is a requirement to ensure there is a senior decision-making presence in emergency departments during peak hours with consultant availability on an 8 a.m. to 8 p.m. basis, subject to resource. That is the get out of jail clause. We lack the human capital to do it in many areas and the managerial capacity to do it on some occasions.

It is very difficult. We need to change everyone's modus operandi. We need consultants and senior registrars in emergency departments over a longer span of hours to make the key decisions. If, because of other pressures, consultant surgeons are unable to use theatre time, which is not good, could they be better utilised in the emergency departments, given that they have the experience? Somebody asked what we could do in the short term. These are the kind of things we could do in the short term. We could make use of the senior clinical decision-makers and ask them to attend on a rostered basis out of hours in order that they can make key decisions, get and interpret the diagnostics, map out the patient's journey and discharge where they can. Non-consultant hospital doctors, NCHDs,will practise defensively. We all know that. It was that way when I was a nurse. I am sure it is still that way in practice, and I would do the same myself. If I get it wrong and send someone away, there will be a follow-on. Therefore, they hold patients and get the registrars to examine the patients. Therefore we need to spread the clinical decision-makers.

I gave a wrong figure for public health nurses, PHNs. We are two fewer at the end of last year than we were in the previous year. This is not due to retirements but because we just do not have them. Any qualified PHN has a permanent post upon qualification. We do not have enough to meet retirements and we have none for locum cover. PHNs spend three or four months of each year covering annual leave in two areas. Patients are prioritised and, after a while, a person becomes so unwell, they end up in the emergency department. Everything we do is connected to everything else.

I agree with Dr. O'Conor on patient need and who decides. When it comes to acute interventions and decision-making, the clinicians, correctly, reign supreme and the system responds. Patient need is relegated. Directors of nursing who seek additional agency nurses to look after patients to the level required by the patient are frequently having their requests turned down due to resource implications. They are told to make do. The reduced number of nurses has to cover the acutely ill patients. To Deputy Bernard Durkan, I make the point that international research well proves that a ratio of one nurse to eight or more patients does harm and results in poor patient outcomes. Nurses are frequently left in acutely ill patient environments responsible for 12 to 16 patients. This compromises care.

I am not being, so to speak, industrial relations about this. It is too big an issue. It is not just about industrial relations. We have staffing agreements based on international research about what is required, and every day we have hospitals which admit they cannot reach them. We have emergency departments working four or five nurses short. I am not even getting into the admitted patients and the additional staff required for them.

Somebody asked me to identify three actions that could be taken. The first is staffing. If we cannot build the beds, we can incentivise the staff in order that patients who are there get better care. We need more nurses and senior clinical decision-makers in the system. It is a labour market out there. These professionals have choices and they are not choosing to work in Ireland, especially in our public health service. Providing additional beds is the second action. The third is to provide home help and home care services over seven days. The idea that they stop on a Friday and do not restart until the Monday, or the Tuesday on a bank holiday, is barmy. A person's deterioration may not be spotted. They need the supports every morning. Just half an hour in the morning and half an hour in the evening can keep a person at home and give them the spur or the rung on the ladder they need. It is taken away for two or three days every week, and the Government says it provides community-based support services. I am not getting into the bigger issue of more bed capacity, which we all know we need. Those are the three immediate things we need.

Dr. O'Conor spoke about the first Tuesday of each year and each week. It is predictable. We asked for a roster for senior clinical decision makers to be in situin the community and in acute settings through the Christmas and new year period, but, as a staff rep, I am still waiting to see it. It is not just the acute system, but also the community system that has to stay awake and operate on a seven-over-seven basis.