Oireachtas Joint and Select Committees
Thursday, 15 January 2015
Joint Oireachtas Committee on Health and Children
Accident and Emergency Departments: Department of Health and Health Service Executive
I remind members, witnesses and those in the public Gallery to ensure their mobile telephones are switched off for the duration of the meeting as they interfere with the broadcasting equipment, even when on silent mode.
Before commencing I remind witnesses of the position of privilege. Witnesses are protected by absolute privilege in respect of their evidence to the committee. If witnesses are directed by the committee to cease giving evidence on a particular matter and they continue to do so, they are entitled thereafter only to a qualified privilege in respect of their evidence. Witnesses are directed that only evidence connected with the subject matter of these proceedings is to be given and they are asked to respect the parliamentary practice to the effect that, where possible, they should not criticise or make charges against any person or persons or entity by name or in such a way as to make him, her or it identifiable. Members are reminded of the long-standing parliamentary practice to the effect that they should not comment on, criticise or make charges against either a person outside the House or an official either by name or in such a way as to make him or her identifiable.
During this session we will discuss hospital emergency department services. I welcome the Minister for Health, Deputy Varadkar. From the HSE I welcome Mr. Tony O'Brien, director general; Mr. Pat Healy the national director of social care; Ms Angela Fitzgerald, deputy director of the acute hospital division; and from the Department of Health I welcome Mr. Charlie Hardy, principal officer and Mr. Jim Breslin, Secretary General. The Minister and the director general of the HSE were asked to attend this meeting to discuss one issue, which is overcrowding in the country's emergency departments. Committee members have requested an update on the current situation and the action which has been taken to address the ongoing issues facing patients on trolleys in our accident and emergency departments. I invite the Minister, Deputy Varadkar, to make his opening statement.
I have not provided the committee with a formal opening statement for a number of reasons. This matter was discussed in a Topical Issue debate in the Dáil yesterday and is also the subject of the Private Members' motion in the Dáil this week. At present, the Minister of State, Deputy Lynch, is covering for me for the second part of the Private Members' motion debate in the Dáil. Rather than repeating everything I said yesterday I thought I would keep it quite short to allow Mr. O'Brien to give a more detailed statement and also allow time for questions and perhaps a free-flowing discussion on some of the solutions to this very long-standing problem.
At eight o'clock this morning 256 people were on trolleys, of which 141 had been on trolleys for more than nine hours; it is after nine hours that it becomes a patient safety issue. Most of these people will be in beds by tonight and the number is continuing to fall. Within this is huge variation. In the midland regional hospitals in Mullingar, Portlaoise and Tullamore, in Kerry General Hospital and in Connolly Hospital Blanchardstown nobody was on trolleys for more than nine hours this morning. In St Vincent's University Hospital, Tallaght hospital , St. James's Hospital, University Hospital Waterford, Letterkenny General Hospital and South Tipperary General Hospital in Clonmel only one person was on a trolley, whereas in Beaumont Hospital the number was 22 and in Our Lady of Lourdes Hospital it was 25. There is long-standing chronic overcrowding in Beaumont Hospital and Our Lady of Lourdes Hospital, which has been going on for as long as I can remember, certainly since I was working in Beaumont Hospital which is a long time ago. There are also hospitals which are not always in difficulty but are at present, such as University Hospital Galway and Portiuncula Hospital.
When comparing year on year we tend to compare the day of the week, with regard to seasonal factors and the time of the year. To use the special delivery unit's numbers, on this day of the week last year 280 people were on trolleys, so the number is lower than it was this time last year. If we use the trolley watch figures of the Irish Nurses and Midwives Organisation, INMO, to compare the third Thursday in January going back historically, 244 people on trolleys were on this morning and the last time it was that low was in 2005. Based on these figures, comparing like with like, it is at its lowest level in ten years. Ward watch includes patients on trolleys in wards, which is done in some hospitals to relieve pressure on emergency departments. These figures have been collected for the past two years so they do not compare like with like, but if I were to use statistics against me and make us look as bad as possible the figure is still lower than it was in 2008, 2009, 2010 and 2011.
It is fair to say the actions which have been put in place by hospitals, the HSE, social care and departments have worked, and I want to express my appreciation to HSE management, hospital staff, social care in particular, and nursing homes for pulling out all the stops over the past while to deal with this surge. I have been looking back over numbers, and surges are not as predictable as one might think. Some people refer to "black Wednesday", which is the worst Wednesday in January, which does happen, but it happened a week earlier this year for a number of reasons, particularly the fact there was a very long Christmas period this year compared to previous years. Surges can happen at other times and we have had peaks in previous years in February, March, April and May which were often linked to respiratory illness and an increase in presentation as a result of this. We are not taking anything for granted and I guarantee the committee there is no level of complacency.
At present approximately 140 people are on trolleys for more than nine hours, and this figure generally reduces to 100 at the end of the day. We are back to what has been normal in Ireland for the best part of ten years, but I do not accept it should be normal. Almost every country in the world has surges of patients, which mean that from time to time patients are on trolleys. Various countries have various ways of dealing with this. In a number of hospitals in Ireland we have a chronic overcrowding problem, which has been going on for the best part of 15 years. When a surge occurs it becomes a total disaster, which is what we need to focus on resolving once and for all over the coming months. This is what the emergency department task force, co-chaired by Dr. Tony O'Connell of the HSE and Mr. Liam Doran of the INMO, will do. It will dust down old plans which were not implemented and come up with new plans. We will focus on this over the coming months and try to get into a position where trolleys are unusual by the summer, which will give us some headroom going into next winter.
This is not straightforward as there is no single solution to this. Delayed discharges are a big part of the picture; hundreds of people in our hospitals could go home if circumstances were right, but this is not what it is all about. Beaumont Hospital has as many delayed discharges as St. James's Hospital, but while St. James's Hospital rarely has people on trolleys for more than a few hours Beaumont Hospital always does. Letterkenny General Hospital has no delayed discharges and has had people on trolleys for a period of time. Cavan General Hospital has 15 or 17 delayed discharges but rarely has people on trolleys. Many factors are at play and delayed discharges are just part of it. Some of it is down to patient flow, management or any number of issues, and it is not simple. One can solve a problem in one place in health but create another one in another area. An element of this is happening at present because elective surgeries have been postponed, which adds to surgical waiting lists. Elective surgery is always pulled back a bit in January, so it is not as bad as it may seem, but it certainly will create another problem down the line. In health one is always fighting on all fronts, but I guarantee the committee we are all up for it.
Through the task force we want to redevelop a partnership approach to addressing this problem involving the Department, the HSE, clinical programmes, key physicians and the unions representing management and nursing. We also have a patient representative on the task force, Mr. Stephen McMahon, which is an important addition.
I had two concerns going into this week. One was the junior doctor changeover, which went well, and the other was influenza. It is the case that influenza-like illness rates have risen from 15.5 per 100,000 to 29 per 100,000 this week.
We are seeing an influenza outbreak and, obviously, the advice is what it always is, namely, that people who are high risk should get vaccinated. GPs are being asked to prescribe Tamiflu, the antiviral medicine, to those presenting with influenza-like illnesses in high risk groups, and we are asking everyone to do what needs to be done to prevent the spread of influenza. That includes covering one's mouth with a tissue when one coughs or sneezes, disposing of the dirty tissue at the earliest opportunity and cleaning one's hands because the illness is, of course, transmitted through contact and droplets. At risk groups include people aged 65 years and older; people, including children, with chronic illness such as lung and heart disease, neurological disorders, diabetes and neurodevelopmental disorders; those with lowered immunity levels due to disease or treatment; all pregnant women, in respect of whom the vaccine can be given at any stage in pregnancy; those with morbid obesity, that is, a body mass index of greater than 40; residents of nursing homes, old people's homes and other long-stay facilities; and health care workers and others who care for those in at risk groups. We are encouraging people in those groups to get the vaccine if they have not done so already, advising GPs to prescribe antivirals to this group and asking the public to help us prevent the spread of influenza through regular hand washing and covering their noses and mouths with a tissue.
Mr. Tony O'Brien:
I am grateful for the opportunity to address the committee. I am accompanied by Mr. Pat Healy, Ms Angela Fitzgerald and Dr. Colm Henry, all of whom are members of the emergency department taskforce in addition to their normal roles. The pressures on emergency departments over the past two weeks are not new or unexpected. As I have highlighted previously to this committee, the population over 65 years is growing by approximately 20,000 per year and the numbers of those aged over 80 years are increasing by 4% annually. Due to reduced budgets over the past number of years, the development of the required capacity within our community services to deliver home help, home care packages, and short and long stay residential care has not kept pace with this demographic growth. Furthermore, acute hospitals have experienced increased presentations and avoidable admissions, increased numbers of delayed discharges and unacceptable numbers of patients on trolleys in their emergency departments.
The data inform us that the numbers of emergency presentations in 2014 are up 2% on 2013 and emergency admissions are up by 8% over the same period. The main factor leading to the current emergency department pressures relates to higher numbers of delayed discharges in acute hospital beds when comparing this year to the same period last year. On 6 January, 745 delayed discharges were reported across the acute hospital services. This figure was approximately 150 more than at the same time last year and has led to a consequent increase in the numbers of patients on trolleys requiring admission, particularly in the first week of the year. This was despite hospital and community investments in transitional care beds during the course of 2014.
Winter planning is an embedded response within acute hospitals and community services. In order to manage increased demands, hospitals have been required to be at a state of escalation since autumn 2014. This is part of the normal planning in place to deal with the expected surge in demand in emergency departments whereby hospitals invoke escalation plans which include the opening of additional overflow areas, curtailing non-emergency surgery, providing additional diagnostics and working in an integrated way with their community service colleagues to strengthen discharge planning. Hospitals have continued to take these steps since September 2014, as required, so that patients who need to be admitted to hospital are admitted to a bed at the earliest opportunity. In preparation for the demands of the winter period, during the month of December the acute hospital system cancelled non-urgent elective activity to ensure maximum capacity to deal with emergency admissions. Primary and social care services in particular escalated their plans to facilitate discharges through the provision of home care, aids and appliances, access to community hospital beds where available, etc. In addition, the Minister for Health convened the emergency task force which supported the measures being undertaken by the hospital and community services to prepare for the anticipated additional demand for services during the key period post Christmas.
In recognition of the increase in delayed discharges and the fact that sufficient funding has not been available for the past six years during the recessionary period, the Minister has managed to secure a total of €25 million as part of the service plan for delayed discharge patients in 2015. Preparatory work for its implementation commenced in November 2014 and additional resources were allocated for delayed discharges in December. The full funding came on stream on 1 January 2015.
As delayed discharge figures reached their highest level by the end of November 2014, an additional allocation of €3 million was provided in December as an interim measure prior to the €25 million coming on stream to enable the early release of the additional 300 fair deal approvals immediately. This was in addition to the regular release of 700 places, bringing the overall allocation to 1,000 places for the full month of December 2014. Also in December, 165 additional transitional care beds were funded and targeted at hospitals in the greater Dublin area to facilitate speedy discharges.
Additional home supports were provided with a specific focus on supporting acute hospital discharge prior to the Christmas period. During Christmas week, 120 home care packages were provided in total, with 87 related to patients in the acute hospitals. The combined efforts of the above initiatives saw a net reduction of 109 delayed discharge patients with approximately 700 delayed discharges reported at the end of December 2014.
The full €25 million package is being implemented since January this year as follows. An additional €10 million for the nursing home support scheme will support in a full year the 300 extra places allocated in December 2014. This has had the impact of reducing the placement list to 1,160 in the first week in January and reducing the funding delay for fair deal from 15 weeks to the current 11 weeks. Short-stay residential care has been allocated €8 million to provide an additional 115 short stay beds, of which 50 of have been earmarked for provision in private nursing homes for the greater Dublin area. The remaining 65 beds will be opened in Mount Carmel on a phased basis commencing March or April 2015 as a dedicated community hospital for Dublin. Home care packages were allocated €5 million to provide 400 additional packages benefiting 600 discharges across targeted Dublin hospitals during the course of the year to facilitate patients to return to their own homes in the community. Community intervention teams were allocated €2 million to allow the service to expand its service levels in the greater Dublin region and deliver services to an additional 8,000 patient cases. In addition, new services are being established in Kildare, Louth and Waterford, servicing the main hospitals in these regions and providing direct access to GPs and nursing homes, thereby facilitating patients who would otherwise have to attend hospital unnecessarily.
In response to the continuing pressures in our emergency departments, all of the focus of our efforts during the month of January has been to maximise the discharge of patients from our acute hospitals who have completed their acute treatment either to home with home care supports where required or to more appropriate residential care. To achieve this we have sought to eliminate red tape as much as possible and during the month of January, as an exceptional measure, all patients who are clinically discharged but who require ongoing levels of residential care are being matched with suitable nursing home placements following clinical review. This will see a potential movement of 250 patients who are currently in acute hospitals to other suitable facilities.
While much of my previous commentary focused on delayed discharge as a factor, it is important to note that there are 28 emergency departments in Ireland and the challenges faced vary between each location. For example, in Beaumont where there has been a persistent level of delayed discharges and a number of people on trolleys, there is a direct relationship with the shortage of residential capacity in north Dublin. However, in Letterkenny, where over the weekend of the 3-5 January, 2015 there were over 31 people on trolleys, the problem was not related to delayed discharges but rather related to a particular spike in the number of unwell elderly presenting at the hospital. Another example is St. Luke’s in Kilkenny, which is a level three hospital with a very good reputation for integrated working across hospital and community and for maintaining low levels of delayed discharges and trolley waits. On Monday, 5 January there were 22 patients on trolleys in that hospital.
The current mainstream and integrated efforts at national level are enabling a cohesive and consistent response to cope with the demands. The leadership role of clinical directors, consultants and nursing management in carrying out additional ward rounds and discharge planning is also proving effective in alleviating the pressures in emergency departments. The role of primary care and social care in extending community intervention team coverage facilitates early discharge or hospital avoidance where possible and the use of public beds to decant patients from acute hospitals has contributed significantly in dealing with demand issues.
Early release of nursing home support scheme funding arrangements in December, coupled with the provision of additional transitional care beds and additional home care packages allowed discharge to continue throughout the month of December and the crucial Christmas period. At this point, nobody on the delayed discharge list is waiting for home care package funding.
Collaboration across hospitals in terms of enabling bed access has also assisted in reducing delayed discharges. Examples of this are the use of rehabilitation beds in Cappagh hospital by Connolly and Drogheda hospitals, the use of elective beds in Navan by Drogheda, and the optimisation of model 2 hospitals at Ennis, Nenagh, Bantry and Mallow, which contributes to alleviating waiting times for Limerick and the south west. The ongoing escalation of matching patients, numbering 250, who are medically discharged with nursing home care placements is proving beneficial in yielding capacity. There are recognised deficits in key service areas which support the discharge process, particularly of older people.
The level of home help service provision has decreased significantly over the past number of years, from €211 million to €185 million. Funding for home care packages has remained relatively static since 2008. Public residential care beds are a key component of service provision and must be maintained at existing levels, despite impending issues with compliance on infrastructure. Reliance on agency staff - medical and nursing - due to market conditions, together with associated challenges in terms of recruiting and retaining senior decision makers, is impacting on our ability to open additional capacity.
The review of the nursing home support scheme currently being undertaken by the Department will need to suggest longer-term solutions to place the scheme on a sustainable footing, recognising the demand-led nature of the scheme and an aging population. The development of the required capacity across primary and social care is essential to meet demographic growth in a predominantly elderly population. The challenge for re-registration of public long-stay beds with HIQA is a significant issue to be dealt with over the coming months, as there is insufficient capital funding available to meet all the requirements. There are over 30 large units providing in excess of 2,500 beds. There is currently insufficient funding in the capital plan to bring this infrastructure to the required standard.
I take this opportunity to acknowledge the discomfort and, in many cases, stress caused to patients and those who have experienced our accident and emergency departments over the past period and reassure them and the committee that we are doing everything possible to deal with the issue. I also thank the staff, including nurses, doctors and others, in the service for their diligence, patience and hard work amid such difficult circumstances.
I will read to the committee from an e-mail I received some days ago on foot of the debate about overcrowding in our accident and emergency departments. It states:
My 76-year-old father was sent by our GP to an accident and emergency department in St. Vincent's Hospital on New Year's Eve. He spent over 50 hours there on a trolley and we had to supply him with pillows and blankets. He did not receive any hot food for the period endured. There was bread and yoghurt for breakfast, a sandwich for lunch and another sandwich for tea every day. Try to survive on that when you are well. I sat on the floor by his trolley. Barely able to breathe, he had to queue for the one available toilet and there were no washing facilities or privacy. There were insufficient numbers of doctors and nurses as we continue to export our expensively trained Irish doctors and nurses to Australia. Meanwhile, seriously ill people are scattered all over our inadequate emergency departments.
The e-mail also highlights difficulties with parking, etc., but this is an indication of what is happening with our accident and emergency departments. I should not need to tell Mr. O'Brien and the Minister about that, but I must reiterate it because that is unacceptable. The accident and emergency task force is to deal with a potential impending crisis but, in effect, we knew for some time that this would happen. The Minister was informed there would be difficulties when he took up his post and he was forewarned about this in November. He was notified of cuts to the fair deal scheme and the difficulties in moving people from the acute hospital setting to step-down facilities, residential care and home care packages. It is not Fianna Fáil, me as Deputy Kelleher or any other Member that gave such a warning; it came from the HSE in its request for over €100 million to deal with the delayed discharge element in our hospitals. It is a critical matter. We have spoken about other issues to be addressed, but the fundamental problem is that 650 to 800 people in our hospitals should not be there and do not want to be there. They should be somewhere else. If it is beyond our capability to shift people from an inappropriate setting to something more appropriate that will benefit them and others, I fear the worst.
I assume the task force relates to accident and emergency departments rather than being an "emergency" task force; if it is an emergency task force, it has not been very energetic in its responses. I do not mean to criticise individuals but I would like to know how often it met to deal with the evident difficulties. Had it planned to meet early in January? Did it meet when we hit the magic number of 601 people on trolleys in accident and emergency departments?
I listened to a long lecture last night from the Minister, which was fine as we were in a political forum in the Dáil Chamber. We have now come to almost accept that 200 or 300 people lying around these departments is okay, but it is not. Nobody should be lying around on trolleys and 76-year-old men should not be looking for sandwiches for sustenance. That is not okay at all. The number is one element, and as this went over the magic figure of 600 people have become outraged, leading to a response. The response did not happen in December, when the event was being planned for; if we are honest, we know the response came after 601 people arrived in the accident and emergency departments. It came on foot of headlines, and that is why numbers have decreased today. As sure as night follows day, if 601 people were not in those hospital departments, we would not be having this discussion. We would plod along if it was only the usual 300 or 400 people on trolleys. There was no planned response whatever and instead there was an emergency action to try to reduce numbers. Nevertheless, that demonstrates that when commitment, effort and minds come together, the number can be reduced without a problem. If it is easy to get it down now, why could it not have been reduced three, four or six weeks ago?
Our level of acceptance of appalling standards for the sickest people is a problem. We do not mind the worried people who are well waiting around, but the people who present at our accident and emergency departments, by and large, are not there for the craic. They are certainly not there for food. They have been sent or referred to the hospital because they are sick and need attention. There are inappropriate and unacceptable standards now built into the system as the norm, but they are far from normal. I am not trying to absolve the role of my political party over the years; there is almost a societal acceptance in this regard. People are almost expected to lie on a trolley in an accident and emergency department for two or three days. That is completely unacceptable.
It comes down to resourcing and priorities. It is wrong to have 700 or 800 people in our hospitals who should not be there. It makes no economic sense. Some hospitals do not want sick patients when budgets run out, as sick patients cost money. If hospitals come under pressure and their budgets are stopped, they cannot carry out procedures but they may keep beds full anyway. This relates to the transfer policy for the fair deal nursing home scheme.
We know what the problem is: we cannot get people who should not be in hospitals out of them. These people should be in step-down facilities, but there is a level of acceptance that 300 or 400 people will at any time be in accident and emergency departments. This is where people must scrounge for pillows and a 76-year-old man must queue outside a single toilet in the morning hours. His daughter had to lie on a corridor next to him for 50 hours.
Then there is a response when there are 601 people waiting. I assure Mr. O'Brien, the Minister, the committee and everybody else that if there were 547 or 552, there would not have been the same outrage. However, when the number went over 600, suddenly people accepted that it is a major problem. Whether it was 601 or 301 on Monday week last, it was still a problem for every person who was lying on a trolley and for those who were trying to provide them with care.
I do not want to be pointing fingers at any individual. This has been going on for years. The Minister came in and lectured me last night for the first ten minutes of his speech about the historical aspect of it, but the norm now is 300 or 400, where we all are happy. However, the number hit 601 and then the system clicked into gear. My point is that, when it clicks into gear, the Minister can come in here and tell me that we have made significant progress. Why could we not do that in November last when we all knew about it? Why could we not do it the previous year, the three previous years, the previous 15 years? Is it beyond our capability to deal with this in a planned, sustained manner and accept that it is an issue of resourcing as well?
It was pointed out that some hospitals, while they have no delayed discharges, still have queues. Of course they do, because there is a patient in every bed. It is merely that these are not delayed discharges. They are there for a reason but they are not considered delayed discharges. The hospitals are at capacity. They operate beyond capacity and it is no wonder these issues arise from time to time. Let us accept it is a resourcing issue and a priority issue.
Finally - this is not a criticism - the front-line staff have stated consistently that patient safety is being compromised and they stood outside the gate yesterday to highlight that. Consultants, nurses and other health professionals have been saying this consistently, and it is time we collectively addressed what they have been raising, not on their behalf but on behalf of those whom they professionally want to help on a daily basis.
I welcome the opportunity to address these matters to the Minister and to the director general of the HSE in this, the commencement week of the resumed Dáil.
The figures from the INMO trolley count for today, 15 January 2015, were provided to me before the commencement of the meeting. The Minister referred to a trolley count of 244, but he failed to also mention that there were 72 further positions created on the wards, which creates an overcrowding situation, and these are not appropriate placements. The total is 316 as of the commencement our meeting.
This is not about trying to portray the Minister or the HSE in a negative light, as the Minister referred to in his opening remarks. It is about people. It is about patients in inappropriate circumstances, on trolleys and chairs, who are not at their best. We must recognise that the situation is outrageous.
On the figures provided by the INMO, I understand that, as happened under the tenure of the Minister's predecessor, these will now be officially accepted figures. We used see a tug of war between one set of figures and another, almost on a daily basis. I hope the Minister is not challenging what the INMO presents here as the factual position applying across each of these hospital sites.
Whatever the Minister's view on the INMO, whatever his view on the voices that he will hear today, what about what Mr. Tony O'Brien stated here this morning? In his presentation, Mr. O'Brien stated clearly that this was neither a new nor an unaccepted situation. He is telling it exactly as it is. He went on to state that due to reduced budgets over the past number of years, the required capacity, particularly in our community services, just simply is not there. He also stated that there was insufficient capital funding available and that there was insufficient funding in the capital plan to bring the required infrastructure to the required standard. Those are not merely messages for the committee. Those are messages for all of us in political life, be it in government or in opposition. It is critically important that Deputy Varadkar, as Minister, listen to and heed what Mr. O'Brien put on the record here this morning. Mr. O'Brien is not defending the indefensible and he is not ignoring the problem; nor is the HSE. The fact of the matter is they are strapped and they need, to repeat what has already been said, a re-evaluation of the resourcing.
On the language used, it is clearly the case that there is great disappointment within the HSE at senior management level. Mr. O'Brien stated that the Minister had managed to secure a total of €25 million. Perhaps Mr. O'Brien or any other representative here might shed light on it. Is it not the case that €106.5 million was properly and scientifically determined as the amount needed in order to avert the problem that has now presented? Why is it that in this instance we are only looking at €25 million, which quite clearly will not be able to address the problem as it must?
I ask the Minister what immediate steps were agreed at the second meeting of the emergency department task force yesterday. What immediate steps are now to be taken to ensure that there is the bed capacity and the required number of nursing staff? It is important to emphasise the Minister cannot keep introducing beds while working with the current complement of nursing staff on the front line. It just is not physically possible. What steps are now to be taken to ensure that there is an immediate recruitment effort? I refer not only to advertising for qualified nurses to return here from the neighbouring island and other settings, but to whether any consideration is being given to the significant number of former nursing staff who took early retirement options presented by the HSE and who live in the communities the length and breadth of the country, who are properly qualified, and who have the energy and wherewithal to step in at a moment's notice where an emergency presents. Is any consideration given to looking at them as even an interim position pending an effective recruitment campaign? I believe there is merit in examining that. I know personally some of those who would willingly step forward. If there are impediments or obstacles because of the circumstances of their departure under the offered early retirement packages, the Minister should overcome those problems, because the far greater problem is the need of those who, as we speak, are in inappropriate settings in the hospital emergency departments and on wards at hospital sites throughout the country. Will the Minister outline the immediate steps that will be taken in terms of localised recruitment and how he will ensure the speedy movement towards recruitment for the 265 nursing posts currently marked as vacant? Will he recognise that we cannot go forward with an increasingly elderly population with 5,000 fewer nurses than there were prior to 2008?
Public residential care beds are a key component, as Mr. O'Brien stated. He continued by saying that they must be retained at existing levels despite the impending issues with compliance and infrastructure. I agree. We all want to see the infrastructural needs addressed and the highest standards laid down by the Health Information and Quality Authority, HIQA, introduced, employed and sustained into the future. However, we are continuing to reduce the public residential care bed capacity across the country. My home county has only one such facility. Due to the need to meet HIQA's determinations, welcome works have been undertaken, but with a reduced capacity. This is not acceptable. There is a total contradiction. We will meet HIQA's requirements while blinkering ourselves to the facts that we have an ever-increasing ageing population and we will provide fewer beds. It is long past time that the alarm bells were heard. We need to act together. I take no pleasure in taking a run at the Minister on any of these issues. Far better would it be were I able to work with him and ensure that, together, we delivered a health system that was fit for purpose and of which we could be proud. There is no room for pride in respect of our health services today.
I thank the witnesses for their presentations. Perhaps everyone knows the answer to my first question, but I could not find it. Nine hours has been mentioned as the length of time over which someone in an emergency department should not remain on a trolley. From where does this figure come? In preparing for this meeting, I read the HSE's June 2012 report on the national emergency medicine programme. It continually referred to a figure of six hours. In the UK, the figure is four hours. We are in a crisis, but we should be aiming for the best care. On what basis have we determined that nine hours is okay and does the clock start when someone gets onto a bed or registers at the accident and emergency department? Maybe everyone knows the answer, but it is not apparent to me.
My colleagues have raised a number of issues around contributory factors and the interconnectedness of the health system, of which we are aware and which was highlighted in Mr. O'Brien's presentation, given the reduction in home help services and reliance on agency staff. Deputy Ó Caoláin referred to residential care beds and community infrastructure. The Minister raised the issue of delayed discharges. Has he a further update on the implementation of the report prepared by the ESRI and the Royal College of Surgeons in Ireland, RCSI, for the Irish Heart Foundation, entitled, "Towards Earlier Discharge, Better Outcomes, Lower Cost: Stroke Rehabilitation in Ireland", with a view to taking a proactive approach? The report showed how better outcomes could be achieved. In the Seanad, the Minister committed to considering whether it could be piloted. We should determine what can be done.
Our previous session on Huntington's disease was compelling and many issues arose, one of which was that, as an unintended consequence of the situation in emergency departments, respite beds were not available. Instead, they were being used to deal with this crisis. Anyone who was present for the presentation on Huntington's disease - Senator Crown described it rightly as a cruel disease - would be appalled that respite care beds were not available because of this.
I wish to address the issue of our ageing population, which Mr. O'Brien referred to, and nursing home care. In the early hours of 20 December 2014, I was faced with the decision of whether to have my father transferred to hospital from a nursing home on the opinion of an out-of-hours doctor. There is nothing a hospital can do for him. We are sending people into emergency departments, which are not the right and fit places for them. They go from one HSE service to another. I feel strongly about this personally because it happened in my own case, but I had to refuse the doctor's suggestion of a transfer repeatedly. It was as if I was doing something against my father's health. This is an issue for us. The committee produced an excellent report on end-of-life care and made a number of good recommendations, for example, nurse prescribers, that could be implemented in nursing homes instead of relying on transferring people into emergency departments. When we did that for my father in summer 2013, he spent 40 plus hours there. He is high dependency and does not have a medical situation with which the hospital can support him. He needs care, which is what he is getting now. Thankfully, he survived the crisis and is still with us.
Given the issue with end-of-life care, will the Minister revisit the recommendations of the committee's report? He replied to the committee, but they are not being taken up properly. We could save people from having to go through the trauma of presenting at emergency departments when doing so is not appropriate for their health care. I have spoken of my personal case, but I know from friends that many people must face this decision. Time and again they are told to send others to hospital. The only pathway available is through an emergency department. This is unacceptable. A person goes from one HSE facility to another. Why is the emergency department the only doorway into a hospital?
I thank the Minister and Mr. O'Brien for attending this meeting and for briefing us on what is a serious issue. As they know, the Lourdes hospital in Drogheda in my constituency is one of those that the crisis has most affected. I welcome the fact that the situation is improving and the number of patients waiting on hospital trolleys is decreasing. I visited the accident and emergency department at Our Lady of Lourdes Hospital on 7 January. To be honest, the situation was terrible. That said, I was hit by how the staff, particularly those on the front line, were working incredibly well. I did not hear one patient complain about them. They are performing brilliantly in difficult circumstances.
We need sustainable and long-term solutions. We in Louth have an immediate solution to the problem affecting Our Lady of Lourdes Hospital. On 7 January, I also visited the Louth County Hospital in Dundalk with its new manager, Ms Louise O'Hare. The hospital's accident and emergency department was closed in 2010 by the previous Government. That decision was a mistake. The problem facing us now in Our Lady of Lourdes Hospital is a testament to this. I commend the Minister and Mr. O'Brien for facing problems head on and agree that we need real solutions to the overcrowding in the Lourdes hospital, for example, extending the opening hours of the minor injuries unit in Louth County Hospital, allowing ambulances to take patients directly to that unit, extending the supports available to home help systems and schemes and reinstating accident and emergency facilities in Louth County Hospital. On my recent visit to that hospital, some 40 patients out of 60 were waiting for the fair deal scheme. If we could accelerate that process, the situation would improve immediately. I would also make 40 additional beds available there.
Louth County Hospital was and is a brilliant facility, has fantastic potential and can be a sustainable solution to the overcrowding problem facing those of us in the north east. Some 120 clinics are being held every week. Will the Minister and Mr. O'Brien make me a commitment that full services, particularly accident and emergency services, will be reinstated in Louth County Hospital?
I will let Mr. O'Brien speak about the more operational areas, but I will make a few responses. Deputy Kelleher suggested a few times that I was well capable of delivering a lecture. He is quite good at it himself, so congratulations on that.
One of the difficulties is that health care in Ireland is too politicised. If there is a problem with a hospital in France, the people in the hospital are held accountable and if there is a problem with a trust in England, the trust is held accountable. In Ireland it gets political very quickly and often it allows the people who are responsible to get away with not taking responsibility. If we were to achieve anything in the next ten years - I do not expect it to happen in the next one or two years - it would be to de-politicise health a little and change the tone of the debate on health care. Both the Government and the Opposition would benefit from that and, more importantly, patients and the public would benefit from a little less political anger and politicisation of health care. Indeed, many of the things that should have been done in the past were not done for political reasons, because they were politically unpopular even though they were necessary changes.
I agree with Deputy Kelleher on one point, that emergency department, ED, overcrowding in a number of hospitals has become normalised and almost acceptable for the last ten or 15 years. However, it is not acceptable to me and I will continue to take a personal lead and give personal attention to it over the next few months. Long after the parliamentary questions stop arriving, long after this committee has moved on to the latest issue in the news and long after the news media have moved on to other pressing issues, I will continue to have a focus on this and double down on it. I am not promising I can fix it all, but I will give it the type of attention that no other Minister has given it in the past.
I cannot account for why hot food and pillows were not provided in St. Vincent's. Perhaps the local management can answer that. I visited the hospital last week and it is running an excellent emergency department. The use of technology by the consultants there is particularly impressive. The hospital opened three five-bed overflow wards and since then the numbers have been under control. I cannot tell why they were not opened earlier. Perhaps it was a decision taken on the ground or it could not find nurses for it, but I cannot give the Deputy the detail on exactly what happens on any given day in 26 to 28 hospitals and I doubt that he would expect me to.
The Deputy is correct that it is the emergency department task force, not an emergency task force. It is established to deal with this issue in the medium term. What happens every day is something different. Every day, twice a day and, on one occasion, three times a day there is a conference call involving some of the senior directors who are with me here, the hospital group CEO, social care and so forth. That is how the emergency response is co-ordinated. It is not a meeting around a table, with everybody travelling to Dublin. That is not how these things are done. The CEO of the group hospital in Limerick must be in Limerick and the CEO in the west has to be in Galway. It is done through conference call, not as a round-table meeting with coffee, sandwiches and so forth.
With regard to the request of the HSE, the Deputy knows how budgets work. Every Department and agency puts forward its request and if one were to add up what every agency and Department requested, we would probably have to double the budget and people's taxes every year, which is not realistic. The total request from the HSE was an additional €1.4 billion, and that was to do everything we would all wish to do in health. The committee members understand that every agency and Department cannot get everything they request. In fact, no agency or Department ever gets everything it asks for in the budgetary round. However, I was able to secure the first increase in the budget in seven years. Under the previous Government the health budget was cut back by 20%. Based on outturn, what was actually spent as opposed to what was estimated, the health spend has not been decreased at all under this Government and will increase slightly in 2015. However, we were nowhere near being in a position to reverse the cutbacks that were made by the previous Government.
In the meantime, demand has risen and I will not pretend otherwise. That is the truth. It is interesting that even though we spend €1.5 billion less than was spent in 2008 to 2009, there is more surgery carried out, more outpatient clinics and more work is done. In fact, the length of stay in hospital has decreased from nine days to 6.7, so there was a great deal of inefficiency there. The health service has become much more efficient in the last number of years.
With regard to the €100 million, it was not for delayed discharges but for the fair deal scheme. Most people who avail of the fair deal scheme are actually in the community, not in hospital. The number for those in hospital would have been lower. However, we certainly did not get everything we asked for and I will not pretend otherwise.
Delayed discharges absolutely are a factor, but they are not the sole cause. It is estimated that perhaps a quarter or a third of the number of people admitted into hospital do not need to be admitted. Often that is due to the fact that the decision to admit can be made by more junior staff who are less risk averse than more senior staff. I was in that position myself and I did it. It is a problem in some hospitals where there is a difficulty recruiting senior staff. Therefore, the threshold for admission is lower than it would be in a hospital that has more senior staff or in a hospital that has better access to diagnostics or to outpatients quite quickly. There are many issues to be dealt with. Emergency department overcrowding happens because ten things went wrong somewhere else and generally not because of what is happening in the emergency departments. They simply get left with the mess, unfortunately.
I do not wish to get bogged down in the figures as it does not really matter, but the SDU figures are calculated three times per day so they give us a different read from the nurses' union figures, which are only calculated once in the day. The Trolley Watch figures are quite similar. Ward Watch is different. That includes people who are on trolleys or extra beds in wards, often in other buildings and up to 1 km away. I do not mind how one counts it. With statistics there are many ways to count things, but I believe people should be accurate in describing what the figures mean. When one uses the ward watch figures and talks about ED overcrowding, that is just incorrect because people counted in ward watch are not anywhere near the emergency department. Also, when one makes comparisons one must compare like with like. One cannot compare the 2 p.m. figure from the HSE numbers with the nurses' figure from 8 a.m. I ask the Deputy to be accurate in what he describes and to compare like with like. I do not care whose figures he uses as long as he uses that basic mathematical, scientific and statistical fact. That is all I will say about statistics. However, I agree with everyone that nobody should be on a trolley for a long period of time. It does not really matter what the number is, it just helps us to control it in some way.
I mentioned funding already. There are competing priorities, such as housing, homelessness and children. People should always use the resources they have efficiently first before they ask for more. Frankly, it is not always the case that people do that in the public service. It is very important that people use the resources they have efficiently and then demonstrate that they need more. I have that responsibility as well and I am in a much stronger position when I go to the Economic Management Council, EMC, and the Minister for Public Expenditure and Reform to seek additional funding when I can demonstrate that money we have is used as efficiently as possible. The health service has become a great deal more efficient in recent years.
Senator van Turnhout mentioned the early support of discharge for stroke. That is being done for chronic obstructive pulmonary disease, COPD, and has worked really well. We wish to do it for stroke too. There are plans for a pilot scheme, but there is an initial investment and cost involved. In addition, it might not be appropriate for every region and might work better in urban regions where outreach is easier than in rural areas. All of that must be figured out.
The Senator is 100% correct about controlling demand. Demand for hospital services is increasing with our ageing population and we will always be running up the escalator, which is coming down fast towards us, unless we control demand. That involves a number of matters. It involves the Healthy Ireland philosophy, making our population's health better, dealing with smoking, obesity, inactivity and so forth, screening, prevention and expanding primary care services, which is very important. With regard to nursing homes, there are approximately 1,000 nurse prescribers in Ireland at present. There was none a couple of years ago. That was achieved by the former Minister, Deputy Reilly. We need more of them. There are also community intervention teams, comprising nurses who go into homes and nursing homes to change the drips, give IVs and the like. As Tony O'Brien mentioned, that is being expanded and there is a specific allocation in the service plan for 2015 to expand it further. However, we are only getting started on this. Perhaps it should have been done years ago, but I can only do my best with our current position.
Another issue is advance health care directives. That legislation will be brought to the Dáil this year. It will empower people to make decisions as to whether they want to end their life in more comfort at home or in the nursing home rather than having to go through an ED and die in the hospital, which is not necessarily right for everybody. We wish to give people the power to make those decisions for themselves.
We are in discussions with the Department of Public Expenditure and Reform on the new capital programme. There will be a new national development plan, NDP, which will run from 2016 to 2021 and we are involved in discussions on that. Obviously, long-term care and community nursing home facilities are high on our request list for that.
I believe I have covered most of the matters that I can cover in that regard.
In regard to the immediate steps being taken arising out of the emergency department task force, what is important is that we keep doing what we are doing. I will ask Mr. O'Brien to update the committee further on the campaign in regard to recruitment of nurses. In regard to the doctors, the key issue appears to be salaries for consultants. It has been difficult to fill a number of senior posts. A second ballot on revised proposals will be held soon. I hope that all things going to plan, we will in a matter of weeks have agreement with the IMO on a new consultant payscale, which will then allow us to commence recruitment of the 250 vacant consultant posts.
It was mentioned that the emergency department is often the only access point for sick older people. The point made by Senator van Turnhout is one the committee would share. I do not know how people will get better if they are to be left on trolleys. Are there other avenues of access for these people and what are the plans around that?
What the Vice Chairman says is only partly true. An alternative access point is the day hospitals. I previously worked in a day hospital which provided in-house services for the elderly. The Smithfield unit has a dedicated frail elderly service. There are proposals under the national clinical programmes to do something significant around streaming frail elderly services separate from the rest of the emergency department population. Mr. O'Brien will elaborate on that issue later.
On Our Lady of Lourdes Hospital, on which Deputy Fitzpatrick made a very good contribution, that hospital is under a lot of pressure. It now deals with as many presentations as St. James's Hospital. It is a very busy hospital, which arises in part because of the changes made in Monaghan and Dundalk and a failure to provide it with adequate resourcing. We need to help out that hospital. Some of the suggestions made, including in relation to bed capacity, ambulance bypass and extension of the opening hours of the minor injuries unit, are valid. I do not think, however, that we should start re-opening emergency departments that were closed. Emergency medicine is not what it used to be. Some 20 or 30 years ago, a person went to the emergency department and saw a doctor who could do anything from taking out one's gall bladder to treating a heart attack, but that is no longer the case. To run a quality emergency department requires a critical mass of patients and access to many specialties. There is much talk about patient safety. It would not be in the interests of patient safety for us to re-open closed emergency departments. If anything, we need to continue reconfiguring our services in order that everyone has access to a level of specialised care. Doctors, nurses and midwives need to be seeing a critical mass of patients or they lose their skills. This is evident the world over.
Before Mr. O'Brien comes in, would the Minister comment on the emergency task force meeting yesterday, including what measures he was in agreement should be pursued in the immediacy? While I reflected particularly on the issue of recruitment, I also put forward the notion of localised recruitment as an interim measure. Perhaps the Minister would comment on whether he has considered this or if, in his opinion, this idea has merit?
It is a good idea but it is a staff matter and I will ask Mr. O'Brien to comment on it further. The emergency department task force will bring a set of proposals to us before the end of the month. It is not an emergency task force, rather it is an emergency department task force. In terms of what is happening in the immediacy, issues such as community intervention teams, CITs, community beds and speedier discharges are being addressed. The role of the emergency department task force is more medium-term in terms of the development and oversight of a plan. As the Deputy will be aware, we have had plans before. This time, we need to ensure this plan is implemented.
Mr. Tony O'Brien:
Before I respond to the questions, my eagle-eared colleague has told me that I may have said that emergency department admissions are up by 8% instead of 1.8%. If I did, I apologise.
I will respond to the questions in the order they were asked. On the real experience that Deputy Kelleher has reflected to us, we have to accept the reality of that. None of us would pretend that at a time when excess numbers of people are waiting for very long periods on trolleys, that experience is anything other than a negative one. There is no question of that. However, I take issue with the suggestion that hospitals may be seeking to hold on to patients in order to manage their budgets in some way. There is no way that statement can be supported or accepted. If hospitals were doing that, it would be difficult to understand how they managed to spend €268 million more than their budgets last year. They are keen to ensure that patients are placed in the appropriate setting because the reality is that if a person is well, a hospital is not a good place for him or her to be. The people who work in hospitals know this more than anybody else.
On the trolley-INMO numbers in regard to trolley usage, the agreed definition used by the special delivery unit and the INMO is that these should include patients who are waiting for a bed. It is only in the those circumstances that they are counted. If a person is in the emergency department for assessment or treatment which is going to conclude within the emergency department or triage area, they do not show up in those numbers. That is the reason these numbers are so significant. While there may be odd minor variations between the hospital trolley use count and that of the INMO, it is an issue we do not get into an argument about. We accept there can be small variations. The overall headline figure is roughly the same.
The key difference is that in April 2013, the INMO decided to introduce an additional measure. On the website this is clearly identified as an additional and separate measure. It is called Ward Watch as distinct from Trolley Watch. This means we are comparing trolley numbers now with trolley numbers in the past rather than ward numbers. However, the INMO wishes to highlight both, for reasons which it has articulated clearly. There may be variances in that. It is an issue of bed use generally for other purposes as opposed to people in additional beds in wards. This would, for example, include the use of beds dedicated under normal circumstances for day surgery or in elective wards. These beds would tend to be counted in the Ward Watch figures. We keep a clear distinction because for a patient on one of those wards as opposed to on hold in the emergency department, there is a very significant difference in both the quality of the experience and almost certainly in the quality of care. The HSE and INMO are agreed that both should be reflected separately, although that distinction tends not to seep its way through to the public discourse.
On the recruitment issue, there are as we speak discussions going on with some of the key stakeholders in this regard. We are clear that the marketplace we need to target is the return of Irish-qualified nurses from the United Kingdom. Britain has been very effective at tempting our qualified nurses away. We are in discussions with the INMO and others about how we might best package a recruitment process to seek their return. We do have one disadvantage in that our salary scales start more or less in the same place. While I am not sure about this I think our salary scale increases by five or six points while the UK scale increases progressively to about 12 or 13 points. We clearly need to ensure that there are opportunities for those who do return to progress in their careers. This is exactly what we are looking at with the INMO. It is hoped this will result very quickly in an active recruitment campaign of Irish nurses in Britain, many of whom I believe would prefer to come back to Ireland, particularly if they have not sown long-term roots, as many will not have done yet. As part of our recovery, this is an area we need to tap into. We will be seeking to recruit directly for particular hospitals because people will want to return to the areas from which they came and so on. Local recruitment within that vehicle will be part of the exercise.
In regard to my earlier use of the word "managed", members may be attaching a little too much significance to it. I used it in the following sense. The Minister managed to secure a budget for the health service this year of €635 million more than it was last year. In doing so, he exceeded my expectations. He managed the process in that sense. There is no negative connotation in that regard.
Mr. Tony O'Brien:
I will respond to the issues Senator van Turnhout raised. I do not wish to address the specific circumstances, which I understand are naturally personally upsetting. The measures the Minister mentioned around CITs, nurse prescribing and so on are designed to support both end-of-life care if that is in a nursing home situation but also care more generally. Clearly there is generally nothing to be gained from patients being moved from nursing homes to acute hospitals if the care they require can be provided in that particular setting.
As Deputy Fitzpatrick knows, I have some local affinity with the Louth County Hospital. Egress is the key issue for Our Lady of Lourdes Hospital in Drogheda. There are 15 beds being worked through to support egress from the hospital. There are 24 private beds coming on stream at the end of this month, with our social care and hospital division working collaboratively with a private provider to skill up nurses for that nursing home given that it will be taking patients of slightly higher acuity than originally intended.
Measures are under way to facilitate the repatriation back to Cavan of trauma patients who were referred in from Cavan but have ongoing medical needs. A recruitment campaign is under way. This week CIT was introduced to augment the rapid response teams.
The hospital closest to where I live is Louth County Hospital. I absolutely do not believe the emergency department should be restored there for many of the reasons the Minister has alluded to. The population of County Louth needs one single emergency department team to provide the quality of care it needs. Clearly that team needs to be able to operate in better conditions than it currently does.
I welcome the Deputy's support for the minor injuries unit. It may need to have more people from the area using it when they can as opposed to travelling to Drogheda, and we are certainly looking at how we can market the MIU in Louth County Hospital more effectively.
Deputy Ó Caoláin used the phrase "nothing to be proud of in the health service". While there are many things not to be proud of, I am absolutely proud of the many men and women who work in the health service and have continued to do their very best for patients in the most difficult of circumstances and who continue to do so.
I will ask Dr. Henry to respond to the issue about the nine hours.
Dr. Colm Henry:
The nine hours refers to the time from the point of arrival at an emergency department or an acute medical unit until the point of departure, be it to home or to a hospital bed. It is called a target time. As the Deputy correctly said, there are other target times in other countries. We use the two targets - a six-hour target and a nine-hour target.
I wish to ask about the recruitment exercise. The Minister has dismissed any prospect of an intervention on this matter in the past. There are difficulties recruiting nursing staff with the significant hike in the registration fees in recent years. It is quite significant and is having a very negative impact on the existing complement of nursing staff, never mind those we might recruit.
I have a final question on the deferred so-called elective procedures.
I have shared my views on the issue of registration fees with the chairman of the Nursing and Midwifery Board of Ireland. I am very conscious that the Nursing and Midwifery Board of Ireland, just like CORU, the Medical Council or the education council, is the independent professional regulatory body for that profession and is accountable to the Oireachtas and not to me directly. The last thing I want to start doing is interfering with the business of the Medical Council or any other regulator or professional body. I have shared my views and concerns on this issue with the chairman of the NMBI.
It is a general policy principle that is broadly accepted across all parties that people should bear the cost of their own regulation and not the taxpayer. Even intern doctors pay about €310 to the Medical Council and accountants may pay €500. There are variations in that. I have certainly expressed my concerns about the potential consequences for the health service of nurses being delisted. However, I will not interfere in the inner workings of a regulatory body that is accountable to the Oireachtas.
I thank the witnesses for the presentations. I have a question about the Bord Altranais agus Cnáimhseachais na hÉireann registration. A nurse who returned from the UK in early December and submitted an application has been advised that despite being due to start in a job on 1 January, the registration could not be completed until the end of January at the very earliest. Can something be done to expedite that? That is also an issue for people returning from abroad trying to register with the Medical Council. I have come across cases of Irish graduates coming back from New Zealand and it taking eight to ten weeks to get Medical Council registration. Appropriate representations should be made with them to expedite those registrations.
How many junior doctor vacancies exist? How many agency doctors will we need to employ in the coming six months? What progress has been made on implementing the recommendations of the MacCraith report? The use of six-month contracts is one of the reasons for so many Irish doctors disappearing out of the country.
The witnesses have pointed to a slight increase in the budget for 2015. Can we have a slight increase in the home care packages? We really should have a substantial increase in that budget. Some 20,000 people a year are coming in under the older than 65 age group. That does not necessarily imply there will be an increase in people seeking those services but in recent years there has been a substantial increase in people seeking home care packages with no increase in budget. Therefore we should give priority to it now.
I thank the witness for the presentation. Every time the Minister has spoken in recent weeks he has been very careful to say that it is not always about money. However, with the exception of one, all of the things he has done and that he has said have worked in recent weeks have required money. The only thing I can find that does not require money is that section in Mr. O'Brien's speech on the leadership role of clinical directors, consultants, nurses and managers.
That correlates with the Minister's appeal on RTE ten days ago asking nurses, emergency department doctors and surgeons to do extra rounds. I am very worried if it is at that level on national media, that we are appealing to management and clinicians to do something that I believe - I might be naive - they should be doing week in and week out. Will the Minister clarify it for me because I might be stupid? Are we at the level where we are appealing at a ministerial level to our senior management teams in hospitals to do the things that they are being paid to do? If that is the case, do we have an issue with our senior management teams in our 28 acute hospitals?
The Minister mentioned that the emergency department task force is not an emergency task force. What does he expect to get from it that is different from what we have expected from the special delivery unit in recent years?
What has happened to the special delivery unit, SDU. Is it gone or is it still there? Does it do something that is different from what we will expect from the emergency department task force? Are any of the people in the SDU now part of the emergency department task force? That is just in recent weeks. When we are setting budgets at the beginning, what is the correlation around fair deal, home care packages and community integration teams? When we are spending €300 million on this or €975 million on that, what correlation is there for that budget versus the actual need and requirements of people who need to access that budget? Is there any correlation? Is it just because we have a finite budget that we can only allocate what we have to allocate?
I am only being opportunistic. The Minister said and accepted that Our Lady of Lourdes Hospital is under pressure. I publicly pay tribute to Margaret Swords and her team in Drogheda. In my humble opinion, they do a stonking job given that there is a genuine lack of resources there. The Minister said he was going to help her. Can he enlighten us as to how, where, when and how quickly he will do that?
I welcome the Minister, Mr. O'Brien and his officials to the meeting. The first thing we need to establish and accept is that accident and emergency overcrowding is unacceptable in any circumstance. That is only the beginning. Having accepted that, we must take action to solve the problem permanently. What we have been doing for years, what we have done in the past week and what we are doing again today is largely short-termism and firefighting. There are little or no examples of addressing the situation on a long-term basis to solve the problem permanently.
In his presentation, Mr. O'Brien indicated the difficulty with reduced budgets over recent years. Of course, he is absolutely correct. Nearly €4 billion has been taken out of the budget, 11,000 staff have been lost, 2,000 beds have been taken out of the system, funding for home help hours has been reduced by about €2 million, and fair deal has been reduced by about 50%. All those cuts introduced by this Government and previous Governments have devastated the system. This is what has happened. Staff at all levels are working daily above and beyond the call of duty. There is no capacity left in the system. South Tipperary General Hospital, which is my local hospital, is running at about 120% capacity every day. This is the case for other hospitals throughout the country. The system is under ferocious pressure and there is little or no capacity left to deal with any surges or additional pressures.
The Minister said today and on a number of occasions that this is a long-standing problem and it has been a long-standing, chronic problem for years. It has been addressed on numerous occasions by reports and investigations. At one stage it was declared a national emergency. The outcome is that we know the solution to this problem. Every manager in every hospital throughout the country, every clinician and every nurse knows the solution to the problem. We simply must address it on a long-term, permanent basis to ensure that accident and emergency overcrowding, which is absolutely horrific for patients and members of their families, is solved once and for all.
We know exactly what needs to be done. Measures like the use of medical assessment units, discharge allowances and the use of rapid access to outpatient department appointments are in place in most hospitals. They are very worthwhile and essential and are very helpful but they will not solve the problem on their own. We need other actions that have been in existence for years and that we have known for years will solve the problem. We need community intervention teams. I note that there is money in the budget and there is a proposal to extend those, but it will not be done for all hospitals. We need them for every area with an emergency department. We need closed beds to be opened and additional step-down beds for patients. We need to restore fair deal to at least the situation we were in this time 12 months ago when it was at six weeks. We need additional nursing, medical and support staff to deal with the problems we have. Unless those measures are put in place, we will be dealing with this question next year, the year after and the year after that.
Could Mr. O'Brien give us some more information on the final paragraph on page eight of his presentation? It suggests that there are 2,500 long-stay public beds at risk in the coming 12 months in respect of standards. I would like some confirmation that this matter will be dealt with, funding will be made available for it and they will continue to remain in place.
I will not be long. I thank the witnesses for coming in this morning. I thoroughly agree with Deputy Regina Doherty that it is about money. While it is also about management, it is certainly about money if one wants to implement something. When the HSE is counting trolleys, does it also count chairs? Are they part of the overall picture? If somebody is sitting on a chair in a corridor, is the chair counted as well?
I am glad to see that 65 beds will be opened in Mount Carmel and that there will be new short-stay residential beds. I fought hard to get beds for local people in respect of the Hollybrook unit in Inchicore. Hollybrook has been a step-down unit for St James's Hospital because of the transition for the new national children's hospital. They were supposed to be 50 extra beds that were short-term but we still have not moved anybody over there and it is not possible to get anybody into it.
It is very difficult to get someone into a home care package. I have had significant problems locally even getting a local district nurse to take a call, which they refuse to do. They will not even correspond with you. When you finally get in touch with them through the person for whom you are trying to get the home care package, the person concerned is told they should not have contacted their public representative and that they should have gone to the nurse. However, this can take a couple of weeks and things do not always work out as easily as that.
Families need to step up to the mark. Many families have shoved the responsibility of looking after older people onto other people. It is very important that families take responsibility. I am an advocate of home help services, which are brilliant, but asking somebody to come in for half an hour in the morning to get somebody out of bed, dress them and give them their breakfast is ludicrous. It does not work. When my mother was ill, it took two of us to get her into the shower because she would kill you if you took her into the shower. It had nothing to do with her not wanting to be washed; it had to do with the dementia. This, along with getting her breakfast and other things, meant that it was two hours before the two or three of us would manage her. We need to look at the home help service because if there is any chance of making an impact in respect of people not having to stay in hospital, it involves looking at home care and how we facilitate elderly people to stay at home. Even the basics of getting a nurse to go out and dress somebody's wound is very difficult. I agree with Mr. O'Brien when he said that we have lost something like €26 million in home help services. This is sad because we should begin trying to resolve problems that end up in accident and emergency in the home.
I do not have any questions other than the one about the trolleys. Could Mr. O'Brien give us any insight into when Hollybrook will become the link for St James's Hospital in respect of using the beds for the purpose they were provided for?
I welcome the Minister, Mr. O'Brien and his officials.
I will concentrate on an issue in the introduction to Mr. O'Brien's speech, in which he states:
The population over 65 years is growing by approximately 20,000 per year and those over 80 years by 4% annually. Due to reduced budgets over the past number of years, the development of the required capacity within our community services to deliver home helps, home care packages, short stay and long stay residential care has not kept pace with this demographic growth.
With this growing population, if we kept the budget as it is, we would run into difficulties. It is illogical even to contemplate a budget cut in this area. Given that there are 20,000 more people over the age of 65 per year, how can we sustain the fair deal scheme? Has Mr. O'Brien considered the future of it and thought about replacing it with something else or how it will be managed?
Deputy Kelleher raised an issue which has also come to my attention. In University Hospital Waterford, there were no pillows or blankets available to people on trolleys. Although the numbers of people on trolleys has decreased today, it is not good enough. If we accept that there are people on trolleys trying to access beds, at least the very basics should be provided for them. I would like to know what resources are being made available to ensure it does not happen again. I welcome the Minister's comment that long after this drops off the front pages of newspapers he will remain committed to dealing with it. He will find that health is broad ranging and interconnected. While we may talk about home care on one day and access to speech and language or occupational therapy another day, it is all interconnected in terms of how we keep people well and at home, away from the emergency departments. I wish the Minister well. The committee is always anxious to see leadership being given and results being delivered. Could the Minister respond to the additional questions?
The Vice Chairman made a very good point and she is correct that almost all health issues are connected in some way. The emergency department is often just the place where the flaws and shortcomings show up. I accept her point. I did not mean any disrespect in what I said earlier and I apologise if that is how it came across.
Hospitals do not need delegated sanction from the director general of the health service or me to procure items such as pillows and blankets. The hospital may have been so overwhelmed that it was unprepared at the time. I hope it does not happen again and that they do not need to procure extra pillows. We can both agree that is not the solution. Deputy Catherine Byrne is correct about home help, home care and social care. If my fairy godmother arrived tomorrow and gave me an extra €50 million, I would give very little to the hospitals. It would go to social care, fair deal and home care packages, which would free up hospitals. In the 2015 budget, the fair deal scheme and home care packages were increased by €10 million each. Whether it is enough to meet rising demand will become apparent as the year goes on. The fair deal is under review and the Minister of State, Deputy Kathleen Lynch, is due to receive the review in a matter of weeks. We will deal with it when it arrives.
The HSE TrolleyGAR counts people on chairs. It counts anybody who is in an emergency department, who a doctor says needs to be admitted and who is waiting for a bed, whether on a chair or a trolley.
Deputy Regina Doherty asked about the things that do not cost money. These include physicians doing two ward rounds per day and senior decision makers being present. Given that senior decision makers are more experienced, they are more likely to discharge patients, can see them more quickly and are less likely to admit them. This is very important. Although postponing elective procedures does not cost money, they come back again to bite us. Discharge planning does not cost money and we should plan for the discharge of patients from the day they are admitted. The full capacity protocol, which is not agreed, does not cost money. It is used in many other jurisdictions to move patients up the house so it becomes a problem for the whole system, not just the emergency department. Encouraging people to use the minor injury units, such as in Dundalk, Smithfield and Cork rather than going to the big hospital does not cost money. Hospital avoidance by referring people direct to diagnostics or outpatient departments, OPDs, does not cost money. The Deputy is correct that many other measures cost money and that all these should be happening all the time. However, when one is in a surge scenario it is worth making the point and asking everybody to redouble their efforts and do what they can.
Mr. Tony O'Brien:
The SDU still exists. Its personnel are still in place and they work as part of the acute hospitals division. There have been one or two personnel changes over the years, including me. A previous member of the SDU, Mr. Jim O’Sullivan, is a member of the emergency department task force. Many of the measures the SDU developed from mid-2011 are still in place. The critical difference is that they have been slightly overwhelmed, broadly speaking but not exclusively, by demographic impact. This morning I was in an emergency department where the consultants on call told me something very interesting. Having worked in the hospital at different times over 20 years they have found that the average age of a patient has increased by one year per year. The demographic effect is real. Hopefully, we will all age and be reasonably well as we do so. As we do, our demands for health care will grow, whether for acute care or home care supports. The economic recession has had an impact on the capacity of successive Governments to keep pace with demographic change in the country and there is no denying it. This is the first budget in many years to seek to address it. At the launch of the service plan, the Minister and I were both very clear that it is a start rather than the solution we need to get to for successive years.
Dr. Colm Henry:
Although we track junior doctors closely through each six-month cycle, one never knows exactly what the figures are until the day of change because people may withdraw their applications or move elsewhere. We have had additional junior doctors in the past year because of our duty to comply with the emergency working time directive, EWTD. Despite these difficulties, as of last Monday, the day of changeover, our outstanding vacancy rate was 170 out of a complement of almost 5,000 junior doctors. This figure has been remarkably consistent over recent years. It hardly changes and tends to be concentrated in the same specialties in the same hospitals. Although we have had worries at times about keeping certain services going, we have managed to maintain front-line services even in the hospitals which are particularly challenged in terms of recruitment.
The question on older people is interesting and is one about which we all need to be mindful. One could argue that by the time a frail older person arrives at an emergency department, it is almost too late to consider alternatives. Like other health care systems in the western world, we must consider alternative pathways for older people that are more sustainable, fairer, kinder and more appropriate to their needs. Older people can present to day hospitals. In Cork, where I work, geriatricians visit the community hospitals to avoid hospital referrals.
In Blanchardstown, we made an innovative appointment where a geriatrician works half time in the community and half time in the hospital. During her tenure, referrals from nursing homes have fallen by 20% to 30%, so simply by her crossing that interface and identifying elderly people, she has managed to avoid their referral to hospital and to treat them as day cases or in step-up beds in hospital. It is a much more humane and kinder approach to people who do not want to be on hospital trolleys. We must expand the idea of addressing the care of older people before they ever come to hospital, identify at risk cases, have case managers look at these people and work with hospitals to identify a menu of options other than referral to emergency departments, in particular in the Dublin area. This takes time and it is a cultural change which requires a change of mindset among all those engaged in health care. It is part of the initiative in which we are engaged. We will be developing such models in Dublin.
Mr. Pat Healy:
In terms of the initiative in December, there were already plans, as part of our escalation process, to have 700 beds available. As has been said, we had approval for an additional €3 million so those 300 beds went in before Christmas. The waiting time has been brought to 11 weeks, so it is currently 11 weeks and it is continuing at that. That is an important part of that. Of course, there is demographic growth and the waiting list. The system works significantly better when, as Deputy Healy said, the waiting list is no more than four to six weeks. It is important to say that as part of the escalation, 165 transitional care beds, in addition to the fair deal scheme, were put in place in December. They made an important contribution also in reducing the number of delayed discharges overall in the time set out in the director general's opening statement. Since then, a really important part has been the focus on transitional care over the past number of weeks. We have worked closely with Nursing Homes Ireland in that regard and it has to be acknowledged that it has worked well with us on that. We identified 250 beds from a survey we undertook with Nursing Homes Ireland and we are targeting those. That has contributed significantly to our capacity to respond.
The work under way between hospitals and community services, in particular social care, is in matching the capacity within the private nursing home sector with the dependency of older people, in particular those who are being discharged, and that is working well. We have seen the reductions. Some 192 have been discharged in the past week, so that is an important part of it.
In regard to the home care packages, it is important to confirm to the committee that has been available. Throughout December, a significant focus was deployed to ensure home care packages and home care services were provided. In the week before Christmas, more than 120 home care packages were provided, some 87 directly to the hospitals. During December more than 296 home care packages were delivered to the hospitals as part of that initiative, or more than 550 when one takes the community and hospital together.
It is clear the initiative put in place in terms of the escalation between the hospital and the community has worked well throughout December. There are usually 20 cases over the week where a bit of work has to be done between the hospital and the community to ensure the person gets home. It might be that the home care provider has to get the staff in place or it might be that a person needs some modification of his or her house but we are working very closely with hospital and the community to ensure that has kept to a very minimum.
Mr. Tony O'Brien:
To return to the nursing unit registration issue about which Deputy Healy asked, what I was referring was the fact that a long stop date has been put in place by HIQA for compliance with the registration requirements. Interim registration was granted on the basis that, over time, full compliance would have to be achieved. That date is mid-year. Some of the stock to which I am referring is actually original work house stock in terms of footprint and in terms of the fabric of the external buildings. The regulations are correct. It is appropriate that we move away from essentially ward-type accommodation to more suitable accommodation – single and double en suite rooms and so on. At present, we are not in a position to do what would be necessary in order to meet the requirements of compliance by mid-year. However, there are processes in place and under way designed to address that issue but, at present, we do not have that funding in place. That is what I was referring to there.
In regard to the registration of nurses and doctors returning from abroad, I think it may vary depending on whether the individuals continued to pay a retention fee. Where they did not, the regulator will go through a process of verifying qualifications and so on. That is not something in which we have a role but clearly it is important and we have seen recent incidences which have emphasised the importance of that checking process to ensure people are registered only on the basis of their strict entitlement to be registered. There can be variability, depending on where people have been in the meantime, the availability of records and their ability to demonstrate their practice and professional compliance in the meantime.
In regard to Hollybrook, the Deputy is right in that the facility has been used to facilitate the decant of what, I think, was called "hospital seven", which was a medium to long-term facility on the grounds of St. James's Hospital. During the redevelopment there and at present, it has not been available for the originally intended purpose. Against that, under the €25 million programme to which I referred to earlier where Dublin has been prioritised, in particular because of access issues, St. James's Hospital has been prioritised with 15 short-stay beds and 40 packages, which are designed to specifically address the issue of patients in that hospital who would be from its hinterland and catchment area. However, the Deputy is right the facility is not being used for the originally intended purpose.
In regard to the overall issue of budgeting, every western society which seeks to run a comprehensive health care system is facing the same issues as we are. Some people use inflammatory language, such as demographic time bomb and so on. There is a requirement for us to re-engineer our services in order to take account of the fact that an increasing proportion of us will be living longer. Hopefully, we will all achieve that status. Some of the things Dr. Colm Henry spoke about are necessary for the re-engineering of our pathways which take account of the fair deal scheme, home care, acute hospital systems and so on.
In response to Deputy Doherty's question on budgeting, we seek, with our colleagues in the Department of Health, to reach an intelligent view of what the future requirements will be and then we have to take account of what we get and how we can apply that. Those two things are not always the same. That is the reality.
In regard to the cancellation of elective procedures, which was Deputy Ó Caoláin's point, at present, I do not have a figure which I can give him. This is a real-time situation. It will obviously be influenced by how long current pressures exist and what the weather, which it is being unkind to half the country, in particular today, does to us and, indeed, what the influenza-like illness index produces. We are now in the 'flu season. We have seen our first spike and are, therefore, on particular alert for a period of about eight weeks, which is what we would expect the 'flu season to be.
An added complication is that the particular strain of 'flu, which has traversed the Atlantic, as it always does each year, is not the strain of 'flu predicted and, therefore, is not the strain of 'flu for which we have vaccinated our health workers and the general population. There are particular risks in that area, which means this could continue for a little bit longer than we would like but all of our measures are designed to prepare us for that. When we get to a point when we can recommence electives – this would be different in different hospitals and it will be calibrated - we will then be in a position to say, and we will do so publicly, what the impact of this has been on electives.
At present, however, it is not really possible to reschedule. We do not want to reschedule people into an early slot which is more than likely going to be cancelled. That would not be good for them or for the system, but we will be open about it when we have the full details.
Mr. Tony O'Brien:
In terms of what we are doing there, I gave some of the details to Deputy Fitzpatrick. The Deputy is right to congratulate Margaret Swords who is now the group chief operating officer for the RCSI hospitals group that includes the Lourdes. Some 15 beds are immediately being worked through for patients currently in the hospital, while 24 private beds are coming on stream at the end of the month. The hospital and our social care division are working with a private provider because the acuity of the patients might not be what was originally envisaged by that provider, so a little bit of upskilling is required for their staff, which is being progressed.
The repatriation of all the Cavan trauma patients who have ongoing medical needs has been agreed with the hospital. There is a modular build in the hospital with provision for 20 beds which will be available at the end of February. A recruitment campaign is under way and a community intervention team has been introduced and is working with the hospital now. So all these measures are designed to address the stress. If these things do not work we do have one or two other tricks up our sleeve.
Ms Angela Fitzgerald:
The modular build we talked about is not just for beds, but it does provide immediate alleviation for the bed situation. As the Minister said, Drogheda has 55,000 attendances which is a significant factor. That is designed to give immediate relief. The other challenge is that they have been particularly affected by the shortage of long-stay beds. Therefore, while the focus was primarily on Dublin, we included Drogheda as part of that immediate response. There is a recognition that they are particularly challenged concerning medical agency, so we have tried to provide additional supports for them. There has been a lot of discussion about the reliance on agency which, we accept, is not desirable. At the same time we recognise there are a small number of places that need some flexibility. We recognise they have particular challenges and are giving them additional support to allow them to operate safely.
I accept, first of all, that the introduction of additional beds without the required nursing supports will not function. It will only make a bad situation worse. I have heard the reply concerning a recruitment project that will concentrate on the neighbouring island to, hopefully, encourage the return of nurses who have left. In the interim the situation maintains and could, as Mr. O'Brien has quite rightly pointed out, get just as bad as it was a week ago. Is any consideration being given to localised recruitment on a temporary interim basis, including former nursing staff whatever the circumstances of their leaving service? Is any consideration being given to that as an interim measure? No matter what recruiting campaign the HSE embarks upon, it will take some little time.
Mr. Tony O'Brien:
The answer to that is "Yes", localised recruitment is agreed and is happening. As I have said before, if this situation continues absolutely nothing will be ruled out. When the things we have done in the last week and a half come to fruition they will make a further significant inroad into the numbers of persons on trolleys, which we intend to sustain. If we experience adverse events, however, be it a spike in 'flu or whatever, we will then respond accordingly. There is absolutely nothing ruled out in terms of that response.
I do not understand why registration should take eight weeks. I have talked to people who have gone to New Zealand and Australia where, on average, it takes two weeks to register. I do not think it is acceptable that it takes eight weeks for health workers to be registered here when they come back home. It just does not make sense. Some representation should be made on the matter to see if priority could be given to registering people who are returning home.
Thank you, Minister. I appreciate that. I wish to thank the Minister, Mr. O'Brien, Ms Fitzgerald, Dr. Henry, Mr. Breslin and Mr. Healy for taking the time to be with us here today. We wish them well because it is not over yet.
I wish to advise members that we have a vote in the Dáil.