Mr. Tony O'Brien:

I thank the members for their seasonal greetings and their questions. I was struck by the football manager reference. The last time I was here, I quoted the great prophet, Eamon Dunphy, in a similar way. I was certainly struck by the fact that the wee county that never gives up keeps trying. Success may have eluded it. Even when the ball gets carried across the line against them, they come back and play again. I hope Deputy Doherty will forgive that reminder. The analogy is not lost on us at all.

I will be asking my colleagues to speak to the social care, primary care and acute hospital issues that are specific to their briefs. At an overview level, I note that Deputy Kelleher asked a very important question, namely, why we are seeing an increase in attendances at emergency departments. It relates to overall demand on health care. It is important to recognise that it is not a static environment. Our population, fortunately, is growing and it is growing older. That is a really good thing but there is an inevitable impact on certain types of health care services. Acute, unscheduled care is one of them. Since 2010, there has been an 18% increase in those aged over 65 years and a 17.5% increase in those aged over 85 years. People in those higher age ranges are disproportionately represented in the population of individuals who present at emergency departments and among those who require admission. That is why the issue of long waits at emergency departments is key. We know that they are disadvantageous for older persons and for frail elderly people in particular. While the fact that we are aging is a good thing, the changing nature of our population creates its own demands.

I can give the committee the exact data for the first half of this month on the patient experience time, which is the official measure we use for the experienced time in an emergency department. This relates to patients who are admitted and not admitted. In the context of the nine hours from registration to discharge or admission to a bed, of the admitted population, 61.9% were admitted to a bed within nine hours. That clearly means that some 38.1% were not. The issues relating to people who wait inordinately long periods are clearly in that proportion of the figure. We are not claiming that everyone is being admitted in the period they should be, we are simply quantifying the scale of the problem. Of the non-admitted patients seen, treated and discharged from the emergency department, 90.8% were seen and discharged within the nine hours. Together, that gives us the 83.5%. Interestingly, if we look at six hours, 44.6% of patients who needed admission were admitted to a bed within six hours of registration in the emergency department. Of those who needed to be discharged, 77.9% were discharged within six hours of registration, giving an aggregate of 69.3%. These figures are important because, over time, they will allow us to measure improvement. They tell us what is working and the scale of the challenge. We do not come here today in any way to diminish the scale of the challenge. The emergency department task force is here until further notice. Our aim is, obviously, reach a point where it is not required but it is here until further notice. To be clear, I am the co-chair of the task force and the other co-chair is Liam Doran, the general secretary of the INMO.

On delayed discharges, I ask the members to go back to page 7 of my submission and look the chart there. What is really interesting about this is that it shows the very dramatic impact a policy, funding and operationally cohesive decision can have. We clearly identified and discussed here at the committee the particular problem of delayed discharges which we identified as a key contributor to the significant increase in emergency department congestion and long waits in the first part of the year. We identified that with the fact that funding restrictions had given rise to long waiting periods for the fair deal scheme which in turn had contributed to delayed discharges. As the chart shows, while it was not quite like turning on a tap, it clearly had an instantaneous, dramatic and, thus far, sustained impact on delayed discharges. As a result, it has fed through, albeit slowly and in small ways, to the emergency department position.

In the context of the current figures in emergency departments, today's trolley graph figure is 289. It is not in the slides. The slides came yesterday. Today's figure is 289. For a little over two years, the INMO has been publishing two figures, which it aggregates together. It differentiates clearly between the two on its website, however. One is trolleys in emergency departments and the other is other patients accommodated elsewhere in the hospital as extra patients under full capacity type measures.

I have no argument with the fact the INMO does that. We do not bother arguing about figures because it is a pointless exercise. The trends in our figures and the INMO’s are broadly similar. That is what we are looking at but the figure to concentrate on is the patients in the emergency departments. Part of the appropriate response to excess crowding in emergency departments is for that challenge to be spread to other parts of the hospital. Our focus is no longer on allowing this simply to be concentrated in the emergency departments, as if it were not a whole-hospital or whole-community problem. I make that distinction and I believe it is right to do so.

Yesterday's figure was a little against the trend, as was that for the day before. We saw about a 30% reduction the day before and about a 5% reduction yesterday. We think that was a direct impact of the expected industrial action. If one puts the two figures together, one actually eliminates the effect. When one does that, one sees a general trend of figures being down around 20%, day by day, in the current month. That still leaves us with a wicked problem because it is not where we need to be. When we discussed this before, as part of a more general discussion when I had just come into the co-chair role, it was clear we did not have an instantaneous solution or a magic wand. Our intention is to make it incrementally better, day by day, so the figures as we come out of this winter period, particularly in January, will be measurably lower than they were last year. Many of the measures in the emergency department task force recommendations are longer-term in nature. All commentators, including the INMO, acknowledge there is currently a measurable and perceivable improvement.

That is no comfort if one is the individual patient who is on a trolley for nine, ten, 15, or however many hours it may be. I acknowledge it is still occurring. However, the directive is designed to ensure that all of the agreed protocols are followed. In other words, no hospital should be tolerating patients waiting that length of time, unless it has exhausted all of the opportunities at its disposal. That does not mean that no patient will wait too long. It means they will not wait too long in circumstances where the hospital has not done all it should have done to minimise the numbers and the length of waiting time. There are financial sanctions for failure to follow the steps of the protocol. The financial sanctions that were there for elective targets will not apply if the hospital can demonstrate that it has had to defer elective work by following all the steps in the procedure, as a result of this situation. That is clearly stated in the directive published three weeks ago.

Deputy Kelleher specifically asked about elective care. There is clearly not a blame issue but an issue concerning the relationship between the total bed capacity of a hospital and the two pipelines of work, or demand, which feed into it, namely, elective - or scheduled care to give it its proper title - and unscheduled. There will be situations where, predictably, we will see certain events or dates where we expect surges in presentation in emergency departments. These will not be people who should not be in an emergency department but people who need admission to a bed. If the hospital is at full tilt on elective or scheduled care, it will not be able to accommodate the emergency admissions, rather than have late-in-the-day cancellations which are very inconvenient to all concerned. I accept and draw the distinction between urgent scheduled care and non-urgent scheduled care because there are categories of urgent scheduled care that are protected in this context. As part of the winter plans, we are directing that a sufficient amount of bed capacity should be retained for emergency admissions which inevitably will mean a reduction in the amount of scheduled activity. This must be on a pre-planned basis, rather than a night-before telephone call which is so troubling for patients who have prepared themselves for admission to hospital.