Dr. Emily O'Conor:

We do not have those nurses. At the moment, the current cohort of emergency department nurses that are there to staff emergency department patients are also looking after these admitted in-patients. Therefore, instead of having five patients to look after, a nurse might have ten to look after. The safest place for nurses to nurse them is where they can see them. There is a clinical risk to putting patients away if one cannot staff them. As I said earlier, if we can build annexes we can build proper beds and staff them.

Why do we have 80 emergency department consultants in emergency medicine? That is all we have ever agreed on. The national programme for emergency medicine has much higher numbers. We need over 200 consultants in emergency medicine, but there is no money for it. We have jobs filled on a locumbasis and there are unfilled jobs because of working conditions and remuneration. Both need to be sorted. I have addressed 8 p.m. to 8 a.m. working, but I can speak more about that if the committee so wishes.

Can we improve with what we have? I think we can, yes. We can continue to improve the way we work.Working from 8 a.m. to 8 p.m. and improving how the system works out-of-hours is part of that. By God, however, we have worked on process change so much over the last few years, and we have made progress. We have managed to keep trolley waits static in Dublin emergency departments despite the increase in numbers of attendances, so there have been improvements, but give us room to breathe and hopefully we can improve processes more.

Yes, the elderly in nursing homes come to emergency departments out of hours. More advance planning led by consultant geriatricians and palliative care teams in nursing homes might prevent some of that. Nursing homes need to know there will not be adverse reporting and family expectations because the loved one has not been transported and has subsequently died. We as a society need to be mature about this. I see very debilitated patients transferred to emergency departments for a blocked catheter etc. at night. We could do better. In addition, we need to be able to die in nursing homes.

As for nurse prescribing, we have lots of nurse prescribers for emergency medicine and ionising radiation. We are one of the best practices for crossover of clinical skills between nursing groups and consultant groups. We have clinical nurse specialists and advanced nurse practitioners. We have really good practice on crossing skills and the boundaries are not as demarcated in emergency medicine as they are perhaps in other specialties. We can lead out on that if the committee wishes.

Deputy Durkan, I have already addressed previous times. Societal expectations have changed, which is the main reason, and population has increased. In the United Kingdom, the Royal College of Emergency Medicine is fighting back again because there is still talk there of reducing bed numbers. That could happen if we got processes so perfect that most patients could be seen in ambulatory manner. Yes, in an ideal world we might have fewer beds but not in the short or medium term with our current processes or those in the UK. Yes, it would be less expensive to maintain patients in car parks. The Deputy is right it is less expensive to maintain patients on trolleys in emergency departments than to open wards and bring in nurses to do that work.