Mary Harney (Dublin Mid West, Progressive Democrats)

I have already welcomed the Health and Safety Authority's report arising from its assessment of 11 accident and emergency departments. The National Hospitals Office has separately analysed assessments of risks carried out in all hospitals and the actions taken to deal with such risks. I stress that this is the first nationally co-ordinated analysis of all accident and emergency departments. Therefore, it is critical that action is taken to follow through on the recommendations emerging from both the HSA and the NHO assessments.

All hospitals inspected by the HSA have been issued with a report of the inspection. The HSA has directed the hospitals in question to submit a comprehensive plan to address these issues, including time scales for corrective action. The HSA acknowledges that the hospitals are fully engaged in the process of addressing health and safety in their accident and emergency units.

The HSA recommended that the HSE should determine on a hospital by hospital basis, after undertaking the necessary risk assessment and staff consultation, whether extra capacity can be achieved within the existing system. The NHO has advised hospital managers to examine the potential for using the total hospital capacity, including inpatient wards, for patients who require admission. Each individual hospital must exercise its own judgment on how to reduce risk. In doing so, hospital managers have been asked to have regard to international best practice in areas such as improving work-flow issues and increasing the use of more appropriate community-based interventions to reduce pressure on accident and emergency services.

The NHO is seeking tenders from companies which are expert in the area of work-flow management to carry out a review of ten hospitals to identify the efficiencies that can be achieved to improve patient services and reduce overcrowding. This is an approach that has contributed significantly to improving accident and emergency services hospital by hospital in the UK. I look forward to the practical steps taken by many hospitals here as a result of this audit work.

One of the issues raised by the HSA was a fragmented approach to health and safety that was exacerbated by the fact that there is no senior clinician in charge of accident and emergency units on a 24-hour, seven day a week basis. While the number of accident and emergency consultants has increased from 14 in 1997 to 52 at present, the HSA has indicated the need to address the extent of senior clinician cover for accident and emergency units. I understand the NHO will invite the IMO and the Irish Hospital Consultants Association to discuss this issue for hospitals with two or more accident and emergency consultants.

Both the HSA and the HSE reports have found violence and aggression to be one of the main risks in accident and emergency departments. Much of this relates to the prevalence of cases of alcohol and drug misuse presenting at accident and emergency departments. An alcohol and injuries study, commissioned by the health promotion unit of the Department of Health and Children, has been expanded nationwide to include six major hospitals and a full report is being prepared. Preliminary results from the wider study of accident and emergency departments appear consistent with the Mater Hospital study that showed 30% of male admissions, 10% of female admissions and almost 25% of all accident and emergency attendances met diagnostic criteria for alcohol misuse or dependency. The full results of the expanded study are being processed and should be available by mid-2005.

The HSE has recently carried out an examination of patients attending accident and emergency departments with psychosocial conditions with a view to developing appropriate care pathways and referral processes for such patients. An action plan is being finalised to include initiatives such as the identification of appropriate care settings at community level and the development of triage arrangements at hospitals with accident and emergency departments to enable more appropriate assessment and treatment of persons with psychosocial issues.

The National Hospitals Office has requested the immediate implementation of guidelines issued by the Health and Safety Authority on dealing with violence and aggression in the workplace. It has also written to each trade union or staff association requesting that the accident and emergency issue, including the issue of health and safety, should be dealt with by way of a working partnership group between management and the trade unions rather than through the normal industrial relations process.

We would all agree that it is totally unacceptable that front-line health care workers might be subjected to threats or abuse. The Minister for Justice, Equality and Law Reform is determined that everything possible should be done to tackle disorderly behaviour and, in particular, assaults on emergency workers such as the staff of hospital accident and emergency units.

The Minister is providing in the Criminal Justice Bill for a fixed charge procedure in regard to certain public order offences. Section 29 of that Bill, which is on Second Stage in the Dáil, provides for such a procedure in regard to disorderly conduct in a public place and in regard to intoxication in a public place. In addition, the Minister is examining the current position in regard to assaults against emergency workers with a view to providing for a specific offence in this respect by way of an amendment to the Criminal Justice Bill. I hope the House will join me in fully supporting the Minister's work in this regard.

Everyone who has taken time to understand the accident and emergency issue in any country will recognise that many factors cause the bottleneck in accident and emergency departments and that each has to be addressed if we are to solve the problem. The Government is confident that accident and emergency services can be substantially and radically improved if people come on board for change.

The issues include alcohol abuse as one factor causing difficulties and discomfort for patients and staff in accident and emergency departments. It is one of many issues, but it would be a mistake to expect short-term actions on alcohol abuse to solve wider problems. Clearly, tackling alcohol abuse will not improve rostering to ensure patients are seen, diagnosed, treated and discharged quickly. It will not supply better out-of-hours GP services so that people do not have to resort to having to go to a hospital in the middle of the night for medical worries or minor injuries. It will not make diagnostic tests available round the clock without long delays for patients.

The Government is determined to make visible improvements for patients in accident and emergency departments and elsewhere throughout our health services. Our economic strategy is working to provide massive resources for public services. The Government has invested unprecedented new resources in health care. However, what is required is not simply a matter of providing more resources. The time has come for all of us, including the Deputies opposite, to acknowledge that the priority now is for all those involved in the delivery of our health services to work together to ensure that these resources are used to deliver much better services for patients.

Regarding the implementation of the ten-point plan, the HSE has identified many of the high dependency beds that we put out to tender and patients will be moved to those beds over the coming weeks. We have also put in place a home care package. Many elderly people in particular and some younger people who are disabled are availing of the home care package to return to their own homes. We have acquired facilities for 500 patients in the intermediate care area, particularly, but not exclusively, in the greater Dublin area. These, together with independent access to diagnostics, the AMU units that will be put in place at three of the main hospitals in Dublin and provision in regard to some of the issues around care of the elderly, will have a dramatic impact on accident and emergency services.

However, above all else we need changes in hospital practice. As I said on other occasions, Dr. Conor Burke from Blanchardstown hospital stated in a paper he produced recently that if every patient at that hospital could be discharged when he or she was medically fit to be discharged, there would be no problem in the accident and emergency department of that hospital. What is required is the daily discharge of patients, consultants working together, people not being admitted to hospital for diagnostics when that can be done on an outpatient basis and the provision of more services for elderly people, particularly in urban areas.

The controversy around the charges issue has added to the problem this year. Many people who may have moved to a nursing home environment have not been prepared to do that because of the controversy. The confusion around that issue is not the cause of the problem but it has delayed the discharge of many elderly patients from some units in our acute hospital system. There are close to 400 elderly patients in main hospitals in Dublin, which is an unusually high figure for this time of the year.

The difficulties and pressures in accident and emergency departments are a priority for the Government. We are determined to put in place all the necessary policies to ensure that we deliver a solution. I believe that by next winter we will see a remarkable improvement in the vast majority of patients' experience of accident and emergency departments.

We need additional bed capacity. It is not secret that the new Mater Hospital will have additional bed capacity. I have plans to provide additional bed capacity at public hospital facilities throughout the country because at present 2,500 public beds are used for private patients. For private patients, there are alternatives to using the facilities in our public hospitals. Those measures, together with many aspects of the ten-point plan, will have a major effect on ensuring that the public hospitals are used efficiently.

We need to ensure there are appropriate work practices and rostering in place, particularly 24-hour consultant cover at accident and emergency departments. Many patients are not discharged if the consultant is not on duty to discharge them and they end up staying in the ward from 6 p.m. until 8 a.m. the next morning when they could have been discharged within an hour or two of having seen the consultant if he or she had been on duty. These work practices have to be changed in the interests of patients and they are a number one priority.

I should have stated at the outset that I wish to share my time with the Minister of State, Deputy Tim O'Malley.

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