Leo Varadkar (Dublin West, Fine Gael) | Oireachtas source

I move amendment No. 1:

To delete all words after “Dáil Éireann” and substitute the following:

acknowledges:— that improving waiting times for scheduled and unscheduled care are key priorities for Government;

— the wide-ranging set of actions which are being put in place by the Health Service Executive (HSE) to achieve improvements in the delivery of both scheduled and unscheduled care;

— the difficulties which overcrowding in Emergency Departments (EDs) cause for patients, their families and the staff who are doing their utmost to provide safe, quality care in very challenging circumstances; and

— that optimum patient care and patient safety at all times remain a Government priority;notes in particular that:— the Minister for Health convened the ED Task Force last year and the publication, in April 2015 of the ED Task Force action plan, with a range of time defined actions to (i) optimise existing hospital and community capacity; (ii) develop internal capability and process improvement and (iii) improve leadership, governance, planning and oversight;

— the significant progress made to date on the ED Task Force plan is as follows:

— delayed discharges are reducing steadily from 830 in December last year to 586 on 15th September, and the average number of patients waiting greater than 9 hours on a trolley in August was 97, down from 173 in February;

— waiting times for Nursing Home Support Scheme (NHSS) funding have reduced from 11 weeks at the beginning of the year to 4 weeks;

— transitional care funding has continued to support 1,903 approvals, which is significantly above the original target of 500;

— over 1,200 additional home care packages will have been provided by the end of 2015;

— 149 additional public nursing home beds and 24 additional private-contracted beds are now open; and

— in addition, 65 short-stay beds have opened in Mount Carmel Community Hospital, which was officially opened in September;

— in June, the HSE reported a performance against the Minister’s 18 month maximum permissible waiting time of 99.6 per cent for inpatient and daycase treatment and 92 per cent for Outpatients’ Department (OPD);

— in order to maintain progress and make further improvements to achieve a 15 month maximum waiting time by end year, the HSE has directed that hospitals which breached the 18 month maximum waiting time in August are to be fined. The fines will be calculated on the basis of the activity-based funding cost of each procedure and are being imposed from 1st September;

— the HSE has provided 1,004,329 inpatient and day case treatments and 2,176,365 outpatient appointments up to the end of August this year - an increase of 3,461 inpatient and daycase treatments and 39,879 outpatient appointments compared to the same period in 2014;

— the provision of additional funding in 2015 to relieve pressures on acute hospitals is as follows:

— €74 million in April 2015 which has supported significant progress to date on reducing delayed discharges and lowering the waiting time for Fair Deal funding, as well as providing additional transitional care beds and home care packages to provide viable supports for those no longer needing acute hospital care; and

— €69 million in July 2015 - €18 million to support the acute hospital system over the winter period by providing additional bed capacity and other initiatives to support access to care and €51 million to ensure achievement of the maximum permissible waiting times for scheduled care;

— this additional funding came on top of measures already taken in Budget 2015, when the Government provided €25 million to support services that provide alternatives to acute hospitals;

— all of the funding referred to above is additional to the welcome increase in the total financial resources made available to the HSE by the Government in 2015;

— a series of campaigns are ongoing to attract frontline staff in order to meet patient care requirements:

— since January this year, around 500 more nurses are working in the health service;

— since September 2011, almost 300 additional consultants have been appointed to acute hospitals around the country, including 57 more this year;

and

— the number of Non-Consultant Hospital Doctors (NCHDs) employed in the health service has increased by over 250 since last year;

— the National Treatment Purchase Fund (NTPF) as it operated under the previous Government did not succeed in eliminating long waits;

— Fianna Fáil’s alternative budget last year provided only €300 million for health, which is much less than will be provided by the Government; andsupports the Minister for Health in his continued determination to bring about improvements in urgent and emergency care services and in hospital waiting lists.

I welcome the opportunity to update the House on what the Government is doing to improve access to services in our acute hospitals and to address the significant pressures they are experiencing. There can be no dispute that too many people are waiting too long, and many emergency departments experience overcrowding. This causes difficulties and distress for patients and their families at the moment they need access to our health service. It also makes the working day much harder for staff. That is why dealing with the problem or, at least, alleviating it is a key objective for the Government.

This is not a new problem. Long waiting times and trolleys have been features of our system for many years and are the most immediate and obvious indication of the pressures on our health service and the poor organisation and variability in practice and excellence. When Deputy Martin was health Minister with a budget and staffing levels that increased exponentially every year little, if anything, was done to address these problems or, at least, nothing that had a lasting impact. Waiting times and trolleys are not the same problem, and people often conflate them. However, increased emergency presentations can lead to scheduled activity being displaced, while delays in diagnosing or treating illnesses can result in a greater need for emergency intervention. There are also links with services and capacity in primary and community care, which support people to move out of hospital to home or residential care, or to stay out of hospital in the first place by getting the service they need in a more appropriate setting, such as a primary care centre or in another community setting.

That is why dealing with these problems will not be done merely by targeting one area. It needs a combination of immediate measures to target the pressure areas, and also long-term, sustainable solutions. These include addressing: the unacceptably long times that some patients have to wait for outpatient clinic appointments, procedures or diagnostics; emergency department overcrowding; delayed discharges; winter planning to increase capacity in hospitals; and recruitment into the health service. Before I talk about these, it is worth acknowledging the sheer volume of activity in our acute hospitals. This year, so far, over 1 million inpatient and day-case treatments have been provided, more than the same period last year. There have been nearly 2.2 million outpatient attendances, nearly 40,000 more than last year. Rather than being cut back, our health services are expanding and activity is increasing. Unfortunately, demand is also increasing.

The fact that activity has not only kept pace with but improved on last year should be welcomed. However, waiting times for many patients remain far too long. In January, I put in place maximum permissible waiting times for routine inpatient and day-case procedure and outpatient appointments of 18 months by 30 June and of 15 months by year end. These are not targets. The targets remain as they were before, and the international standard is that nobody should wait for longer than six months. These are maximum permissible waiting times, which is a different thing. These are not good enough either, and I am the first to say it, but they are realistic and reflect the need to focus on dealing with the longest waiters. Emergencies and urgent cases always have priority over routine ones.

I am pleased to say that in June, the HSE reported a performance against the 18 month maximum of 99.6% for inpatient and day cases and of 92% for outpatients. We always acknowledge that for certain sub-specialties in particular where the capacity does not exist either in the public or private sector, it would be difficult to achieve. However, what was achieved was achieved by working with the hospital groups to focus on maximising internal capacity and, where necessary, on targeted initiatives. It is important to understand that when we count numbers on waiting lists, they include a large number of duplications and people who have already been treated or no longer require treatment. A hospital recently did a validation exercise of its waiting list and found that between 25% and 30% no longer needed treatment or had had it elsewhere.

Although I need to confirm this and examine it in more detail, when the party opposite was in office and waiting lists were calculated, it did not include people who had been waiting less than three months. They were not counted. This changed in 2011. This adds hundreds of thousands of people who would not have been included in the figures before 2011. While I want to get confirmation of it, if what I believe to be correct is correct, I will certainly come back to the Deputy on it.

Deputy Kelleher specifically raised the issue of a patient with cancer who waited on a trolley for four days. I asked for a report on it, it was investigated and we cannot confirm it. A patient was found to have spent three days in an individual room in an emergency department. The patient was admitted for other reasons than cancer and the doctors took a decision on clinical grounds that it would be better for the patient to stay in that room than be on a ward with other patients. Sometimes, the stories one reads in the newspapers are not true, particularly regarding horror stories in health. Very often they are true, but not always. I ask Deputy Kelleher, as an experienced Deputy and former Minister, to bear this in mind. Last week, there was a story about two wheels falling off an ambulance. Although I do not yet know exactly what happened, I know two wheels did not fall off the ambulance. This is par for the course, unfortunately, in our health service. Maybe some people believe it improves matters; it does not.

The Deputy also raised the NTPF and how it worked. It did not work. We had the NTPF for a very long time, and there are still people waiting very long periods of time - years in many cases - because the NTPF was self-selecting. People would telephone after a number of months on a waiting list and some went privately. Many perverse disincentives were connected to it. It never succeeded. Many people received treatment under it and it had a massive budget of €100 million at one stage. However, it never succeeded in eliminating long waiting lists. The more targeted approach we have now is to identify those who have been waiting for very long times and find solutions for them.

The HSE is working with hospital groups towards the new maximum waiting time of 15 months by year end. It has also directed that, from September, hospitals which breach the 18 month maximum waiting time will be fined. The cost of individual procedures and appointments will be diverted away from non-performing hospitals to a hospital where the procedure or appointment can be performed, principally in public or voluntary hospitals. It is essentially money following the patient. An additional €51 million provided by the Government to achieve these targets, on top of the funding already provided, demonstrates the absolute priority we place on improving waiting times. All hospital groups are engaging with the HSE on finalising their plans.

For the small number of specialties where it is not possible to meet the maximum waiting time because of a shortage of specialist staff in both public and private sectors or the availability of appropriate pre or post-surgical supports, alternatives such as outsourcing are being pursued, including the potential of outsourcing abroad. For example, capacity in Dublin public and private hospitals has been identified to address particular pressures in scoliosis surgery capacity, which the Deputy mentioned. Some are being done in Blackrock and Tallaght, not just in Crumlin. A new theatre is under construction in Crumlin to allow us to increase capacity from March next year. There is continuing collaboration to identify further external capacity to ensure the 15-month maximum waiting time for these patients is met. This is in addition to the specific measures already in place which include observing the national waiting list protocol, prioritising day-of-surgery admission where clinically appropriate and adhering to the relevant HSE national clinical programmes guidelines. The clinical programmes have a central role in working with hospitals and other service providers on initiatives that will provide safer, more cost-effective services, reducing the amount of time patients have to stay in hospital and enabling the management of chronic conditions outside of hospital settings, thus freeing up capacity for those who require acute care.

There is always a requirement to manage the balance of scheduled and emergency activity in hospitals. This will be the case as long as hospitals have emergency departments. Particular problems can arise in hospitals that provide specialist services, where it is necessary to prioritise not only emergency and trauma surgery but also cancer and complex non-urgent cases.

Inevitably, this will affect waiting lists. The challenge is to manage the impacts. New patient care pathways such as medical assessment, minor and local injury units and urgent care centres and the provision of care in non-hospital settings are increasingly used to support the efficient use of hospital resources. The national clinical programmes have a key role to play in this work and are working with the Irish hospital redesign programme which was established recently to drive local change and innovation.

Clearly, the number of delayed discharges in hospitals has an impact on the availability of beds for elective and emergency admissions. In December I established the emergency department task force, which comprises senior doctors and lead hospital consultants, union and patient representatives, senior executives from the HSE and officials from my Department. In April a plan was published, which sets out a wide range of actions for both immediate and longer term impacts. Based on the task force action plan, the Government provided additional funding of €74 million to alleviate delayed discharges. This came on top of the €25 million provided in budget 2015 to support services that provided alternatives to and relieve pressure on acute hospitals. This additional funding underlines the strong priority we are placing on this issue. Delayed discharges are reducing steadily. The latest figure is 586, which is a seven-year low and compares with a high of 830 in December. It means that we have freed up 250 beds a day that can now be used by acutely ill patients but which were previously unavailable.

There will always be a certain level of delayed discharges. The figure will probably always come to several hundred. Those who have worked in hospitals and elderly care services can explain why that is the case. It takes a few weeks to set up a home care package. The home adaptations that are sometimes needed can take a few weeks or months, even when this is done quickly. Patients who need to go to nursing homes have the right to visit various facilities with their families in advance of being discharged from hospital - they should be able to see one or two, at least - in order that they can decide which is the right nursing home for them. If someone is going home to a carer who needs to give up his or her job or change his or her working conditions, that carer will have to give notice. Of course, issues can arise regarding wards of court. It will never be the case that there will be no delayed discharges. That does not happen in any country in the world of which I am aware.

The waiting time for the nursing home support scheme - the fair deal scheme - has decreased from 11 weeks at the beginning of the year to between two and four weeks. That is a significant improvement. Funding is being continued to support over 1,900 transitional beds for those who are waiting for a fair deal package or who are waiting to go home following a period of convalescence. By the end of 2015, we will have provided an additional 1,200 home care packages. Some 149 additional public nursing home beds and 24 additional private contracted beds are now open. These beds are located in places such as Moorehall in support of the hospital in Drogheda. Some 65 short-stay beds are being provided at Mount Carmel in support of the Dublin hospitals. These significant increases in capacity have fed through to emergency department performance. While the current position is still extremely challenging, the number of patients waiting for nine hours or more on a trolley each day has fallen to an average of 83 during September. This compares with average figures of 127 in June and 173 in February. According to the INMO trolley watch which draws up a like-with-like comparison, the number of patients waiting on trolleys for any period of time - even less than one hour - has actually fallen by 15.8% since 2011, the worst year on record. The SDU figures are similar. I accept that there has been an increase in the number of patients waiting on trolleys for any period of time - even less than one hour - by comparison with this time last year and the year before.

We need to sustain the improvements made into the challenging winter period. Additional funding of €18 million has been provided for the winter initiative to increase capacity in acute hospitals during this period. Work is ongoing on specific initiatives, some of which have commenced. For example, a new eight-bed clinical decision unit is now open in Our Lady of Lourdes Hospital in Drogheda, with further beds to open. The day hospital service in Beaumont Hospital which is designed to keep older people out of hospital has gone from two days to three days a week. It will be a five-day service from November. Additional beds have been provided at Connolly Hospital in Blanchardstown to provide overflow capacity and take some benign surgical work services from Beaumont Hospital. The Leben building at Limerick University Hospital which will open in November will provide an extra 23 beds for that hospital. These initiatives are being developed by each hospital group according to its needs and capabilities.

It is well known that the difficulties in the health service have been exacerbated by recruitment challenges. It is less well known that progress is being made. According to the HSE, the number of staff employed in the public health service has increased by over 4,700 whole-time equivalents in the past 12 months alone. There has been a focus on medical and nursing recruitment. As Government policy is to move to a consultant-delivered service, the number of consultants has grown significantly in recent years to 2,700. That includes an increase of 290 consultants since the Government took office.

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