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 in Emergency Departments (EDs) is a key priority 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 care in EDs;

— the difficulties which overcrowding in 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 Taskforce last year and the publication, in April 2015 of the ED Taskforce 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 Director General of the HSE is co-chairing the ED Taskforce Implementation Group from now until March 2016. This is to ensure that all relevant parts of the health service, including acute, social and primary care, are optimising resources to deal with the particular challenges associated with the winter months;

— the significant progress made to date on the ED Taskforce plan is as follows:— delayed discharges are reducing steadily from 830 in December last year to 567 on 3 November and the average number of patients waiting greater than nine hours on a trolley in October was 115, 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 three to four weeks;

— transitional care funding has continued to support 3,000 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;

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

— 270 of 300 additional beds funded under the winter capacity initiative will open by the end of November. The remaining 30 will open in February 2016; and

— 129 hospital beds which had been closed for refurbishment or for infection control purposes during 2015 will be reopened by the end of November;— the HSE has provided over 1,400,000 inpatient and day case treatments and over 2,400,000 outpatient appointments up to the end of September this year – an increase of 8% inpatient and day case treatments and 2.3% 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; and

— a series of campaigns are ongoing to attract frontline staff in order to meet patient care requirements;— in the past 12 months there are over 500 more nurses working in the health service;

— since September 2011, over 300 additional consultants have been appointed to acute hospitals around the country, including 78 consultant appointments this year;

— the number of Non-Consultant Hospital Doctors employed in the health service has increased by 338 since last year; and

— ED consultants have increased by 30 since 2007; andsupports the Minister for Health in his continued determination to bring about improvements in urgent and emergency care services.”

I welcome the opportunity to update the House on what is being done to improve access to services in our acute hospitals. I acknowledge that too many patients throughout Ireland are still spending far too long in our emergency departments waiting to be seen, moved to a hospital bed or sent home. This causes difficulties and distress for patients and their families and makes working conditions more difficult for staff. That is why dealing with this problem is a key objective for the Government.

The events of last week, when a number of individual cases were highlighted in the media, were met with the familiar cries for more beds, money and staff. We have heard much the same from Deputy Kelleher and others tonight. However, this is already happening. The problem is more complicated with multiple causes and they all need to be addressed. Any efforts undertaken must be sustained.

I reconvened the emergency department taskforce in 2014 to provide focus and momentum to deal with the challenges presented by hospital overcrowding. Progress is being made on implementing the plan. The Government has allocated more than €117 million in additional funding this year to reduce overcrowding. We have got the fair deal scheme waiting time down to between three and four weeks, from 15 weeks this time last year. This has freed up 225 hospital beds every day and is supporting hospitals to re-open closed beds as well as add more beds. Over 500 more nurses are in place compared to 12 months ago and we have more registered doctors than ever, with a further 338 non-consultant hospital doctors and 78 consultants appointed this year.

As I mentioned there are a number of different causes that can give rise to hospital overcrowding and it is worth setting them out. First, there are demographic pressures. The growing and ageing population is causing a small but relentless increase in demand year-on-year. Second, the level of attendances can increase or decrease for all manner of reasons, including general practitioner referrals, influenza, weather or accidents. Third, admission rates vary widely from hospital to hospital. In some hospitals, patients are twice as likely to be admitted than in others. This can be cultural or down to the fact that a particular doctor will admit more patients than necessary. Less experienced doctors and locums have a lower threshold for admissions than experienced or more senior doctors, who are more confident in sending a patient home. There is also the issue of elective admissions. This involves patients being brought straight in for surgery or from a clinic and into a hospital bed rather than through an emergency department. Some hospitals manage this better than others by taking more people in when trollies are low and restricting the number when numbers on trollies are high. Others manage it less effectively. There is also the question of length of stay. Some hospitals can sort out the average patient in four days. Others might take a week, thereby using twice as many beds to do the same amount of work. This is often linked to getting tests and scans done, skeletal services at weekends or slow decision-making due to infrequent senior clinician-led ward rounds or board rounds. Other factors include care provided on an outpatient basis and the operation of acute medical assessment units.

Some hospitals can complete investigations in a single day and therefore the patient need not be admitted. Others must admit a patient. This requires a bed to be allocated simply to get investigations carried out. Then there is the question of bed capacity. Some hospitals may simply not have enough beds. Another area where capacity can be a problem relates to the delayed discharge of patients from hospitals. Some areas do not have enough nursing home capacity or home care packages and this means patients can be delayed leaving hospital. I was keen to explain this point to Deputy Keaveney, although he has left us. That was why the decision was made to spend more time meeting the HIQA standards. The alternative was to start closing down or blocking admissions to district hospitals and community hospitals throughout the country, something neither the Minister of State, Deputy Lynch, nor I could stand over. It does not make sense to say that a four-bed or six-bed ward is not up to standard while we allow other services to have 40 people on trolleys in an emergency department. That is why we made the decision. It was for practical reasons. More important, we now have the type of budget that was not available in the past six years because of the economic crisis. It will allow us to refurbish and replace these old nursing units, some of which are over 200 years old. I welcome the support of the Irish Nurses and Midwives Organisation for that decision.

There are many other issues related to efficiency or lack of efficiency in the operation of a hospital. Hours can be lost getting the discharge paperwork for a patient done, getting prescriptions written or getting the bed cleaned for the next patient. This could be done in an hour but sometimes it can take as long as five hours, thus leaving someone else on a trolley during that time even though a bed is available. I visit hospitals all the time on either an announced or unannounced basis. Often I see overcrowding in the emergency department and then empty beds on the wards. That is most frustrating and simply not acceptable.

Another cause is bed closures. This can occur for a number of reasons, including staff shortages, renovations or infection control. There is also the interaction with primary care provision in a given area. Where community intervention teams are in place patients can avoid admission or be sent home early since the nurses in the community intervention team can administer intravenous drips at home or in a nursing home. They can also check wounds or monitor blood levels. When these services are not in place, patients have to stay in the hospital until everything is sorted out, thus lengthening the average length of stay. There is no simple or quick-fix solution to the problems in our emergency departments. I note Deputy Kelleher brought the matter back to the time of my predecessor, the former Minister for Health, Deputy Reilly. Of course he could have brought it back further to the time when he served in Government alongside the former Minister, Deputy Harney, or when his party leader and now candidate for Taoiseach, Deputy Micheál Martin, was Minister for Health and Children.

Our approach to tackling this issue is to address the challenges throughout the health service. We must ensure all relevant parts of the health service, including acute, social and primary care, are working together to make the best use of resources. Experience has taught us two key lessons. First, additional hospital beds alone will not resolve the difficulty. Services and capacity in primary and community care are equally essential. They support people outside of hospital enabling them to access care in a primary or community setting or assisting them in the move out of hospitals to home or residential care. Second, today's cancelled operations are potentially tomorrow's emergency presentations. Therefore, it is equally important for us to balance planned and emergency care needs to prevent delays in diagnosing or treating illness that could result in greater needs for emergency intervention next week, next month or next year.

The real answer is to continue to implement the tailored solutions we are already working on, in particular the 88 actions identified through the emergency taskforce. The actions are a combination of immediate measures to target the pressure areas - fire brigade action, as someone else referred to it - as well as long-term sustainable solutions, which of course will take time to implement. These are designed to address emergency department overcrowding, provide specific care pathways for frailer patients, specifically elderly patients, and facilitate early discharge planning, beginning when patients first come into the hospitals with community and primary care services closely involved. The solutions also envisage more efficient discharge processes, including weekend discharges in order that patients can be discharged as soon as they are medically fit and better access to home-care and care in the community. Other plans include making the best use of all the non-emergency department facilities available, such as medical assessment units, minor injury units and urgent care centres as well as reducing delayed discharges.

Delayed discharges refer to patients who have been medically discharged and are waiting to go to a nursing home or home with supports. They are now steadily reducing. The latest figure is 567, the lowest in many years, compared to a high of 830 last December. This means we have freed up approximately 265 beds every day to be used by patients, which is a capacity increase equivalent to a medium-sized hospital. In addition, by the end of 2015 we will have provided over 1,200 additional home care packages, 149 additional public nursing home beds, including a new community hospital in Mount Carmel and another to open the next few weeks, 24 additional private contracted beds to support Drogheda and 65 short-stay community beds. All of these have been open since the summer.

These very significant increases in capacity are beginning to be reflected in emergency department performance. While it is still extremely challenging, the number of people waiting for nine hours or more on a trolley fell to an average of 115 in October, compared with 127 in June and 173 in February. We know the hospitals which are most affected, and these have been the subject of a particular focus in supporting them to implement solutions.

We also know the hospitals that have demonstrated specific improvements in areas such as length of stay, trolley waits, delayed discharges and helping patients and their families negotiate the fair deal applications process. These include Mullingar, St. Vincent's, Connolly Hospital Blanchardstown, St. James's, Portiuncula and Mercy University Hospital. I could have mentioned Wexford, as Deputy Browne did, favourably as well. Common to all of these sites is strong executive and clinical leadership, and integrated working across the community and social care services and national clinical programmes.

We also need to provide more alternative models for pre-hospital care so that ambulances do not necessarily have to transport every patient to a busy emergency department. I have asked the National Ambulance Service to review protocols and I expect some progress on this matter in 2016.

We have a very high volume of activity in our acute hospitals. On average, 250,000 outpatient appointments and between 120,000 and 130,000 inpatient or day case procedures are carried out every month. The HSE has provided over 1.1 million inpatient and day case treatments and over 2.4 million outpatient appointments up to the end of September this year, an increase of 8% in inpatient and day case treatments and a 2.3% increase in outpatient appointments compared to the same period in 2014. The health service is expanding and doing more, rather than being cut back, and the facts show that.

As I said, we must also address access to hospitals for elective work. Additional funding of €51.4 million provided by the Government in 2015 has allowed the HSE to maximise capacity across public and voluntary hospitals, as well as outsourcing activity where the capacity is not available to meet patient needs within the maximum allowable waiting time. The latest NTPF figures published last Friday show reductions in total inpatient and day case waiting lists, in the numbers of patients waiting between 15 and 18 months and those waiting over 18 months. Similarly, there have been reductions in the total number of people waiting for outpatient appointments, which has fallen below 400,000 for the first time this year. At the current time, 85% of patients wait less in a year.

The HSE is working with hospital groups towards a new maximum waiting time of 15 months by the end of the year. As part of this work, the HSE is applying fines to hospitals which breach the maximum waiting time in order to incentivise improved performance for the longest waiters. The Opposition talks about accountability a lot, but seems to express absolute outrage at the notion that any hospital be held to account for its performance. Where hospitals fail to meet performance targets which others can meet, and where those reasons are internal as distinct from other causes, then that needs to be tackled. When additional resources are invested, patients and taxpayers have a legitimate expectation that questions should be asked if improvements are not secured and actions taken. What is the Opposition’s alternative? Its solution is to throw good money after bad, as it did in the past. That is not a solution or an alternative.

Primary care services are also helping by providing alternatives to hospital emergency departments, such as GP out-of-hours services and primary care teams, reducing emergency department attendances through avoidance measures such as access to primary diagnostics and the provision of chronic disease and minor injury care in primary care settings and also enabling earlier discharge from hospitals. GP out-of-hours activity has increased by 10,000 patients in 2015 and community intervention team, CIT, activity, which is particularly focused on relieving pressures in emergency departments in hospitals, has increased by 30% compared to last year, with some CITs now actively working in nursing homes. Where equipment, aids and appliances are required to facilitate hospital discharges, community teams are given priority to acquire these, and palliative care and end-of-life services in the community are also being enhanced, such as additional beds in Galway and nurse specialist appointments which are now under way.

The difficulties in the health service have been exacerbated by recruitment challenges, which is well known. Less well known is the progress being made. According to the HSE, the number of staff employed in the public health service has increased by over 4,700 full-time equivalents over the past 12 months, with a focus on medical and nursing recruitment. Government policy is to move to a consultant-delivered service and the number of consultants has grown significantly in recant years to 2,700 full-time equivalents. Between 1 January 2015 and the end of September, the HSE has offered 82 consultant posts, 78 of which have been appointed and 69 have taken up duty. The number of non-consultant doctors has increased by over 1,000 in the past five years and now stands at 5,500, the highest ever. There are 500 more nurses on the health service payroll than 12 months ago.

We are now facing into what is very likely to be a challenging winter period. It is imperative that we sustain the momentum of the various initiatives I have already outlined. To that end, additional funding of €18 million has been provided for winter initiatives which will increase the capacity in our acute hospitals. Some 301 additional beds are being opened and 129 beds which had been closed are being reopened, subject to staffing. I appreciate the positive comments of Deputy Brown on the spina bifida services in Beaumont Hospital, which are very good. I understand what he said about the wisdom of closing St. Damien's ward at this time of year. It is never a good time to close down or renovate a ward, in particular in a hospital as busy as Beaumont, but it needed to be done and it is a specialty kidney and renal ward. It had to be done for patient safety and outcome reasons. I am assured by the management in Beaumont that the ward will reopen this month.

Work is ongoing on other specific initiatives, and some have already commenced. For example, a new eight-bed clinical decision unit and four-bay surgical assessment unit are now open in Our Lady of Lourdes Hospital, with further beds to open later this month. The day hospital service in Beaumont has increased from two to three days and will become a five day service in the course of this month, giving elderly patients, in particular, an alternative way into the hospital rather than having to go through the emergency department. A similar system exists in the Mater through Smithfield.

Additional beds have been provided at Connolly Hospital Blanchardstown for overflow capacity and to take some benign surgical work from Beaumont, alleviating the situation there. The new Leben building in Limerick has been opened, providing an additional 24 beds in the stroke and cystic fibrosis units. At long last the cystic fibrosis and respiratory unit has opened in Cork University Hospital.

I have heard much talk from the Opposition about the need for additional resources to address the problems in our emergency departments, but unfortunately all it has been is talk. Sinn Féin and Fianna Fáil in their alternative budgets for 2015 provided nothing at all to address emergency department pressures. In contrast, we have provided €117 million and a further €51 million to address waiting lists. It is fair to acknowledge that they recognised the issue in their alternative budgets for 2016, promising to provide €86 million in the case of Sinn Féin and €90 million in the case of Fianna Fáil, but that is still less than the €117 million we provided in 2015 and the further significant funding we will provide in 2016.

Both parties talk a lot about the need to hire more staff, but Sinn Féin’s plans are to cut consultant and management pay and increase their taxes, in a move that would be guaranteed to make recruitment more difficult. Fianna Fáil, in its alternative budget, made no provision for the Lansdowne Road pay restoration for nurses, young doctors, ambulance drivers, paramedics and therapists. I do not see how we could possibly recruit more staff if we were not to fund or reneged on the commitments made in the Lansdowne Road agreement.

It is little surprise that in the case of Fianna Fáil joined-up thinking is so absent. After all, it ran away from the health ministry in 2004 after Deputy Martin’s period as Minister for Health. During this time, the Fianna Fáil-led Government, supported by Independents, promised to end waiting lists permanently within two years and ensure sufficient bed capacity in hospitals. Instead, it set up the HSE. Thereafter, so scarred by the experience it was happy to leave the ministry to Mary Harney even after the demise of the Progressive Democrats in 2007. Nobody in Fianna Fáil wanted the job, so it left it to an Independent. I expect it is the same old Fianna Fáil, and it does not want the job now and will not want it after the election.

Fianna Fáil's record in health speaks for itself. It set up the HSE and now wants to get into power to stop Fine Gael dismantling it. It spent more than €100 million on the IT systems known as PPARS, which did not work. It took free GP care from the over-70s, but the current Government has restored it not only to the over-70s but to all those under six years of age. Let us not forget Deputy Micheál Martin's famous response to the emergency department overcrowding that occurred when he was Minister, which was to complain that the hospitals had not ordered enough trolleys.

My focus is on patient outcomes, not on rhetoric, which is all we hear from the benches opposite. I am focused on making sure that patients receive the care they need when they need it. This is a substantial challenge for the health services, which were serious damaged as a result of the economic crisis, caused in no small part by the actions and inaction of the last Government.

In any debate about health care, whether it is in this House or in the media, numbers are thrown around like confetti. The House should be assured that we are making some progress, and this is borne out by a reduction of 13,000 in the number of people on trolleys, which equates to a 16.7% reduction compared with 2011, the year in which we took office, and the fact that 85% of people who require an outpatient appointment or surgery are seen in less than 12 months.

The initiatives I have outlined this evening are slowly but surely gaining traction and are beginning to make a difference not in all places but in some places and not for all patients but for some patients. It is too simplistic and, indeed, wrong to suggest that it is just a question of increasing funding or staff or capacity in our hospitals. On any given weekday the number of people on trolleys peaks at around 300; it rarely exceeds 500. One would think, therefore, that putting an extra 600 hospital beds into the system would resolve the problem. I hope I have explained the reasons it will not be that simple. I ask the Members opposite, any of whom could be in the next Government, to be careful about the comments they may make because they may live to regret them in only a few months' time. Sustained investment, sustained reform and performance improvement are needed. Short-term solutions will only work in the short term, if at all. I can assure the House of my ongoing commitment and that of the Government.

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