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

I welcome the opportunity to speak for the first time in the Thirty-second Dáil and to inform the House of the current state of our health service and, in particular, emergency department overcrowding and waiting lists, which I know are major concerns for Members.

Meeting the ever-increasing demand for health care is particularly challenging. It arises from our growing and ageing population and the development of new treatments and technologies which give people hope but which often come at a high cost. There is no doubt that our health service faces particular challenges in meeting patient demand for emergency care and scheduled or elective care. We are all very conscious that emergency department overcrowding and excessive waiting times cause distress for patients and their families as well as for the staff dealing with them. In turn, long waiting lists can exacerbate emergency department overcrowding, as today's cancelled day case elective surgery patients can become tomorrow's emergency admissions. Patients in our health service deserve to have access to necessary care within a reasonable timeframe.

With the welfare of patients, patient outcomes and patient safety in mind, a range of measures were implemented by the last Government to seek to reduce the levels of emergency department overcrowding and long waiting times. During 2015, more than €117 million in additional funding over and above the budget allocation was made available to the health service to reduce waiting times for fair deal funding, improve access to community care packages and increase hospital bed capacity. In addition, the waiting list initiative resulted in funding of approximately €30 million being provided to the HSE in order to achieve reductions in the outpatient, inpatient, day case and endoscopy waiting lists.

This year has been an exceptionally busy year so far for our health service. The HSE reported that in the first quarter of this year alone there was an increase of 6.7% in patient attendances at emergency departments compared to the same period last year. Typically, increases in attendances are in the region of 1% and in some years attendances have decreased. Despite a significant and sustained increase in patient attendances, the overall performance of emergency departments in a number of hospitals has improved. The vast majority of patients attending emergency departments nationally received the necessary care within a reasonable timeframe.

At the end of February, more than 75,000 patients who attended were admitted or discharged in less than nine hours. It must, however, be acknowledged that a number of hospitals remained in deep difficulty and patients had to wait much longer than they should have done. Approximately 20% of patients spend more than eight or nine hours in emergency departments and we must endeavour to reduce this figure every year, aiming to reach a figure of about 5% which is the internationally accepted norm.

We know that a range of factors contribute to overcrowding in emergency departments. It is not simply a matter of extra beds. Britain has no more public hospital beds per capitathan we do and has an older population but does not have the same levels of overcrowding as Ireland. While extra beds have made a difference in some hospitals, it is evident they have made very little difference in others.

We know the range of factors that contribute to overcrowding includes the following: patient attendances; the acuity of patients; the hospital admission rate or conversion rate, that is, the percentage who are seen and then deemed necessary for admission, which varies massively from about 20% in some hospitals to 50% in others; the length of stay, which again varies significantly from four or five days for the average patient stay in some hospitals to ten days in others; and factors such as flu, viruses and hospital efficiency, not to mention the weather and other environmental factors. The quality of and access to primary care and social care in the hospital's catchment area is also of fundamental importance.

Consequently, emergency department overcrowding is not just a problem for emergency departments or hospitals alone to resolve. The response has to be multifaceted and across the health service. A range of initiatives are being implemented as part of a four-pronged approach. First, a number of measures have been introduced to reduce the number of patients attending hospital by improving access to primary and community care services. These initiatives include offering a wider range of outpatient services, such as the community intervention teams and the home IV antibiotic OPAT programme, which allows some patients to avoid being admitted to hospital altogether and allows others to go home sooner, thus freeing up hospital beds. Second, GP out-of-hours services have been expanded, and while this does not reduce admission rates, it can reduce attendance rates. Third, there is improved access to diagnostic services such as X-ray and ultrasound. Fourth, there has been an expansion of minor surgery capacity in general practice.

Community intervention teams, CITs, have enabled patients to receive care in their own homes and communities which previously they could have received only in hospitals by, for example, administering intravenous antibiotics, monitoring bloods, dressing wounds and so on. These nurse-led teams prevent unnecessary hospital attendance and enable suitable patients to be discharged earlier. These services have been expanded in recent months to areas such as Sligo, Waterford and Tipperary, and there are now 13 such services nationwide. Between 2014 and 2015, there was a 34% increase in CIT referrals and the CIT-OPAT services are estimated to have reduced the requirement for hospital beds by approximately 72 beds per day. Also in primary care, minor surgery clinics have been established in 20 GP practices, with numbers to be expanded to 40 practices by the end of 2016. Out-of-hours GP services have also been expanded to alleviate some of the pressure on emergency departments, which, as I said, reduces attendances although it does not reduce admissions. A 10% increase in usage has been recorded in recent months.

The second category of measures has focused on expanding hospital capacity or bed capacity. Additional funding was provided to open 246 new hospital beds and reopen 116 previously closed beds, thus providing an additional 362 beds when compared with this time last year. That overcrowding has not reduced as substantially as we would have expected illustrates very clearly it is not a simple function of just putting in more beds - far from it.

The number of whole-time equivalent staff in the health service increased by almost 5%, or 4,000 staff, between December 2014 and December 2015. Again, this demonstrates that more staff on their own do not provide a solution to our problems. The extra staff hired include nurses, hospital doctors and consultants - we have never had more hospital doctors and consultants working in our public service - as well as other health and social care professionals. In particular, more than 800 additional nurses are on the payroll and hundreds of additional doctors were also employed in the health service last year. Recruitment of further front-line staff is ongoing but remains an enormous challenge in light of the desirability of, and growing demand for, qualified Irish health care professionals in health services abroad and also the general international shortage of health care staff.

Task transfer between doctors and nurses, which was agreed in February, is another action which can contribute to improving hospital capacity and the efficient use of expertise. Tasks that are now being carried out by nurses as standard include IV cannulation, phlebotomy, first-dose IV antibiotic drug administration and nurse-led discharge. Actions to facilitate timely discharge of patients from hospitals are a third prong of the approach to reducing overcrowding. The health service has demonstrated significantly improved performance in reducing delayed discharges throughout 2015 and 2016.

Increased funding for the nursing homes support scheme - the fair deal - has been a key action in reducing delayed discharges. In 2015, an extra €44 million was allocated to the scheme, providing an additional 1,600 places and reducing the waiting time for approval from 11 weeks to four weeks. A further €30 million was allocated to cover the cost of providing the following: 1,500 transitional care beds throughout the country, 2,500 additional transitional care placements to the year-end to enable discharges from certain hospitals, home care support to an additional 860 people, and 173 more community beds in district hospitals and community nursing units throughout the country.

In 2016 the net budget for the fair deal scheme is €940 million, almost €1 billion. This represents an increase of €43.1 million on the outturn for last year. The scheme will fund an average of almost 24,000 clients per week, which is an increase of approximately 650 on last year. As of 12 April the number of delayed discharges had fallen to 608 from a high of 830 in December 2014. There will always be a certain number of delayed discharges and these are not the same people - it changes every day. It can take time to put a home care package in place because we need to give patients the opportunity to check out one or two nursing homes before deciding where they need to go. Also, if patients are going home to a carer, it needs to be understood that the carer may need time to organise leave from work etc. There will always be a base level of delayed discharges at somewhere between 400 and 500.

To further achieve a reduction towards that number the HSE is in the process of establishing a bed bureau for the greater Dublin area. Contrary to media reports there is not a shortage of nursing home beds in the Dublin area at present.

In 2016 the HSE has provision for €324 million in home supports, including home help and home care packages. Home help assists with more routine tasks while home care packages can provide a range of services including primary care, nursing therapies, enhanced home care hours and respite care for more dependent older people who might otherwise need nursing.

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