Jan O'Sullivan (Limerick East, Labour)
Link to this: Individually | In context

Question 2: To ask the Minister for Health and Children her plans to ensure that the cut in the operational budget of the Health Service Executive for 2010 does not result in overcrowded accident and emergency departments, longer waiting times for operations, diagnostic procedures, reduction in essential community supports and other negative outcomes for patients; and if she will make a statement on the matter. [7126/10]

James Reilly (Dublin North, Fine Gael)
Link to this: Individually | In context

Question 4: To ask the Minister for Health and Children her views on whether reducing in-patient procedures by between 46,000 and 54,000 in 2010 means that patients will have to wait longer for essential diagnostics and treatment and will result in increased pressure on accident and emergency departments; and if she will make a statement on the matter. [6905/10]

Mary Harney (Dublin Mid West, Independent)
Link to this: Individually | In context

I propose to take Questions Nos. 2 and 4 together.

The HSE National Service Plan 2010, which I approved on 5 February, commits the HSE to delivering activity levels for 2010 which are broadly in line with 2009 levels. The plan was laid before both Houses of the Oireachtas on 8 February and has been published on the HSE's website. During 2010, the HSE will provide me with monthly performance reports on all aspects of progression of the plan.

As part of the Estimates process, the Government made a series of decisions that will reduce HSE costs by approximately €1 billion in 2010, comprising savings of €630 million on pay and almost €400 million in non-pay. However, it also made available additional resources to assist the HSE in responding to priority demographic and other needs and to support ongoing reform of the public health services.

Planned activity levels for primary community and continuing care services in 2010 are in line with 2009, with some growth in activity proposed in areas such as fair deal, home care packages and medical cards schemes.

In respect of acute hospital services, the plan targets a reduction of 54,000 in-patient cases through a combination of reducing emergency admissions by more than 33,000 and providing access to diagnostics on a non-inpatient basis to at least 10,000 patients who would otherwise be admitted only for that purpose. It also targets a further increase in day case activity to 689,000 which is in line with the trend during the last decade whereby the number of day cases carried out in the public hospital system increased from 273,000 in 2000 to an estimated 679,000 in 2009.

The national service plan commits the HSE to specific and demanding targets for improvement in average length of stay, the proportion of a specified basket of procedures to be undertaken on a day surgery basis and day of surgery admission. These targets have been informed by international evidence and data indicating that within the Irish health service there is an appreciable variation in performance as between different hospitals for similar procedures. The Executive will therefore focus on reducing this variance in performance as well as on protecting in-patient beds for elective surgery in order to reduce waiting times.

I recognise that meeting these targets will require co-ordinated and sustained effort, involving clinicians, management and other professional and support staff. However, the changes required are driven not only by efficiency considerations but by evidence that they deliver other benefits in terms of patient safety, a more user-friendly service delivery and better patient outcomes. Achievement of the performance targets in relation to emergency admissions will require increased access to the specialist skills and senior clinical decision-making available in medical assessment units, to diagnostics and to other ambulatory care services. Accordingly, under the national service plan the acute sector will continue to manage emergency admissions while at the same time achieving elective activity targets.

By reforming the manner in which services are provided, I am confident the HSE will deliver the volumes of service provided for in the plan, while at the same time continuing to improve service quality and patient outcomes.

Jan O'Sullivan (Limerick East, Labour)
Link to this: Individually | In context

It is a scandal that almost half the number of patients admitted to hospital through the accident and emergency department are not admitted within six hours. What changes or improvements in this regard will take place in the coming year? Will the Minister confirm that 1,100 acute hospital beds are to be closed this year owing to the cuts proposed in the service plan? If that is the case, how is the Health Service Executive to reach its targets in terms of reducing the number of people on trolleys in accident and emergency departments and in regard to reducing the waiting times for people to be admitted to hospital? How can the Minister square that circle? It seems to me to be impossible.

The cuts are right across the board. How are more people to be treated in the community if the community is also suffering cuts and the effects of the moratorium? The Minister stated she will address the fact that the fair deal scheme is causing people to remain in hospital unnecessarily. That people cannot leave hospital owing to the situation in regard to medical assessments is a serious problem. The Minister spoke about this issue in a general way. What specifically does she intend to do in regard to the conditions of the fair deal scheme, in particular the financial assessments which are the core of the problem? For example, will people be permitted to leave hospital before their assessment has been completed? What specific measures does the Minister have in mind?

Mary Harney (Dublin Mid West, Independent)
Link to this: Individually | In context

A later reply to a question dealing with the industrial relations environment may deal with some of the issues raised by the Deputy. As regards the Deputy's request to brief her party on the fair deal scheme, I am happy to do so. I would be happy to provide same for the Fine Gael party.

On fair deal, a completely new legal system has been introduced. In many cases we are dealing with people of diminished ability and issues in respect of family residence require court approval and so on. There is a time lag in respect of the backlog. The majority of the 7,000 applications to which I referred are in respect of people already in care or in the acute hospital system. A backlog was inevitable given the new scheme came into operation only in November. We all anticipated such a backlog. I am satisfied that when those decisions are made, many of which will not require court approval and some of which have been already approved, people will be able to move rapidly to appropriate care. Many of the people who have made applications are people already in care and who are opting for this system as opposed to the subvention system. Others may not have received any support.

On the closure of beds, the plan contains no proposal to close X or Y number of beds. The plan is to move from in-patient to day care. Best practise is that 80% of surgery should be done on a day case basis. We have quite a bit to go to reach that target. We must also reach the target in respect of same day admission, even where overnight is required. Among the initiatives currently underway with the appointment of Dr. Barry White as clinical director is the ringfencing of beds for surgical or elective activity, having new care pathways led by specialist clinicians around the country so that there is less emphasis on people having to go into hospital, in particular for those with chronic illnesses such as diabetes, respiratory and other conditions, and a greater emphasis on providing that service on a non-hospital basis.

James Reilly (Dublin North, Fine Gael)
Link to this: Individually | In context

The plan is seeking a reduction of 33,313 emergency admissions and a reduction of 54,000 in-patient procedures, all of which is to be compensated by a small increase of 10,569. The arithmetic does not work out.

When one compares the figures for planned in-patient surgery for January 2010 in respect of people waiting in pain to have gallstones removed, to have hernias repaired or for knee or hip replacements with the figures for 2007, 2008 or 2009, the reduction has been huge. I spoke today with a Dublin surgeon who told me all surgeons are experiencing a reduction from eight to one cases per day owing to the unavailability of beds. This plan will further reduce the number of beds available.

While the Minister did not mention a figure, the one being bandied about in terms of bed closures this year is 1,100. There is no question but that this will impact negatively on patients. The Minister must know how many beds are to be closed. I am sure she can confirm whether the correct number is 1,100, which is the figure being bandied about. When will the Minister focus on sorting out hospital inefficiencies rather than on cutting services and closing beds?

Mary Harney (Dublin Mid West, Independent)
Link to this: Individually | In context

The Deputy will be aware that the manner in which hospitals and clinicians are now assessed is across performance indicators. The key performance indicators are available on a monthly basis and make for very interesting reading. There is a huge variation, even in emergency departments, between the number of patients seen per medic or nurse in one part of the country as compared with another and between hospitals. There is also a variation in costs, which I accept is in some instances related to the acuity of what is being dealt with. One must compare like with like. If one compares ratios of patients to doctors or nurses, there is a huge variation across the country. Now that we have performance indicators we are able to access this information. What one does not measure one cannot manage. We did not have these indicators before nor did we have appropriate waiting times in emergency departments.

Three years ago we were only measuring people waiting 24 hours for treatment. We recently commenced measuring those waiting 12 hours for treatment and more recently six hours. From the end of March all hospitals will be required to measure not alone patients waiting six hours for treatment but the length of time of treatment from when they arrive at the door which, rather than the time the decision is made by the clinician to admit the person, is the issue. All of these steps are being taken with a view to improving and driving efficiency.

On beds, we often become obsessed with numbers.

Jan O'Sullivan (Limerick East, Labour)
Link to this: Individually | In context

The Minister would too if she were left waiting on a trolley for hours.

Mary Harney (Dublin Mid West, Independent)
Link to this: Individually | In context

Yes. What is important is that the patient is treated. If it is appropriate for treatment to be provided on a non-hospital basis in a primary care setting, day case basis, same day surgery and so on, that is where it should be given. The issue for surgeons, which is being addressed by Dr. White, is the ringfencing of beds. Many surgeons say that they do bring in their patients in advance to ensure they have a bed. That has been part of the problem, but it is being addressed at the moment. Those clinical leads will be in place on a interim basis in March and will be appointed on a permanent basis later.

Jan O'Sullivan (Limerick East, Labour)
Link to this: Individually | In context

In the context of the 48% who are not admitted within six hours, it may well be, as the Minister said, that there are people on trolleys in A&E departments around the world. However there is a big difference between being on a trolley in a cubicle in an A&E unit, and being on a trolley out in a public space in the way of nurses who are trying to do their work. There is, for example, no privacy if an elderly man or woman has to use a bed-pan. Let us look at the situation honestly. If one is in a crowded A&E unit with nowhere to go for six hours or more, surely that is very different from the rosy picture the Minister paints of people waiting on trolleys in A&E units around the world. They may do so and it is fine if they are in a cubicle. There are a certain number of cubicles in our A&E departments, but we are concerned about those who are out in public spaces literally blocking corridors. I wish the Minister would realise the seriousness of this problem for people who have to endure it.

James Reilly (Dublin North, Fine Gael)
Link to this: Individually | In context

I do not want to get into semantics with the Minister but I hope we are measuring the number of people in A&E, rather than measuring people. The bottom line is that there have been serious delays in surgeries and people are being left in pain needlessly. Another issue is now arising. Given the Department's focus on breast cancer, people who are being screened for suspected cancer are being brought in a bumped up the list ahead of men and women who have proven bowel, bone or lung cancer. This is having a deleterious effect on people with cancer. They require operations, yet they are being bumped down the list to ensure the figures stack up, so I am told, for the breast cancer scheme. There is a lot of shifting around here, so I would like the Minister to address that issue.

There is no doubt that hospitals are unable to cope, and this is particularly so in those serving north Dublin, including Beaumont, the Mater, James Connolly and Drogheda. Some 61 people were on trolleys the other day in Beaumont Hospital. People are waiting 72 hours for treatment and this is not anecdotal, it is happening daily. People are contacting me by e-mail and telephone to ask what the Minister is going to do about this.

The Minister could simply put out to tender services for physiotherapy, speech, language and occupational therapy, which are associated with existing nursing beds in the community, thus moving people out of hospitals. If they are not moved soon after their acute phase of treatment, they do not get rehab and are left there for four or five months, the opportunity is missed and thus they will end up in long-term care and will never get home. Will the Minister consider that?

Mary Harney (Dublin Mid West, Independent)
Link to this: Individually | In context

Yes. We are providing additional beds. I am in dispute with some of the Deputies from Kerry because we are providing more rehab beds as opposed to long-stay facilities, such as those in Tralee. That is because that is the requirement and that is what is advised.

James Reilly (Dublin North, Fine Gael)
Link to this: Individually | In context

I am concerned with Dublin where the problem is acute.

Mary Harney (Dublin Mid West, Independent)
Link to this: Individually | In context

I am concerned with patients everywhere. As regards the issue of treating patients in hospital, many people end up in accident and emergency departments who do not require such treatment. When the Deputy and I were growing up in this city, an emergency department was for a genuine emergency. Unfortunately, because of some of the issues he has raised, people have ended up in accident and emergency departments as a route to access acute hospital services or because they need diagnostics.

James Reilly (Dublin North, Fine Gael)
Link to this: Individually | In context

Very few.

Mary Harney (Dublin Mid West, Independent)
Link to this: Individually | In context

In some cases it was the only way of accessing those diagnostics. I accept what Deputy Jan O'Sullivan says about having people in unsuitable facilities, particularly in some of the older A&E units that have poor facilities. That is why we strongly support the escalation policies, as the A&E consultants do. I have been reading about great hospitals all over the world, including Stony Brook Hospital in New York which is regarded as one of the best hospitals there. It has a full capacity protocol policy and that is exactly what they do when they have an issue in their A&E department. I saw it for myself in Vancouver when I was there. That is the policy we want to implement here, although there is resistance to it, particularly in the Deputy's own area. That is the kind of approach that has delivered success elsewhere, rather than having large numbers of people in A&E.

Jan O'Sullivan (Limerick East, Labour)
Link to this: Individually | In context

Does the Minister mean to move people into crowded wards instead of crowded A&Es?

Mary Harney (Dublin Mid West, Independent)
Link to this: Individually | In context

I want to give the Deputy the evidence, which she should examine. I know she is a person who genuinely looks at the facts.

Jan O'Sullivan (Limerick East, Labour)
Link to this: Individually | In context

I have been in Vancouver General Hospital and it is a hell of a lot more spacious than Limerick Regional.

Mary Harney (Dublin Mid West, Independent)
Link to this: Individually | In context

The A&E consultants themselves support it and I know this is on the agenda of the A&E forum. We thought we were close to agreement there, but there are still outstanding issues. The Deputy's own A&E consultant, Dr. O'Donnell in Limerick, who is regarded as one of the best - he is a terrific doctor with great leadership skills - has been a strong advocate of this policy for quite some time. He said this is better and safer care, and I accept that.

James Reilly (Dublin North, Fine Gael)
Link to this: Individually | In context

It is not safe care though. That is the point.

Mary Harney (Dublin Mid West, Independent)
Link to this: Individually | In context

Yes, it is better and safer.

Jan O'Sullivan (Limerick East, Labour)
Link to this: Individually | In context

There is not enough space in the wards.