Thursday, 13 January 2011
Question 6: To ask the Minister for Health and Children in view of the record number of patients on trolleys and chairs in accident and emergency departments of our public hospitals during January 2011, if she has carried out an assessment of the likely impact on this situation of the cuts to the health budget imposed in Budget 2011 and the further cuts signalled for 2012, 2013 and 2014; and if she will make a statement on the matter. [1772/11]
Question 23: To ask the Minister for Health and Children the total number of hospital beds closed nationally as at the end of December 2010 due to the cost containment measures, refurbishment, infection control and any other matter; and if she will make a statement on the matter. [1683/11]
I propose to answer Questions Nos. 6 and 23 together.
It is important that the clear focus of the health service is on the number of patients we treat and not on the number of beds. Increasingly, our focus is on measuring and improving patient outcomes and this will continue over the coming years.
There are approximately 11,800 inpatient beds and 1,800 day beds in the public hospital system. The exact number of beds available at any one time fluctuates, depending on such factors as planned activity levels, maintenance and refurbishment requirements and staff leave arrangements. Beds may also be closed from time to time in order to control expenditure, given the need for every hospital to operate within its allocated budget for the year.
HSE data on the number of beds closed at the end of December 2010 indicates that, for the week ending 2 January 2011, some 1,378 inpatient beds and 229 day beds were closed for seasonal reasons or for infection control, refurbishment or cost containment. However, in the week ended 9 January, the number of beds closed had fallen to 997 inpatient and 64 day beds. The reopening of the excess of 500 beds is in line with normal practice, whereby bed capacity is reduced over Christmas and reopened when the seasonal holiday period comes to an end. The HSE 2011 national service plan, which I approved on 22 December, sets out to achieve increased efficiency with broadly the same level of overall hospital activity as in 2010.
For acute hospital services, the focus for 2011 will continue to be on increasing day case rates where appropriate and on key performance improvements in areas such as same-day admission and minimising length of stay. Hospital activity levels have a target of a 2% reduction in inpatient activity, offset by a 3% increase in day cases. There will be a continued and concentrated focus on reducing variations in length of stay for similar treatments.
The HSE is driving efficiency in the acute hospital system by increasing the proportion of surgery undertaken on a day basis, increasing the admission of inpatients on their day of surgery and reducing the lengths of hospital stays consistent with patients' clinical needs. The actions being taken by the HSE in all regions are focused on protecting front line services, particularly emergency services, maintaining the quality and safety of services and delivering to service plan targets.
The HSE's commitment to implementing a number of national programmes, such as the acute medicine and surgical programmes, will support the achievement of these targets in 2011. The HSE is working hard to improve emergency department services and patient experiences across the country. The key to addressing this challenge is integrated, proactive management by all concerned based on implementation of the standards and frameworks of the acute medicine programme and related programmes. The HSE plans to continue the implementation of these measures over the coming years. I am confident this is the correct approach and will allow the HSE to address the impact of planned health service budget changes signalled over the next few years while maintaining the numbers of patients treated and improving patient outcomes.
Last week, a record-breaking number of 569 patients were on trolleys and chairs in the accident and emergency departments of our public hospitals, and today's figure is 442. I know the Minister and the HSE consistently refuse to accept the figures presented by the Irish Nurses and Midwives Organisation. As in so many other areas, the Government has its own figures, but few are buying it. I do not propose that we have any further tussle about that.
In 2006, the Minister said that the accident and emergency situation was a national crisis. Yet the figures last week were even worse than at that time in 2006. The Minister is entitled to her break, but she was not in the country at the time. For example, at Our Lady of Lourdes Hospital, Drogheda, which is in my own region and Deputy Morgan's constituency, the highest ever number of patients on trolleys was reported. The equivalent of two full wards were waiting for admission from the emergency department. I ask the Minister to consider that for a moment. Was she aware that two full wards of patients were waiting for admission in the emergency department of Our Lady of Lourdes Hospital, Drogheda? That has been correctly described by the INMO as being extremely dangerous for both patients and staff.
The INMO has called for an urgent meeting with the management of the HSE. Does the Minister not recognise that this is the same management that had given commitments to achieve efficiencies in order to alleviate overcrowding when it went ahead with its own plans, which were described as the reconfiguration of hospital sites across the north-east region? These had a direct impact on the accident and emergency services at my own local hospital, Monaghan General Hospital, as it was then known, and at Louth County Hospital in Dundalk. None of the commitments or promises from the HSE management has ever come to anything in terms of making good the beds that were lost across the region or dealing with the current outrageous circumstances.
Does the Minister not accept that the increase in overcrowding due to bed closures and the downgrading of hospitals across our region was correctly predicted not only by this Deputy and other voices in this Chamber, but by the INMO itself, and that the results we are seeing today are consequent upon those actions? Let us be clear. A total of 1,500 beds were closed before budget 2011 was introduced last month.
I again ask the Minister whether she has assessed the impact of budget 2011 on the crisis across our public hospital accident and emergency departments. That is something she did not mention in her response. I am anxious to know whether the Minister has carried out any impact assessment of the measures proposed in budget 2011, not only in the current year but also over the period of the four year plan to which she is a party.
Before I call the Minister, I must advise the House that we are falling into a serious problem with Question Time. Standing Orders provide approximately one minute for supplementary questions. We are drifting into the making of Second Stage speeches during Question Time, and this limits the number of questions that can be dealt with during the period. It is contributing to poor order in the House.
There were a number of questions. We must become less focused on beds and more focused on activity. I say this for a number of reasons. If we compare the figures for 2010 to those for 2005, we will see that we are now treating an extra 100,000 patients in emergency departments, an extra million outpatients, an extra 250,000 day cases and an extra 20,000 inpatients. That is in addition to 16,000 extra births. This all represents additional activity with fewer beds than we had then.
The focus of the reform programme is on seeking to get more from less. In particular, hospitals are trying to deal with more day-case activity and same-day admissions for surgery. We have a list of 24 procedures which should be dealt with as day cases: same-day surgery with the patient going home the same evening. The list is based on the basket of 25 day-case procedures used in the UK, but because we do not have abortion in Ireland, the list contains only 24 procedures. The HSE is making great strides in this regard, although there is major variation across the country. If every hospital operated to the standard of the best in the country, there would be enormous improvements.
Let us take as an example St. James's Hospital in Dublin, the largest hospital in the country, or St. Luke's General Hospital in Kilkenny. Even last week, when there were major challenges, they were able to cope successfully. While I am not saying that all of the issues are the result of the internal functioning of hospitals, including Our Lady of Lourdes Hospital, I feel there is major room for improvement. The task of the teams that have now been appointed for Our Lady of Lourdes Hospital, Beaumont Hospital and Limerick Regional Hospital - the next will be Tallaght hospital - is to work with the hospitals in this regard. In the UK, a person with a lot of management experience was brought in, accompanied by a television camera. If one brings in a television camera one can achieve many changes.
Everybody, including nurses, must think about how he or she works. In particular, I want escalation protocols to be put into effect, as they have been all over the world. These protocols are highly successful. Advice from emergency consultants, as well as other medical advice available to me, strongly supports it. The Chief Medical Officer has provided evidence to the Joint Committee on Health and Children to show the effectiveness of these protocols when patients are moved from emergency departments up to the wards. Some 25% of patients are admitted within one hour and there is a major improvement over a four-hour period. These are the types of change I expect to see from nurses and others working in the system through the Croke Park agreement so that the stock of beds can be used as effectively as possible.
There will be major challenges this year; I am not going to pretend there will not. We have effectively taken â¬1 billion out of the public health Vote for 2011 compared to 2010. That is an enormous amount of money. Even with the major work practice changes we will achieve through the Croke Park agreement, there will still be enormous challenges. The commitment is to provide a similar level of service in 2011 to that provided in 2010 in terms of activity, although there will be some changes.
I mentioned swine flu earlier. I am not going to pretend this is the reason for the problem in accident and emergency departments, but it is having an impact. We now have two confirmed deaths, unfortunately, and the flu has consumed 72 intensive care beds and 393 hospital beds. It is not the reason for the crisis, but the incidence here is doubling every week. It has doubled this week compared to last week and it doubled last week over the previous week. I am sad to report that there have been two confirmed deaths in the Republic over the last week as a result of swine flu.
I join with the Minister in stating that it is sad to note that anyone has fallen victim to swine flu. We convey our sympathies to the families concerned.
When the Minister makes the point about more from less, will she not acknowledge that all we are seeing is more anguish, more stress for patients and front line service providers in our accident and emergency departments, and more people unnecessarily on trolleys and chairs over a long period? There can be no doubt that we are looking at a much disimproved situation from what the Minister previously described as being a national crisis only a few years ago. It is worse today. The Minister cannot defend that.
Given the suggested â¬1 billion cuts in the current year, has an impact assessment specific to accident and emergency departments been carried out concerning our public hospital sites? Has the projected â¬1.5 billion in cuts over the period of the four year plan been worked through in each of the subsequent years? Will the Minister indicate that her Department is conscious of what is happening and what is likely to continue to happen over the lifetime of this plan, if it is adhered to?
I was agreeing the service plan in the context of the budget and the financial position for this year. Every effort was made to minimise any impact on services to patients and to maximise the cuts in the procurement of legal services, telecommunications and all services procured by the HSE, including fees on the drugs bill. A huge proportion of the cutbacks will come from that source in addition to the redundancy package, which will bring savings of between â¬50 million and â¬70 million because the take-up was not as anticipated. Every effort was made concerning all the services procured by the HSE, which is the biggest procurer in the country. All of those companies were spoken to with a view to reducing substantially the cost of providing those services to the public health system so that we can maintain services to patients.
It is wrong to say that things are getting worse. By every yardstick - whether it is infection control, life expectancy, infant mortality, cancer treatment, the performance of hospitals in terms of their volume of activity - there has been huge progress. It may surprise the House to know that we get a high volume of correspondence and if any of the Deputies opposite succeed me, I will leave the file for them to see. That correspondence is from patients and their families saying how wonderful the service is and how much it has improved from their previous experience. I know there are people who work in the health service who love to run it down. The health service is quite unique in that respect, but I get fantastic feedback from the vast majority of those who work in it - whether they are consultants, junior hospital doctors or nurses - about the improvements taking place.
Sometimes, as changes happen, it is not as evident to those of us who are not in daily contact with that work. That is not to say that people are not working under enormous pressure, that there are not huge challenges, deficits and difficulties - of course there are. It would be a sad reflection on all of us, however, given the huge investment of public resources that has gone into the public health service, and the commitment to change that has occurred in recent years, if we were not seeing substantial improvements, year in and year out, across virtually all headings.
It is a sad reflection that the health service has not improved. That is the problem, given all the money that has gone in and all the waste that is there. The Minister referred to me accusing her of misleading the DÃ¡il. I will cite one instance that springs to mind immediately. She said the cancer czar, Professor Tom Keane, had met the Irish College of General Practitioners and agreed new protocols for GP referral when no such meeting had taken place. All that took place was a lunch, but the Minister failed to correct the record no matter how many times she was reminded of it. That is just one example.
On what I have said, other doctors are saying it publicly. I am careful in what I say and I do not believe in scare-mongering, but I have already given the Minister two instances. I join Deputy Ã CaolÃ¡in in conveying my sympathies to the families and loved ones of those who have lost their lives to swine flu.
The big issue here - the Minister was asked about this in the previous question, but she did not answer it - is the lack of isolation facilities within the accident and emergency departments. They are so overcrowded that people are sitting on top of each other because trolleys are not available. I have already outlined the situation and I do not wish to reiterate it. We are still talking about plans for tomorrow instead of action today, which bothers me. The Minister has still not told us why she will not tender out to nursing homes for rehabilitation. There are 2,000 such beds so surely some nursing homes could be asked to tender 30 or 40 beds for occupational therapy, speech and language therapy and physiotherapy. That would take the pressure off the 500 people who are lying in hospital but do not need to be there at the moment. Those beds could thus be freed up.
Why is not every hospital operating to the best standards? The Minister has had six years in office. If she knows what best practice is, why has she not been able to standardise it? What in the name of God was the HSE for, except to bring uniformity of care to 4.2 million people? It has utterly failed as a project, like so much else that the Minister has put in place, including her non-existent co-located hospitals.
The Deputy has an interesting perspective. Some days he accuses me of taking the privatisation route in long-term care, while he then asks why I do not tender out to private nursing homes. The Deputy cannot have it every way. He opposes things but then proposes them as a solution to a problem.
He just prefers them to be down the road so that doctors can spend their time in their cars going from A to B.
I must again correct the Deputy concerning Professor Tom Keane. I gave accurate information to the House, that Professor Keane had a meeting. I did not know the nature of the meeting, whether it was over lunch or coffee. He had a meeting with the Irish College of General Practitioners. That is a fact.
For the Deputy to suggest that there have been no improvements in the public health system is bizarre. I cited infection control and cancer outcomes. Does the Deputy deny that the reorganisation of cancer services has been enormously beneficial for patients with better treatment and faster access to highly skilled expertise? Would he deny that life expectancy, which is a measurement of the public health system, is increasing faster in Ireland than in any other country?
If the Minister wants to have that sort of debate I am perfectly happy, but I would much prefer her to answer the question. Why does she not tell the House the facts about nursing home wards? She should alleviate people's stress.
It is time for the Deputy to bring some honesty into this debate and stop the hypocrisy. He goes on about reference pricing, but as a practising doctor did he do a lot of generic prescribing? I would love to see his record on that.
I would love to see the record of that. I would be very happy to acknowledge that if it is the case. The answer to having cheaper medicine is to get more non-branded drugs prescribed.
No. We will not outsource services like that to nursing homes. Nursing homes already have contract arrangements to provide long-term care. We have 30,000 long-term care beds in the country, some 21,000 of which are in the private nursing home sector, while 9,000 are in the public nursing home sector. The fair deal is working successfully. We do not anticipate outsourcing more activity of the kind the Deputy suggests. We want to ensure that our public hospitals work as effectively and efficiently as possible and that those who work in our hospitals provide services that are performed to best practice from a staffing, industrial relations and operational point of view. That is what the Croke Park agreement is all about.
When I saw that three of the first four ordinary questions had gone in the lottery to my colleagues, Deputies Reilly and Ã CaolÃ¡in, I was going to suggest that, considering their good luck, they should do the lotto this evening. However, seeing that Question Time is almost over, it is not of any great advantage to them.
I join my colleagues in expressing sympathy with the families of the two people who have died as a result of swine flu. Can the Minister provide any further information in this regard? I do not know how much of it is a matter of public record.
The Minister referred to a special team that will go into some hospitals to deal with overcrowding in accident and emergency departments. She mentioned Drogheda, Beaumont, Limerick and Tallaght hospitals. Will she outline the terms of reference of this team, what exactly it will be doing in the hospitals, when its work will commence, whether there is a prioritisation in terms of the order in which the various hospitals are inspected, whether the same team will operate in all the hospitals and how broad is the team's remit?
One innovation that has improved the situation in terms of transferring patients into hospital beds and out of clogged accident and emergency departments is where general practitioners have greater access to clinical decision makers. That works well in certain hospitals, including in Limerick where there is an effective unit. A similar system is also in operation in Kilkenny. Having said that, problems persist in Limerick and they are largely a question of patient volumes and lack of capacity. To what extent is work being done to ensure better relationships between general practitioners and acute hospitals in order to alleviate the situation in accident and emergency units and, for example, facilitate access to diagnostics, which was one of the issued raised by the Minister?
The Minister tells us she will not reopen closed hospital wards or bring acute beds back into service because there is not enough money to do so. Does she regard additional beds as essential in view of the numbers - 569 nationwide the other morning - on trolleys, with 50 alone in Our Lady of Lourdes Hospital in Drogheda? If not, why not? Does she regard herself as having a duty of care to patients in accident and emergency units? I heard a graphic account on local radio the other day of people with blood running out of them sitting in the accident and emergency department waiting for treatment.
Does the Minister see herself as having a responsibility to manage with some degree of comprehension the system for which she has ministerial responsibility? Does she accept that money can be found for banks because we are told it is essential? This is brought up in the context of almost every issue but what could be more important than caring for people in acute situations who are having to wait 13, 14 or 15 hours on plastic chairs? Does the Minister accept that her attitude in this regard is nothing short of Thatcherite, that she is simply walking over these patients and that it is completely unacceptable? Does she see herself as having responsibility in this matter?
I want a more realistic response from the Minister than the ones she has given to the House thus far. The situation in accident and emergency wards is a scandal and it is disgraceful that the Minister is getting away with it. She can do what she wants because there is no accountability whatsoever in this bloody Government. It is long past time that she and her colleagues were thrown the hell out of office and somebody put in who can look after these patients-----
They are being pursued with the enthusiastic support of the Deputy's party. His party also formerly held the health ministry in the North during which time many closures took place.
In regard to Deputy Jan O'Sullivan's question, there are genuine capacity issues in Limerick and that is why we have sanctioned the new extension which will be operational at the start of 2012. That is needed not only for Limerick itself, but as part of broader reform in the mid-west region. Limerick has some of the most dynamic doctors in the country in the accident and emergency unit and other departments.
In regard to the teams that are going into hospitals, the view was that assistance needed to be given to some hospitals in respect of their operational issues, particularly in regard to accident and emergency services, but also in terms of their broader remit. The teams have already commenced work in Beaumont and Drogheda and, as far as I am aware, Limerick. I will provide the Deputy with the terms of reference; they are not rigid but rather involve the input of people with expertise and experience from this country and abroad who have undertaken this type of task before. It is not a big stick approach but rather a case of sitting down with the key stakeholders who run the hospitals to see how they can be operated differently with a view to improvements. Six hospitals have been identified, of which work has already commenced in three, with the next being Tallaght.
We are providing more capacity in Limerick. In general, however, the problems being identified in accident and emergency departments in some hospitals have to do - not exclusively, but in the main - with how those particular hospitals function. Our effort is focused on ensuring they function to the appropriate standard that is required.