Dáil debates

Tuesday, 19 June 2012

Other Questions

Accident and Emergency Services

2:00 pm

Photo of John HalliganJohn Halligan (Waterford, Independent)
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Question 110: To ask the Minister for Health if, in view of the fact that no hospital in the country met the nine hour accident and emergency waiting time target for admission or discharge, he is contemplating the closure of a number of A&E departments in smaller hospitals; and if he will make a statement on the matter. [29435/12]

Photo of Richard Boyd BarrettRichard Boyd Barrett (Dún Laoghaire, People Before Profit Alliance)
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Question 121: To ask the Minister for Health if, in view of the fact that no hospital in the country met the nine hour accident and emergency waiting time target for admission or discharge, he is contemplating the closure of a number of A&E departments in smaller hospitals; and if he will make a statement on the matter. [29396/12]

Photo of James ReillyJames Reilly (Dublin North, Fine Gael)
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I propose to take Questions Nos. 110 and 121 together.

In July last year I announced the establishment of the special delivery unit, the development of which is a key part of my plans to radically reform the health system in Ireland. I identified two key priorities for it, namely, addressing trolley waiting times and reducing the maximum waiting time for elective surgery. I am happy to say the SDU has delivered notable improvements on both objectives.

The next phase of work in the area of unscheduled care includes a focus on monitoring the total patient journey time, including time spent on trolleys, as part of the new national score card for measuring performance. New target times which are being introduced this year are for 95% of all attendees at emergency departments to be discharged or admitted within six hours of registration and that those who need to be admitted through emergency departments should wait no more than nine hours from registration. Galway and Roscommon hospitals will be expected to comply with these targets. This phase commenced in February.

Acute hospital services, including complex emergency medicine, must be delivered safely. We know that the requirements for safe delivery of a clinical service include a sufficient volume of activity to maintain clinical skills. The delivery of any service in a given hospital will be determined by the level at which that service, in the context of changing clinical and technical practice, can be provided safely.

All services provided by the HSE are carried out in the context of HSE service plans and informed by a range of issues, including clinical best practice and patient safety. The HSE is working with the Health Information and Quality Authority to determine the type of services that can be safely provided across the range of acute facilities. However, I have requested that no changes take place in service delivery without informing me before their implementation.

Photo of Richard Boyd BarrettRichard Boyd Barrett (Dún Laoghaire, People Before Profit Alliance)
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We are still not getting clarification from the Minister, even though others and I have been asking for a long time about the fate of accident and emergency services in places such as Loughlinstown, Bantry, Mallow, Navan, Dundalk, Ennis, Portlaoise and Nenagh and whether they will be downgraded, as mooted, a move I would consider to be utterly unacceptable. Can we have clarity as to when these decisions will be made and we will be informed?

The Minister spoke about the reduction in the number of patients waiting on trolleys and the new target that they would only be waiting six hours either to be admitted or discharged. Are these claims of success belied by the fact that in the first four months of the year 26,000 patients had to wait on trolleys? The reason there has been a reduction in the number is that the Minister is packing trolleys and beds into wards and essentially causing overcapacity. The real problem is that he is refusing to reopen the 2,000 beds which have been closed in the system and provide the necessary staff. He seems to be considering closing accident and emergency services in smaller hospitals. However, this does not add up. He cannot seriously suggest he is going to improve the position when the bottom line is that 2,000 beds have been closed, there are not enough staff and he is planning to close or downgrade accident and emergency services in a number of hospitals.

Photo of James ReillyJames Reilly (Dublin North, Fine Gael)
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As I stated in response to an earlier question, we have reduced the number of people on trolleys by 20%. I have acknowledged there are too many people waiting on trolleys and that we are now to move to a model using the total patient journey time. There has been much criticism in some newspapers of the employment of consultants from the United Kingdom who have behind them the achievement of a four hour journey time from registration to either admission or discharge. They are in this country, on relatively short-term contracts, to help us get a handle on how our system is managed. The system and the management thereof have constituted the problem. We have excellent doctors and nurses, and some excellent managers and administrators, but the system itself, because of the central control and command, has disempowered the front-line staff and those at local level from making the sorts of decisions they need to make to have the service run more effectively and efficiently. We are addressing that.

Photo of Richard Boyd BarrettRichard Boyd Barrett (Dún Laoghaire, People Before Profit Alliance)
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Is what has disempowered the front line not the fact that it has been massacred in terms of numbers? Some 5,000 nurses and midwives have been lost from the system. Some 2,000 have been lost in the past year and, as I said, 2,400 beds have been closed. The front-line workers and the INMO and other organisations are saying that is the problem the Minister needs to address.

The target of six hours from registration to either discharge or admission seems utterly fantastic given the backdrop of cuts being imposed on staff and beds and the fact not even the nine hour target has been met. The HSE performance report shows not a single hospital in the health service has met the nine hour target, never mind the six hour target. Is it all a question of bandying figures, indicating targets that are unrealistic and massaging the trolley figures by simply packing too many trolleys and beds into wards that do not have sufficient capacity or staff?

Photo of James ReillyJames Reilly (Dublin North, Fine Gael)
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The Deputy's contention on packing trolleys into wards is utterly untrue.

Photo of Richard Boyd BarrettRichard Boyd Barrett (Dún Laoghaire, People Before Profit Alliance)
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It is not untrue.

Photo of James ReillyJames Reilly (Dublin North, Fine Gael)
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There is a full capacity protocol, which has four bars to it. It has been in operation. It is not ideal but it is far safer to have patients in wards than in emergency departments. International practice and research have proven that. It is a matter of working differently and having shorter stays in hospital, more primary care and chronic illness care in the community. All these developments will take time.

The Deputy asked about small hospitals. That issue is being addressed through a small hospital framework document, which will be circulated shortly to the various interested parties for consultation. Local politicians will be included.

We are about maintaining safe services and appropriate services in the hospitals. As I stated previously, all the brouhaha about the removal of some services from the small hospitals will be nothing by comparison with the riot that will occur when we start to remove from the bigger hospitals services that more rightly belong in the smaller ones. We are determined to do so, however. Let the large type 4 hospital deal with the tertiary and regional care issues it should be dealing with. It never made sense to me that people with varicose veins and inguinal hernias should be going to big hospitals such as Beaumont, the Mater and St. Vincent's. It is like sending a ten year old Volkswagen to the Ferrari testing centre to have it serviced. It does not make sense, although it would surely do a great job.

The Deputy mentioned Portlaoise hospital. It is not in the group in question as it is a level 3 hospital.

Photo of Caoimhghín Ó CaoláinCaoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)
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Notwithstanding the work of the special delivery unit, does the Minister accept the long waiting times and the overcrowding in accident and emergency departments are directly related to the fact there is, among other factors, inadequate acute hospital bed provision? Is it not the case we cannot move patients from accident and emergency departments into the wards if there is not adequate provision of beds to cater to that need? Are we not creating a continuing crisis for people, particularly in accident and emergency departments? This has its echo throughout all hospital systems. I urge the Minister, as he was a voice here over a long period of time and made the case consistently in Opposition, to recognise that, while there are other aspects to it, some of which he has named, we cannot continue to keep our heads in the sand in relation to the 2,400 acute hospital beds which, according to the INMO, are now closed. Whether he accepts that figure or the HSE's lesser figure is academic. It is the need that exists. I would join others in appealing to the Minister to accept that and address as urgent the need for the reintroduction of beds within the system and even to give us a sense of a plan or timeframe within which he will work towards this and, equally importantly, the lifting of the recruitment embargo.

Photo of James ReillyJames Reilly (Dublin North, Fine Gael)
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There were many issues raised. We have had the emergency department crisis running for several years. There was a ten-point plan issued several years ago at the height of the Celtic tiger and it failed to address this issue. The issue here has not been money per se alone. It must be about reforming the way we work and the system we work in, and that is what we are about.

I want to place on the record of the House my gratitude to all those working in the front line who have done sterling work to maintain a safe service, as I stated, during the grace period and also to achieve the progress they have achieved to date.

We in this House and everybody working in the health service knows there is a great deal more to do. We know there is waste and inefficiency. We know we have a system that is a whole of itself and no one part of it can function independently of the others.

We have a considerable job of work to do in terms of sorting out primary care and ensuring the right patient is seen by the right person at the right time. There is a great deal of work consultants are doing that GPs could be doing, there is a great deal of work GPs are doing that nurses could be doing, and there is much work that nurses are doing that health care assistants are doing.

One must ask the question why it is that one model for a hospital in this country has nine nurses to each health care assistant while another has three. Why can some community nursing units only manage a ratio of one nurse to one health care assistant when the London School of Nursing recommends one nurse to 2.5 health care assistants in a community nursing unit? There is a host of stuff.

I mentioned physiotherapy in one of the other questions. This is important because it shows we can change the way we work. In Cork, they succeeded in this, and it started in the UK. They screened GP referrals to consultants for orthopaedics and found that 40% of them did not need to see the surgeon at all. The physiotherapist was able to deal with them. I am sure that applies to other areas with other specialties too. Then we have a nonsensical system where if one wants to get counselling for a patient in the public system, one must refer him or her to the psychiatric clinic. A whole host of things must change.

Photo of Caoimhghín Ó CaoláinCaoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)
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They must, but bed needs are still a part of it.