Joe Carey (Clare, Fine Gael)
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I welcome the opportunity to raise this important matter in the House today and thank the Ceann Comhairle for selecting it for debate. The issues raised in the HIQA report on University Hospital, Limerick, confirm the unacceptable situation of overcrowding at the emergency department there. While it has been an issue for many years, overcrowding has escalated since the turn of the year. It is not acceptable that patients are left on trolleys for extended periods. It is not acceptable that vulnerable, sick and often elderly patients are crammed into a confined space and put at risk of cross infection with little or no privacy or dignity. It is not acceptable that doctors, nurses and other staff be asked to work in this type of environment.

The report is welcome and must be acted on. The HIQA report can and must be the catalyst for chance within the Limerick hospital group. All short, medium and long-term options must be explored including the provision of additional bed capacity at the site at Dooradoyle, Limerick, bringing forward the opening of the new, state-of-the-art emergency department at Limerick by cutting red tape from 2016-17, improved use of the three model-2 hospitals at Ennis, Nenagh and St. John's, and exploring the option of incorporating a model-3 hospital within the UL hospital group.

Public confidence in our health service is essential. It is critical that the issues raised by HIQA are acted on strategically. The report strengthens the hand of the Minister for Health, Deputy James Reilly, to seek additional funding and resources. I ask that a case be made to the Minister for Public Expenditure and Reform with a view to seeking the required funding to enable the Minister for Health to bring about the changes which are required so that we in the mid-west region can have a functioning health service of which we can all be proud.

Kieran O'Donnell (Limerick City, Fine Gael)
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I welcome the HIQA report which reaffirms what we already know - that there is major overcrowding in the accident and emergency department at University Hospital, Limerick. It is not fit for purpose and is unacceptable for patients and the staff who do such fantastic work in the hospital.

The report discussed fast-tracking the new accident and emergency service at University Hospital, Limerick. The new building is complete with the exception of the internal fit-out for the accident and emergency unit. I have seen the building myself. My understanding is that the fit-out will not commence until November and has currently gone out to tender. Why is there a six-month delay? Why was the contract for the fit-out not in place to commence when the building was ready, which is now? What can be done to fast-track this?

We need to have the new accident and emergency facility open as a matter of urgency for the people of Limerick and the wider region. A possible interim measure would be to open the acute and medical assessment unit located above the current accident and emergency department on a 24-hour basis. When triage takes place, medical issues could be directed to the acute medical services overhead while trauma cases could be directed to the ground floor and the existing accident and emergency unit. What we need now is action. Can we bring forward the completion date for the fit-out of the accident and emergency unit at University Hospital, Limerick? What has caused the six-month delay?

Pat Breen (Clare, Fine Gael)
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I welcome the presence of the Minister for Health to take the matter. I thank him for being here. It is obvious that all five Members who are raising the matter have the same goal, which is to make the accident and emergency unit in University Hospital, Limerick, a pleasant place for patients. We want to get rid of the overcrowding which has reduced privacy and bring dignity back to patients again. That is extremely important.

I welcome the HIQA report, which is timely. We all knew about it anyway, but it is time for us to work together to get a solution which takes us over the next two years. Colleagues have spoken about fast-tracking the emergency department at Limerick and I certainly agree that it is an option we should consider. We should be looking at further options to reduce the crowds coming into the accident and emergency unit in Limerick. It is quite obvious that the hospital is over capacity. We know there is a problem at University Hospital, Limerick, and that there is a problem trying to fill doctor positions. There is a real problem for staff who work in atrocious conditions. Morale is very low in the hospital.

This is about good management of the system and trying to make good what is in place. There must be a re-examination of the whole system to see if the HSE got it wrong in relation to reconfiguration. These are all issues we must examine. A meeting will take place at the hospital next Monday morning for the Oireachtas Members from the region. I welcome the opportunity to be at the meeting to raise my concerns about reconfiguration. I am also anxious to hear today what the Minister has to say on the current situation. That is important. It is also important that we all work together to ensure that the conditions patients are experiencing in the accident and emergency unit are alleviated. It is totally unacceptable. We are all here with the single goal of making the accident and emergency unit a better place.

Michael McNamara (Clare, Labour)
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I do not envy the the Minister his position. He inherited a health system which was largely dysfunctional. I do not envy any of his colleagues their jobs, all of which are about doing more with less.

2 o’clock

This is not about the Minister and his position or his colleagues and their positions; rather it is about my constituents. The Minister should put himself in their shoes. The 2009 HIQA report indicated to them that the current configuration was inadequate and unsafe. A plethora of medical experts told them that the answer was to move emergency services to Limerick Regional Hospital, as it was then called. It now has the more grandiose title of University of Limerick Hospital. Five years later my constituents are effectively told by HIQA, the body that told them the then configuration was unsafe, that the emergency unit to which they entrust their lives and those of their elderly parents and children is not fit for purpose. We are no longer being told that the problem with the health service lies with a lack of funding but with management. We are now being told it needs more money. There is dysfunction at the heart of the service, for which the Department and the Cabinet which acts collectively must take responsibility. The problem must be fixed.

I will read from the press release issued by HIQA. It reads: "The absence of a statutory governance framework is hindering the development of strong governance and patient safety functions". That has nothing to do with the availability of money; rather, it is a failure of this House and the Government to put such a statutory governance framework in place. The report states: "Moreover, 22% of patients requiring emergency hip fracture surgery had their surgery cancelled due to a theatre list overrun", despite the studies conducted in Limerick showing that theatre were underused and mismanaged. It also states "The single most significant risk observed by the Authority in ULH during the course of this review was the persistent overcrowding in the Emergency Department (ED)".

Derek Keating (Dublin Mid West, Fine Gael)
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The Deputy is over time.

Michael McNamara (Clare, Labour)
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This is important because it indicates a failure of the Government to take responsibility for dealing with the overcrowding. The report states:

The single most significant risk observed by the Authority in ULH during the course of this review was the persistent overcrowding in the Emergency Department (ED). The overcrowding impacted negatively on patients (adults and children) and on staff. It impeded access to patients for care and observation, reduced privacy and dignity, increased the risk of transmission of infection and prevented adequate cleaning of the department.

Patrick O'Donovan (Limerick, Fine Gael)
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I agree with my colleagues in much of what has been said. This was an announced a visit by HIQA and one must ask what it would have discovered if it had been unannounced. There should be follow-up unannounced visits. I have said before that I am very concerned about two groups, namely, the patients using the regional hospital in Dooradoyle and the staff working there, whose morale is on the floor. It is not helping that we are moving around the deckchairs in how the Limerick Regional Hospital Group is being managed. This adds to the uncertainty. A person said to me at the weekend that the only people who found the report shocking were those who had not been in the accident and emergency unit in Limerick for a long time. It is suffering the consequences of a flawed and failed reconfiguration programme that saw services in Nenagh, Ennis and St. John's hospitals being moved to an already crowded Limerick Regional Hospital, with no facilities being made available by the previous Administration. We are now living with the consequences and must fix the problem. We must fix it for our constituents who deserve better. Unfortunately, I have had cause to spend more than my fair share of time in the accident and emergency unit in Limerick Regional Hospital. It is not acceptable that in 2014 we must wait for a HIQA report for something to be done.

The new building is under construction. I refer to the comments of Deputy Joe Carey on capacity across the mid-western, western and southern regions as an interim measure to divert patients away from the area in their own interests. This has continued for too long. With his colleague, the Minister for Finance, the Minister for Health has invested substantially in the hospital and its physical infrastructure. We now have a statutory agency, the one that stated services in Nenagh, Ennis and St. John's hospitals were unsafe, stating the hospital that was supposed to be the relief valve for these hospitals is unsafe. The people of the mid-western region deserve better.

James Reilly (Dublin North, Fine Gael)
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I regret that I only have four minutes in which to reply because many good points have been made and I need to inform the Deputies of several points. I thank them for raising this matter and affording me the opportunity to welcome publication of the HIQA report on the review of governance in the University of Limerick Hospitals Group. It is the first hospital group to be assessed against the national standards for safer and better health care which I approved in accordance with the Health Act 2007. The review is an independent assessment of services against explicit standards and it is important that the findings, good and bad, be made clear. This will help to drive improvements in the quality and safety of health services. I want to move away from reports being used to undermine and close services and use them to address the issues raised within them and fix them.

The report makes it clear that significant challenges remain, as outlined by the Deputies, particularly in emergency services. It also identifies the significant progress made in corporate and clinical governance and on the reorganisation of services within the group. Among the many positive developments are the establishment of a new management structure, including the board of management, the CEO and management team and the clinical directorate; the reconfiguration of surgical, critical care and paediatric services; and the establishment of an infection prevention and control team.

With regard to risks, the HSE has identified actions that have and will be taken to address the concerns raised and provide an improved and safer service for patients. The key risk area identified is unscheduled care. I fully acknowledge that there are ongoing pressures on the accident and emergency unit, which is why an extensive capital project is under way to build a new state-of-the-art unit.

It will be difficult to cover the issues raised in the short time I have available. I want to respond to Deputy Kieran O'Donnell by saying there has not been a delay. The tendering has been undertaken in parallel. When he meets Ms Ann Doherty, he will be told very clearly that there is no second fix. A huge amount of work remains to be done before the fit-out is undertaken. The tender will be complete and there should be a seamless progression towards the fit-out. There should not be a delay.

Since the report was published, a separate paediatric emergency area has been fully opened. It provides a separate, family-friendly area for children who require an emergency response. It clearly reduces overcrowding to some extent.

A 17 bed short stay unit opened on 25 April and is being managed by the acute medicine physicians. The unit admits short stay patients who can be discharged within 48 hours of admission.

A new €35 million critical care unit opened recently. This is a major step forward in the development of acute hospital services across the region.

The acute medical and surgical assessment units are open and accept direct referrals from GPs and the emergency unit. GPs can bypass the emergency unit. Further information campaigns will be undertaken locally to advise GPs and the public of the availability of three local injury units and medical assessment units in the region - in Ennis, Nenagh and St. John's hospitals. These are very good model 2 hospitals with a critical role in supporting people in the area.

In parallel with these measures, the special delivery unit will support the hospital and provide the expertise required to provide both interim and long-term sustainable solutions to deal with the issues of bed capacity, excessive trolley waits and overcrowding in the emergency unit. The establishment of the hospital groups has the potential to bring about significant improvements in the way we organise acute hospitals. In that regard, I am satisfied that group boards are capable of exercising authority assertively and constructively. Deputy Michael McNamara did not read further from the report which states: "Notwithstanding, the Authority welcomed the fact that the reporting relationship between the HSE’s National Director for Acute Hospitals and ULH was described as being both supportive and enabling, thereby allowing the Board of Directors, CEO and Executive Management Team flexibility in reorganising and restructuring their services as appropriate". The issue cannot be addressed until the legislation is enacted to create trusts. We made it clear that we would have a trial period for hospital groups to see how they worked and where there were deficits.

Deputies referred to the absence of a model 3 hospital in the group.

I believe this is something we need to examine closely.

I want to assure people that we will continue to work to make this hospital as safe as possible. Other issues in the report that have not been raised by the Deputies here are of equal concern to me and must be addressed - in particular, the length of time people with a broken hip must wait on trolleys. This is a critical issue and I have asked for information on this to be sent to me. Four hours is the gold standard, but I want to know how many people wait longer than six hours. Surgery for a fractured hip should never be cancelled because of theatre lists. I understand from speaking to management that they have issues around the figure in regard to this. Sometimes the cancellations have not been due to lack of theatre time but for medical reasons, where the patient is not fit for surgery or has developed complications that must be sorted out.

This is not to ignore what HIQA is doing here. It provides a great service and I welcome the fact that it is there. I wish the CEO of HIQA, the Chairman and all its staff the best. HIQA exists to help us see where there are problems so we can fix them. That is what we intend to do.

Joe Carey (Clare, Fine Gael)
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I welcome the Minister's comments, particularly his commitment to a special delivery unit that will liaise with the Limerick hospital groups to come up with both short-term and interim solutions to the bed capacity issue. I welcome his comments regarding the exploration of the establishment of a model 3 hospital within the hospital group also. I believe this report will help drive improvements at University Hospital Limerick, and I look forward to working closely with the Minister and the CEO of the hospital group to bring that about so that we will have a health service of which we can all be proud.

Kieran O'Donnell (Limerick City, Fine Gael)
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I thank the Minister for his comments and welcome the commitment to provide a model 3 hospital along with University Hospital Limerick, which is a model 4 hospital. On the issue of the build, we need to know whether the accident and emergency unit will be completed by 2016. We represent the patients and constituents in Limerick and we know that the issue of overcrowding at University Hospital Limerick is not going to disappear unless the accident and emergency build and fit-out is fast-tracked. The shell of the building is complete and the main contractors are due to come off-site shortly. However, it seems the fit-out will not start until November. Why is it not happening sooner? We need this accident and emergency unit to open.

The HSE is coming before the Committee of Public Accounts tomorrow and I have alerted it that I intend to raise this issue there. I represent the people of Limerick City and this issue is of huge significance for them. I will also raise the issue with those in the management of University Hospital Limerick when I meet them next Monday. We are all on the same page on this. It is about patient safety and looking after hospital staff. The biggest issue raised in the report was overcrowding in the accident and emergency unit. Therefore, we need to bring forward the new purpose-built, state-of-the-art facility as soon as possible.

These are legitimate questions that I have been asked to ask on behalf of the people of Limerick and people who use the accident and emergency unit. Many of these people are elderly patients and they have been in touch with us regularly on the issue of overcrowding. Now is the time to act. We have the opportunity, so we should fast-track this project and work together.

Pat Breen (Clare, Fine Gael)
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I want to focus on the issue of the absence of a model 3 hospital in the mid-western hospital group, which is a contributory factor in the overcrowding at University Hospital Limerick. I was delighted to hear the Minister's comments in regard to exploring the idea of a possible model 3 hospital in the region. Ennis is well placed to become a model 3 hospital and such a hospital would help resolve the issues around overcrowding. If we look at the size of County Clare and the distances people have to travel from Blackhead or Loop Head to University Hospital Limerick, we see good reason to place a model 3 hospital there.

This could be done relatively cheaply. Doctors could be on a rotating roster between both hospitals and the infrastructure is already in place. All that is necessary is the will on the part of the HSE to put a model 3 hospital in place, similar to the models in place at Galway University Hospital and Cork University Hospital. I am glad to hear the Minister is exploring all options in this area and I thank him for his response. I hope we can work together on this to ensure we get the greatest benefits for the people of the mid-western region in the area of health services.

Michael McNamara (Clare, Labour)
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The Minister spoke about patients with hip fractures waiting more than four hours. I could point the Minister to a patient in my constituency who waited four days. Each day she waited, this patient knew that her chance of a successful operation was diminishing, yet she waited day after day.

Talk of a model 3 hospital is all well and good, but let us be realistic. Live horse, get grass. We cannot even open an emergency unit, much less a new level 3 hospital. The plan is for a level 3 hospital for 2020. That is great, but what about now? I join Deputy O'Donnell in asking when will the new emergency department be open and taking patients. This is not an unreasonable question. If, as the Minister pointed out, the problem is legislation, when will we have that legislation? If we can sit overnight to liquidate a bank, and if we can sit in July for emergency legislation, we can sit this coming July to deal with legislation, provided the problem is legislation and that this is not just an excuse the Minister can hide behind.

A lot of politics is being played in this House and a lot of politics was played in advance of the last election in regard to health. It is interesting to hear that the lack of further expenditure on health is laid at the door of the Minister for Public Expenditure and Reform by one Deputy and that the thanks for the expenditure there has been is laid at the door of the Minister for Finance by another. We are in Government and must front up and take responsibility. I would like the Minister here to take responsibility and tell me when the emergency department will open and when we will have legislation, if that is the problem.

Patrick O'Donovan (Limerick, Fine Gael)
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I will not take lectures from anybody. The question I asked related to the capacity that exists in the western region, the south east and the south, in places like Tralee, Mallow, Cork and Galway, particularly in regard to ambulance services. If these services come from peripheral areas, such as north Clare or west Limerick, could they use capacity in other areas? In other words, rather than sending an ambulance into Dooradoyle where the accident and emergency unit is already full, could capacity in Tralee, Mallow, Cork or Galway be used? The south east of Limerick, for example, is within striking distance of Clonmel. We have an immediate problem, but rather than looking at fixed geographical boundaries, we should consider looking at measures outside those boundaries.

I welcome the commitment in regard to a model 3 hospital. The visit referred to in the report was an announced visit, but it needs to be followed up by a similar unannounced visit. We must ensure two things. We must ensure patients are safe, which is HIQA's remit, but we must also look after the staff who are looking after the patients in these hospitals. Their morale is on the floor.

James Reilly (Dublin North, Fine Gael)
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I thank the Deputies for their contributions. Deputy Carey mentioned the risk of cross-infection. I am happy to report that we have the lowest incidence of MRSA in our hospitals now since records began.

I want to mention the model 2 hospitals. We need better use of these hospitals. This does not just mean using the beds in these hospitals, but that the staff working in these hospitals must co-operate and be part of the larger group and be prepared to work on different sites. We must not have a situation in which staff refuse to move from their own model 2 hospital. This is not acceptable.

I agree 100% with Deputy O'Donnell that we need to expedite the new accident and emergency unit and ensure it is opened as soon as possible. That is our goal.

My understanding, having spoken to the manager, is that there is no delay. There will be a seamless passage through. That said, the Deputy will receive a more comprehensive answer from the HSE tomorrow and I utterly respect his right to seek such on behalf of the people of Limerick. If there is anything else we can do to accelerate this, we will do it.

Deputy Breen made reference to "all five of us" but I would say "all six of us". We are all here to improve the situation. There are issues around how things are managed but I wish to put it on the record of the House that we have a very good manager in Limerick University Hospital group and we will be sorry to see her go. Her departure will be Cork's gain, or more specifically, Cork City Council.

Deputy McNamara said earlier that in the past it was all about money and now it is all about management. It is not all about any one thing but about everything. Regarding the case he mentioned, can I presume the woman was not waiting on a trolley for four days with a fractured hip?

Michael McNamara (Clare, Labour)
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No, she was not on a trolley.

James Reilly (Dublin North, Fine Gael)
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I will look into the case. There may have been medical reasons for the long wait, but maybe not. I accept the Deputy's bona fides in that regard.

I want to make sure that everybody understands what I am saying because I do not want a mixed message to go out from here. I am committing to exploring the lack of a model three hospital in the group.

Michael McNamara (Clare, Labour)
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The Minister could explore the moon too.

James Reilly (Dublin North, Fine Gael)
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I am not committing to putting one in or building one. There has been no mention of building a new hospital. There is no point-----

Billy Kelleher (Cork North Central, Fianna Fail)
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Was that an election promise?

James Reilly (Dublin North, Fine Gael)
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I do not believe Deputy Kelleher is involved in this discussion. He will have his opportunity shortly.

Billy Kelleher (Cork North Central, Fianna Fail)
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I am involved.

James Reilly (Dublin North, Fine Gael)
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Yes, he is involved in the sense that it was his Government that left the mess behind. It was his Government that reconfigured these hospitals and did not put in-----

Billy Kelleher (Cork North Central, Fianna Fail)
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The Minister should address the Deputies who raised this Topical Issue.

James Reilly (Dublin North, Fine Gael)
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Sorry, but seeing as the Deputy has raised his voice in this debate, let us be clear about this. It was Deputy Kelleher's Government that reconfigured those hospitals and put the horse behind the cart instead of the other way around by closing facilities before new facilities were built. It left it to the next Government to clean up the mess.

Deputy O'Donovan made reference to unannounced visits which is something that HIQA does already and will continue to do. It has done it with other hospitals and the Deputies will see the results of that in reports published today on other hospitals.

Change is always challenging and difficult and people feel threatened by it occasionally but I believe the changes we are introducing vis-à-visthe hospital group will devolve more authority and autonomy locally, giving local people a much greater say in how their service is configured and delivered. I believe that is important. I will finish by assuring Deputies that we will expedite all of those issues that can be expedited, some of which were not raised today but are contained in this report - particularly the issue of the use of the model two hospitals and their staff. The aim is to ensure that we have a safe service. In that context, the report does not say that this is unsafe service but rather that there are risks that must be addressed. We will do everything we can to address those risks as quickly as possible. I, as a doctor and Minister for Health, do not want to see patients suffering.