Terence Flanagan (Dublin North East, Independent)
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I thank the Ceann Comhairle for the opportunity of raising this most important issue and I thank the Minister for Health for being present for this Topical Issue matter.

Fast and effective action is needed to address the ongoing hospital crisis as a matter of urgency. There is a serious problem with overcrowding and patients waiting on trolleys in accident and emergency departments throughout the country. In particular, I refer to Beaumont Hospital, as it is in my constituency of Dublin Bay North, which I visited recently. I am appalled at reports that terminally ill patients have been left on trolleys. It is shocking to think that people are being subjected to this treatment.

The situation in the accident and emergency departments is not fair, but it is also not fair on the medical staff who must work extremely hard in a pressurised environment, day in, day out. They should be commended on the brilliant work that they continue to do under such difficult circumstances. The overcrowding at Beaumont Hospital has become so bad that the nurses have voted in favour of industrial action on 27 January. They are clearly concerned about the situation - the excessive workloads and the conditions in which they must work every day. As the Minister will be aware, nurses held a protest today outside the Dáil to voice their concerns, one which I supported. Nurses are running from patient to patient in hospitals. They do not have time to take the patient's name and they are concerned about the Minister's recent comments that nurses need to work even harder. With such comments, they wonder what world he is living in.

The solutions to deal with the accident and emergency crisis include the need to open additional beds as soon as possible to address the crisis temporarily, but it is more recruitment in the nursing profession and permanent positions rather than temporary contracts that are needed. We need to get some of the medical staff who are abroad back into the country as well as being a lot more efficient regarding discharging patients from hospitals, dealing with home care packages and the fair deal scheme.

Finian McGrath (Dublin North Central, Independent)
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I welcome the fact that the Minister is in the Chamber because it is an important issue. This is a major crisis in accident and emergency departments and it is important that the Minister understands that. There is a national emergency. I am not talking up this issue. This has gone on for many years, but in recent days and weeks there has been a massive problem in the accident and emergency services.

The first point I would make to the Minister is that his brief is that of Minister for Health. He should focus on health and the Members in this House will support him when it comes to supporting services in the health service. It is important that the Minister gets that message.

I also attended the protest outside the gate of Leinster House and I met the nurses. They all are concerned about hospital overcrowding, but they also have solutions. They have been presenting solutions to many of us for the past number of months.

We must deal with the capacity issue. There is a shortage of beds and resources have to go into staffing the health service and providing the beds. If we deal with the issue by providing in region of 600 beds, it would have a major impact. We need to focus on that issue. I hear Ministers state there are other issues, that it is this, that and the other. It is a capacity issue; it is a beds issue. That is the important point in starting to implement solutions.

It is easy for us to come in here and try to score political points, but I do not want to be jumping up and down, as it were, about people on trolleys, as the Minister's predecessor, the Minister, Deputy Reilly, did when in opposition during the term of the previous Government. I want solutions and I want the Minister to listen to the solutions provided.

We also must focus on and think about patients. There is a considerable personal cost on patients when they sleep on trolleys or chairs. They lose their personal dignity and they lose a lot of the social networks.

I would say to the Minister to focus on the issue, which is capacity, beds and resources, and he will have the support of Opposition Members. When it comes to tax cuts for the wealthy, the Government should park those and give the funding to those in the hospitals.

Richard Boyd Barrett (Dún Laoghaire, People Before Profit Alliance)
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Yesterday, a shameful 601 people who had been admitted to hospital were left lying on trolleys. A record 601 people, who needed a bed and appropriate care, were put through the indignity and needless suffering of being left on a trolley in an overcrowded accident and emergency unit. Nurses, absolutely at the end of their tether and run off their feet, have now been forced by the Minister to protest and take industrial action because of the inaction of the Government to deal with this crisis. As professional health workers, they now feel that it is safer to turn people away from accident and emergency units than to admit them.

Contrary to years of the Government mantra about how it is all about efficiencies and it is not about throwing money at the health service, the INMO is categorical. What is needed is for the 2,000 beds that are closed in the system to be reopened. Thousands of nurses need to be recruited to provide the care for those who will occupy those beds. The INMO states that 523 beds which are closed could be reopened tomorrow if the resources and nurses were provided and that the other 1,500 beds could be opened fairly quickly if the Minister recruited the nurses. That means demanding of the Minister for Finance, Deputy Noonan, and the Taoiseach that the budget for the health service, which is utterly inadequate, be raised to reverse the damage of thousands of beds and thousands of nurses being taken out of the health service and to put those back in to deal with this crisis.

The international best standard is hospital bed occupancy of 85%. We are running at 100%, and we have unloaded more on top of that from the small accident and emergency units that have been downgraded and closed. That is the crisis. The Minister has been told what he could do to address it. Will he do it?

Derek Nolan (Galway West, Labour)
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I thank the Minister for attending in the Chamber to respond to this Topical Issue. He is aware that nurses in Galway have announced they will work to rule from 3 February onwards. This is not the first time they have raised conditions in the accident and emergency unit in Galway. They had a one-hour protest in September, at which time I engaged with them and we have been trying to come forward with a number of solutions. In fairness to the hospital, it has taken some steps. There has been limited recruitment but not enough. At the time I raised the matter in the Dáil with the Minister. One of the concerns related to the physical infrastructure in the emergency department, ED. The Minister accepted that the emergency department in Galway is simply not up to scratch. I am aware he will do his very best to get the hospital on the capital plan.

Another issue I raised with the Minister that has been put forward by the nurses as a practical solution is that they would really like to get an independent person from outside University Hospital Galway who could examine the way in which the ED works; whether they are doing triage right and if they have the correct ratio of nursing care assistants to nurses in order to put in place a temporary plan they could buy into to get them over the hump before they are in the position of having a new emergency department at which time more medium and longer term measures could be taken on board.

Among the nurses to whom I spoke, some are coping well who have been working in the system for a very long time and they are hardened, but others are broken by the system and what they see when they go into emergency departments because of the empathy and sympathy they feel for people who are on trolleys, some of whom are terminally ill or otherwise extremely ill and have worried families around them. The former CEO of the Saolta University Health Care Group said they were not offering dignity to their patients. That is not something we can allow to continue. If we can do things in the interim such as exhausting the panel of nurses that have been identified and bring in external people to see what we can do in a cost effective way in order to do something different, then we should do so now.

Jonathan O'Brien (Cork North Central, Sinn Fein)
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I do not need to explain to the Minister the crisis in the emergency departments, in particular in the past week or so, and the record number of patients lying on trolleys. There is a number of reasons why that is happening. In the vast majority of hospitals the number of people awaiting discharge but who do not have the necessary step-down facilities is ever increasing, be it due to the lack of home care plans or the delay in the fair deal scheme. In Cork, a public nursing home has beds that are currently closed, which could take some of the people who are at present taking up beds in Cork University Hospital, CUH, and the Mercy University Hospital, MUH. The reality is that we have healthy people in beds who are waiting to be discharged and we have sick people on trolleys. The situation must be rectified.

I do not believe that it is all down to finance. Other issues also arise such as planning, co-ordination, integration, and staffing levels, which all need to be addressed in a comprehensive and holistic way. The ED task force, which was designed to address some of the issues, is not working. I do not know the reasons why that is the case. The Minister will have a better knowledge of why the task force is not delivering what he hoped it would deliver. We cannot continue with the situation. We have beds that are closed which could be opened. I accept that will require finance, planning and co-ordination in addition to staff. If we could get to a situation whereby we discharge healthy people more quickly then we would have fewer people waiting on trolleys. The matter must be addressed.

Leo Varadkar (Dublin West, Fine Gael)
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I thank the Deputies for raising this issue. It will also be discussed during Private Members’ business tonight and tomorrow and at committee tomorrow as well.

At the outset I emphasise that the Government regards trolley waits of more than nine hours to be unacceptable and acknowledges the difficulties which any overcrowding in EDs causes for patients, their families and the staff who are doing their best to provide safe, quality care in very challenging circumstances.

As of this morning at 8 a.m. the TrolleyGAR update from hospitals indicated that there were 298 patients on trolleys. The figure includes patients on trolleys in regular wards but not those in day wards. The figure fell to 217 at 2 p.m. today and 131 of those were on trolleys for more than nine hours. Most such patients will be in beds tonight but of course more patients will come in in the meantime. While 298 people waiting for a hospital bed is nothing to be proud of, we should all acknowledge that through the hard work of staff, hospitals working together, supported by HSE services, management and my Department, we have significantly reduced the numbers.

The nurses' union trolley watch number this morning, at 268, was the lowest in seven years for the equivalent peak Wednesday in January. The last time it was lower was in 2007. This morning's SDU TrolleyGAR figure stood at 298. That is the lowest figure recorded for the equivalent peak Wednesday in the four years of recorded hospital statistics. When recording started in 2012, the figure for the equivalent peak Wednesday in January was 355.

All hospitals have escalation plans to manage patient flow and patient safety in a responsive, controlled and planned way that supports and ensures optimal patient care. Triage is used to prioritise patients in order that those with the most acute needs are seen and treated as soon as possible. Senior clinicians are a key part of the process. As part of their everyday duties, they work closely with hospital management to minimise potential risk and ensure the safest possible care.

Measures to manage ED surges involve the health service as a whole, including primary, community and continuing care. The aim is to ensure that all available capacity and options are utilised and brought to bear on the situation. Some of the measures taken to reduce overcrowding include opening additional overflow areas and community and transition beds - hundreds of beds have been opened in the past week; the curtailing of non-emergency surgery, which unfortunately will impact on waiting lists later in the year, but it must be done; the provision of additional diagnostics; and a focus on discharge planning and additional home care packages as well as fair deal nursing home places – 400 of the former and 300 of the latter were approved in December but, unfortunately, they did not all come through until January.

Members will all be aware that I convened the emergency department task force to develop lasting solutions to overcrowding by bringing a new focus to the challenges presented by this chronic problem that has been ongoing for 15 years. The task force comprises stakeholders such as senior doctors, lead hospital consultants, GPs, HSE national directors, union representatives and senior officials from my Department. The task force will meet on a monthly basis to develop and oversee the implementation of effective measures to improve access to acute hospital services. It works in partnership with primary, acute, community and ambulance services.

I attended today's ED task force meeting. I take this opportunity to welcome the appointment of Mr. Liam Doran as co-chair of the task force. An important point to make because the task force is not the only thing happening in this regard is that conference calls among several HSE staff and hospital group chief financial officers, CFOs, are happening daily, twice daily and sometimes three times a day since the beginning of the year. I have participated in some of the conference calls.

I am aware that the INMO is threatening industrial action as a response to this very difficult situation. I am also aware that seven out of 26 hospitals are affected by the threat of industrial action, which is a most unfortunate situation. While I am assured that a work to rule will not affect patient care, I was present in hospitals and working there for previous work to rule situations and I am aware of their impact which will make life harder for other front-line staff, in particular junior doctors. The issues currently experienced across EDs require co-operation across all areas. Only by working together can we give patients the services they need.

I reassure the House that we are all working hard to find solutions to the management of emergency care, with optimal patient care and patient safety at all times remaining a Government priority. I am out of time but I will respond to some of the Deputies’ points when responding to supplementary questions.

Terence Flanagan (Dublin North East, Independent)
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I thank the Minister for his response. I accept that he has inherited a significant issue and crisis. He will be aware that ten reports have issued on the matter since 1997 setting out the solutions to the crisis. At this stage action is required as that will speak much louder than words alone.

Nurses are at breaking point due to the conditions in which they work. Nurses and patients are under pressure and are stressed. The situation is shocking. As a medical person I am sure it is not something the Minister can stand over. The immediate solution is to provide more beds and to ensure that nurses and other medical professionals are put on permanent contracts rather than temporary contracts. They will not remain in situon temporary contracts as they need security in order to have proper employment and to pay their bills.

Finian McGrath (Dublin North Central, Independent)
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The bottom line is that this morning, 298 patients were on trolleys and as the Minister outlined, at 2 p.m. today, there were 217. This is not good enough. We need a lasting solution. We have put forward proposals and part of the solution is that we need to deal with the issue of beds and the issue of resources. We also need to look at the implementation of many of the constructive ideas put forward by nurses and doctors. I welcome that Liam Doran has been asked to act as a co-chair. This is a sensible proposal. However, we need to listen to the people on the ground and we need to ensure that our patients are treated with respect and our senior citizens are looked after in a fair way. That is the way to deal with the issue. The Government needs to put in the resources and stop giving away the extra resources from this year's budget to wealthy people. The resources should be put into our health services. That is the way to deal with this issue.

Richard Boyd Barrett (Dún Laoghaire, People Before Profit Alliance)
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I acknowledge the positive decision of the Minister to bring Liam Doran onto the task force. However, what the INMO and any medical professional says is that we need more beds and more nurses and this requires more resources. What we are dealing with now is an absolutely unacceptable and unprecedented crisis in accident and emergency departments. It is a case of the chickens coming home to roost, of 5,000 nurses being taken out of the system, of 2,000 beds being taken out, of 2.3 million home care hours being cut. Neither a health service, hospitals nor accident and emergency departments can be run on that basis or on the basis of 100% bed occupancy, because this means there is no room for manoeuvre if there are any surges and then a crisis immediately ensues. The international best standard is 85% occupancy. The beds must be re-opened and more permanent nursing staff must be employed and extra resources and money must be provided in order to do so. If the Minister does not grasp that nettle, if the Government does not get that message, this crisis is just going to continue.

Derek Nolan (Galway West, Labour)
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I thank the Minister for his response. I am sure a number of the issues he outlined will have a positive impact. I am slightly concerned about what we consider to be normal practice, which nowadays means having large numbers of people on trolleys at any one point. We need to get away from that. Some of the topics discussed by the Minister are focused on the national situation. One of the issues I encounter in talking to nurses in Galway is the sense that local management is not willing to engage and to have the type of relationship and task forces at local level for which we strive at a national level, so that the nurses, doctors and health care assistants can contribute in order to make the best of what we have.

We will need to look beyond getting over the annual busy periods and to have a more long-term plan for dealing with the regular flow of patients and putting in place a plan on how the ideal is to be reached. We must work towards limiting the time spent in accident and emergency departments.

Jonathan O'Brien (Cork North Central, Sinn Fein)
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I thank the Minister for his reply. As I said in my initial contribution I do not believe it is just a question of finances because it is also down to the need for planning, co-ordination and integration to achieve a solution. The purpose of the emergency departments task force was to examine the situation in a holistic manner and to come up with long-term solutions. However, short-term solutions are needed. Whether it is a case of the lowest number of people on trolleys today compared to the same day over the past number of years, the fact remains that more than 200 people are currently sitting on trolleys while healthy people are taking up beds because the step-down facilities are not in place to allow them to be discharged and in the meantime, sick people are waiting on trolleys. This situation needs to be addressed as a matter of priority.

Leo Varadkar (Dublin West, Fine Gael)
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I thank Deputies Jonathan O'Brien and Derek Nolan for their constructive contributions. I thank Deputies Boyd Barrett and Finian McGrath for their contributions.

Deputy O'Brien is correct that delayed discharges are part of this problem, numbering 850 in December which we have reduced to 750 currently. However, the difficulty is that 110 new delayed discharges come in every week while only 100 are discharged. We need to get ahead of that and stay ahead of it for a sustained period of time.

Deputy Nolan's suggestion with regard to Galway is very good. We have external people in Tallaght hospital at the moment who are working on a hospital redesign project. They will move on to Our Lady of Lourdes Hospital in Drogheda. If there is a willingness - because willingness is essential - by everyone in Galway to embrace it there is no reason they cannot be included in that external review and hospital redesign process.

Deputy Boyd Barrett's information is not correct. There may well have been 2,000 beds closed in the system over the past ten years but these are not all acute beds because some of them are community beds. Many of them have been demolished, many are not HIQA compliant and many have since been turned into radiology departments and endoscopy suites and so on-----

Richard Boyd Barrett (Dún Laoghaire, People Before Profit Alliance)
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Five hundred and twenty-three-----

Leo Varadkar (Dublin West, Fine Gael)
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-----and they cannot be turned back into acute beds. Of the 500 that could potentially be opened, more than half of that number are currently open and where possible, we will open some more. However, there are issues to do with decanting, with fire certificates, electrical issues and with staffing in some cases.

Beaumont hospital has had a problem with overcrowding for over ten years. I visited there in the past couple of weeks. I worked there for four months as a senior house officer, SHO. I met some of the staff who were working there when I worked there and they are still working there. Quite frankly, it is a very great tribute to them that they stick it. I understand their anger and their frustration. I never, ever said that nurses have to do more work so I do not know where that comment comes from. What I did say is that everyone has to be part of the solution, which is quite a different thing. Everyone needs to be part of the solution.

I do not think for one second that additional nursing staff or a change in contracts from temporary to permanent will in itself solve the problem. More nurses and more nurses on a different type of contract does not discharge anybody any quicker nor does it create a single bed. It may be part of the solution but it is probably a relatively small part of the solution.

In the case of Beaumont, the hospital currently has 100 delayed discharges and approximately 30 people on trolleys. In theory, if the delayed discharges were reduced from 100 to 50, there should be nobody on trolleys. However, I know full well that the way that hospital is currently managed and organised, this would not be the case. What would happen is that discharges would slow down and electives would be increased and we would still have people on trolleys in the emergency department, as has been the case every day, except Christmas week, for the past 15 years. There is a more fundamental problem in a number of our hospitals than merely money and staff, although I accept that money and staff may well be part of the solution.

Michael Healy-Rae (Kerry South, Independent)
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Ye promised a lot.