Micheál Martin (Cork South Central, Fianna Fail)

Last year we asked the system to come up with a more innovative approach on how to deal with the discharge policy. The Southern Health Board came up with a very good initiative which the Department funded and asked to be replicated in the eastern region. It has worked more effectively in the south through the effective management of the discharge which leads to a better turnover. We have met with the hospital management and we will continue to emphasise that. Unfortunately, when 300 people are discharged, another 300 take their place. The long-term care issue is the key to accident and emergency in Dublin. The discharge of patients to appropriate long-term care settings is a critical factor. Some hospitals have come up with different approaches.

The system of subventions for nursing homes was introduced in the early 1990s. In 1993, it started off with €5 million. In 1997 it increased to €35 million and by 2003 it had reached €110 million. This year it will reach €120 million or higher. That gives the range and speed of the leap forward made. It also reflects the ageing issue. In Dublin there has been less investment in community care than there has been around the country. That is a historical development. The strength in community and connections to community are not as strong now in urban areas as they would have been 20 or 30 years ago. All that has impinged on the hospital accident and emergency department.

There are now 51 emergency medicine consultant posts in acute hospitals as opposed to 14 in 1997. That is the largest increase in any specialty aside from the cancer and heart specialities. We have also invested in additional nursing staff and security arrangements in accident and emergency departments. We are being told by the hospitals that this has resulted in better clinical decision making in the hospitals in the accident and emergency departments, as well as enhanced management diagnosis and treatment of patients. There are huge pressures on accident and emergency departments but the actual quality of the management of the patient is better. Unfortunately, overcrowding repeatedly occurs because of the wider issues across the system.

The other issue is bed capacity. The acute hospital bed capacity national review called for 3,000 beds by 2011. We said we could provide 709. The base funding is in place for that and 589 of those beds have already been commissioned. We have exceeded the target of 450 private beds through the national treatment purchase fund, which has now treated up to 15,000 patients on the waiting lists. Many hospitals are down to six months, while some are down to three months waiting times for surgical procedures. The dedicated funding stream is eating into the waiting list. The validation by the hospitals of the lists would open one's eyes on how big the waiting list really is. We have been given a figure of 20,000 to 21,000 for the waiting list. This validation occurs when people out there are asked whether they are available for the operation. In many instances people did not need the operation, had had the operation and so on. It will be interesting to follow the evolution of the management of the waiting lists by the NTPF.

Emergency medicine departments sometimes have to deal with injuries and conditions, which are more appropriate to a primary care setting. General practitioner out-of-hours co-operatives have been established and are operating in at least part of all health board areas, with one health board, the North Eastern Health Board, having a region-wide project. Between 2000 and 2003, €46.5 million was allocated to the health boards for the purpose of out-of-hours co-operatives and this figure does not include the fees paid to participating GPs. An amount of €24 million has been allocated for 2004. The satisfaction rate with the GP co-operative service is very high from both patient and provider perspectives. In fact a recent survey by the Western Health Board's service, WestDoc, indicated that of the persons surveyed, 30% said that they would have gone to the emergency medicine department if the service had not been available.

However, there is one difficulty. This is happening all over the country but not in Dublin. Dublin is the one problem area for out-of-hours GP cover. Despite our allocation and offer of funding, there has not been a take-up. There is not the same enthusiasm in Dublin for the establishment of out-of-hours GP co-operatives. Around the country, doctors are approaching us in delegations, asking when will they be provided with extra money to complete the coverage in a health board area. That has never happened in the Dublin area. The ERHA has informed me that it is working with various interests to see if it can come up with a solution for Dublin. That has a bearing on the anecdotal evidence that an accident and emergency unit at night effectively serves as a GP, where people attend the accident and emergency department as a first response. We allocated funding out in Dublin for GP co-operatives, but the ERHA was not in a position to get agreement to provide out-of-hours cover.

In order to address the needs of patients presenting at the emergency department some hospitals have established minor injury or illness units. These units provide rapid assessment and appropriate treatment of minor injuries by nurse practitioners or junior doctors. The main advantages of having a separate minor injuries area within the emergency department include the better streamlining of patients and decreased waiting times. St. John's Hospital in Limerick is a very good example of that.

The processing of patients through the emergency services of a hospital has been greatly assisted by the use of medical assessment units. One such hospital is St. Luke's in Kilkenny where innovative solutions and a hospital wide response have improved the delivery of emergency services to patients. The consultants in St. Luke's Hospital approached us through public representatives and asked for funding for their ideas. We gave them €2 million and they took the beds off the corridors. They put in a medical assessment unit, a pre-discharge unit and made huge progress. The benefit of having a medical assessment unit on site has facilitated the rapid assessment and treatment of medical patients. Another recent development is the acute medical assessment unit at St. James's Hospital. I invite anyone to have a look at how they are doing the business there. This unit has contributed to a noticeable improvement in the delivery of emergency services at the hospital. The problems in St. James's Hospital are now exclusively of a long-term care variety. In other words, they are not in a position to discharge as quickly as they would like. They have put in a very sophisticated chest pain programme, where anyone presenting with chest pain will go directly into the chest pain facility rather than the accident and emergency department. Within 12 hours, they will have a full diagnostic process carried out and will know whether they have to stay or can be discharged. Prior to the development of that unit, a patient presenting would spend three days in that hospital. I tell hospitals around the country that, if they have innovative ideas, I will be open to supporting them. A key finding in the Comhairle na nOspidéal report on accident and emergency services was that a hospital-wide response was needed to meet the requirements of the emergency service. Improved processing of patients through the emergency department, via minor injuries units or medical assessment units, is but one aspect of the hospital-wide response needed. Delivery of the emergency service at hospital level is interdependent on the in-patient elective service, day patient and out-patient care. The effective delivery of emergency services, therefore, cannot be dealt with in isolation from the delivery of all hospital-based services.

One of the outcomes of the Comhairle na nOspidéal report on accident and emergency services, in which clinicians were involved, was that, historically, hospitals did not take possession of such services in a hospital-wide approach. In other words, it was seen as something out there on its own. Doctors and nurses were allocated, but not everyone took possession of the ball and said that they had an obligation and responsibility. That mindset is changing, and this is critical since it is the key to prioritisation within the overall hospital ethos of a successful accident and emergency department.

I acknowledge there are ongoing pressures, the critical one being the long-term care issue rather than the acute hospital beds themselves. That is important in the context of an overall hospitals capacity to deal with elective and medical admissions. However, the nature of health is changing. The complexity and acuity of patients now arriving has by and large increased. Age is a significant factor in the presentation to accident and emergency. There is a lack of community support in some areas, particularly in the Dublin region. I know Members from all over the country are present, and I am not claiming there are no problems elsewhere. However, the problems in the east are particularly acute because of the way in which the system has evolved over time compared with other regions where there is more of a health board-wide response. In Dublin one does not necessarily have that, since many of the hospitals grew up individually rather than as part of a health board system. As a result there are many gaps in community links with hospitals, and the same is true with community care. Over the last few years we have changed that, and we must do more with that to get the right response. It will require more resources to provide the long-term care beds to alleviate the current difficulties. We are working with the hospitals to do just that. In doing so, I am careful to say that I will not simply throw money at the problem. We wish to ensure a return. The type of scheme that, we had last year got such a return, and we need more of that.