Mary Harney (Dublin Mid West, Progressive Democrats)

Somebody told me the Order of Business in the Seanad is much longer than in the other House as it has more important matters to discuss.

What is happening at our accident and emergency departments throughout the country is not acceptable to me or the Government. Some 1.2 million people per year, or 3,300 patients per day, visit our accident and emergency facilities at our hospitals, which is more than 25% of the population. Given that we have a relatively young population, it is a startling statistic at many levels. In Dublin there are six accident and emergency hospitals. Leicester, which is a city of a similar size, has one. I remember the days in Dublin when people would inquire which hospital was on call at night on the southside and which hospital was on call on the northside. There were just two.

To a large extent what is happening at accident and emergency departments is a symptom of the problems in the wider health system. Sometimes people end up in accident and emergency departments because they do not have access to general practitioners. That is particularly the case on the northside of Dublin, out of hours. Among the issues being addressed in our ten point plan is access to general practitioner services on a 24 hour basis. If we do not have that service we will not solve the accident and emergency issue. Another reason people end up in accident and emergency departments is that they are not able to get a quick outpatient appointment and, therefore, the necessary inpatient procedure. We have long waiting times particularly in certain specialties.

The national treatment purchase fund was established some time ago by the Government with a focused approach in trying to get appointments for those who had been waiting a considerable time for a surgical procedure to be carried out. That initiative has been extraordinarily successful and has dealt with more than 28,000 patients. That it is focused has helped it to be successful. Essentially, it buys spare capacity in the private sector for those patients.

Recently, I asked the national treatment purchase fund to come forward with initiatives for the long waiters for outpatient appointments. Even with new consultant appointments it will be some considerable time before we can substantially reduce the waiting time in some crucial areas. That initiative will have an impact on accident and emergency departments.

A third area where accident and emergency departments are used is for minor injuries that can be dealt with in more appropriate settings. The VHI has announced that it will open two minor injury units in Dublin, one on the southside and, hopefully, one on the northside. There are also initiatives surrounding minor injury units at our main hospitals, so that those whose illness is relatively minor can be dealt with in a speedy fashion alongside the accident and emergency services. Acute medical units will be provided at Beaumont and Tallaght hospitals. A similar type unit already in place in St. James's Hospital works extraordinarily well.

The population is aging. Each year 12,000 reach the age of 65 and 1,500 the age of 80. Approximately 5% of those in that age group need institutional care. That is a European average and it is no different here. Therefore, more institutional facilities have to be made available for long-term care. I am a strong fan of support being given for a home or community setting. Much will have to be done to redress the imbalance where most of the support is around the nursing home subvention or a bed in a public facility. If more was done to help families who have dependent relatives, particularly elderly people, more people could be kept at home. Notwithstanding initiatives to keep people at home we need more institutional care particularly in the greater Dublin area but not exclusively in Dublin. There are approximately 400 elderly patients in the acute hospital system in Dublin, Cork, Galway and other places. In comparison with Dublin the number is relatively small.

Among the initiatives in the ten point plan is the acquisition of beds, particularly high dependency, because 100 of those 400 patients are high dependency and, traditionally, the private nursing home sector has not catered for that type of patient. A requirement in the tendering procedure is to specify the particular needs of these patients, some of whom are PEGfed while others have complications that need to be dealt with by specialist nurses. We need to ensure they have access to doctors and so on. That tender is over and the facilities are being inspected and we expect those beds to be in the system over the next ten days to two weeks.

We have acquired capacity for 500 patients to have interim arrangements between hospital and home, in other words, step down facilities. Often, when patients complete their acute period in the hospital they may need a convalescent type of arrangement. This week many patients were transferred from the acute system throughout the country into a step-down facility.

We have devised a new home care package for approximately 400 to 500 people which is tailor made to the needs of the person requiring the care. Therefore, it cannot be too prescriptive. If rules are not flexible they will not deal with the particular circumstances. Clearly, care has to be provided on a seven day basis. Many of the support systems in the community, whether community home care teams or the home help service, which are 9 a.m. to 5 p.m., Monday to Friday, do not satisfy the needs of the elderly and disabled persons. We are moving to a seven day arrangement by giving the resource to the family or the carer and allowing them to purchase what they require to meet their needs. Other initiatives that can help speed up what is happening at accident and emergency departments are diagnostic facilities such as an MRI scanner at Beaumont. Greater access is needed to diagnostic facilities particularly for general practitioners.

The most important issue in a hospital is how it operates internally. Dr. Conor Burke, a respiratory physician at Blanchardstown and the Mater hospitals, who has a huge reputation internationally and is one of the leaders in his field globally, said in a paper published recently that at Blanchardstown Hospital, without any extra capacity, if the patients were discharged when medically fit to be discharged there would not have been a single person on a trolley in the accident and emergency department. That is a startling statistic. If patients could have been discharged when they were medically fit to be discharged nobody would have been on a trolley. We have got to ensure discharge every day in the hospital system, not Monday to Friday only and that doctors discharge for each other as they do when on holidays. Other than holiday time they discharge only for themselves and virtually nobody is discharged on Saturday or Sunday in the acute hospital system. There are some superstitions about going home on a Saturday — doctors have said this to me — so, perhaps, they can be brought forward to Friday to deal with that issue. That is not a good enough reason to occupy an acute hospital bed which costs approximately €4,000 to €6,000 per week, depending on the hospital, while other patients are on trolleys.

Those are some of the initiatives being put in place. I am determined to ensure they succeed. If they do not solve the problem there will have to be other initiatives. One thing is certain, the problem will be solved. I wish to reflect on something I said a few months ago. I said that by March people would see an improvement because many of these initiatives are coming on stream. The reality is — I say this in sadness — that because of the confusion surrounding the supports for the elderly, hospital managers have told me — only last week I had another meeting with the managers of the five Dublin academic teaching hospitals — it is more difficult to encourage patients to move from the acute hospital setting into the nursing home setting because, as has been said, "people feel that in a while it will all be free".

Our society could not nor cannot afford the provision of free care to everybody over the age of 65. This is not the case anywhere and it is not sustainable here. We will need to do a combination of things. An additional number of people are in the acute system who might otherwise be in a more appropriate setting. However, this is not the reason for the problem in accident and emergency departments but rather a contributory factor to the problems currently in the system which, as the weather improves, while not eliminated should certainly be alleviated.

I am pleased to be in the House to discuss the crisis in accident and emergency services which is part of the wider problem in the health system. The Health and Safety Authority has published a report this week on health and safety issues from an employee perspective. It has made some very critical observations. A reconfiguration within the hospital system is required. The fact that in emergency situations many patients and staff are working in dangerous conditions cannot be solved overnight. We cannot build new hospitals overnight nor can we provide new beds overnight. We must therefore consider how to reconfigure within the current hospital system. Everybody will be required to play their part in that change process.

We have more nurses to patients than anywhere in the developed world. We must ensure the resources within the hospital system are used in a more effective and balanced way. For this reason, I have requested the Health Service Executive to undertake an audit of all hospitals and hospital procedures because I want to ensure that the good performers are rewarded, that good behaviour is rewarded and that inefficiencies and ineffectiveness are rooted out.

This year the Department will spend €1 billion more than last year when expenditure was €950 million more than the year before. We spend €1,000 per capita more on health care than is expended in Northern Ireland or the United Kingdom. We spend 37% more than is expended in the Netherlands, 9% more than in Germany, 8% more than in France, 70% more than in Italy. If this economy was not doing so well, we would not have those resources. Due to the fact that we are expending such resources, it must be done as effectively as possible which means we must change behaviour in so many respects. Nobody can be immune from that change, including the Minister, the Department and everybody else working in the health system.

I look forward to returning to the House with better news in respect of accident and emergency services. There is much good news to report. Last night I met a man who told me his mother who was seriously ill was taken last Saturday night to St. James's Hospital in Dublin and she was back home within two hours. He said this is not the sort of news reported in newspapers or on radio.

Fewer than 10% of those who attend accident and emergency departments have to spend a night on a trolley and, therefore, 90% are dealt with on the same day and many are dealt with very quickly. That 10% figure is unsatisfactory and it must and will be addressed by the Government over the course of this year.