Kathleen O'Meara (Labour)

I welcome the opportunity to contribute to this very important debate. This is not the first time we have discussed the issue of health care and I thank the Minister, Deputy Harney, for speaking to us and being very up-front in terms of what she said.

I would like to address the issue of elderly care which plays a role in the crisis in accident and emergency services. It can be difficult to discharge elderly people from general and acute hospitals, whether or not they have medical conditions. Often they do not need to be in hospital and are, as the Minister said, in inappropriate settings. However, it seems impossible to locate other settings for their care.

This issue relates to one of the proposed reforms which the Department of Health and Children, in the context of the Hanly report, intends to implement. I would ask the Minister to reconsider this in light of what she said during this debate. The hospital action groups' examination of the Hanly report took account of the downgrading and removal of secondary care, including accident and emergency departments, from a considerable number of hospitals around the country and the impact that will have. Hopefully this will not happen although I am not sure.

Removing people from acute beds in smaller hospitals such as Nenagh, Roscommon, Ballinasloe, Bantry and others and relocating them to Limerick potentially creates a situation similar to that experienced in Dublin. It is harder to discharge older people when they have been removed from the infrastructure of the people who know them, such as their GP, nurses, hospital and community.

My uncle died a year ago and in the last two years of his life visited Nenagh hospital for a week at a time, on and off, for various medical conditions. He went from the nursing home in Roscrea to Nenagh General Hospital where he was met by nurses and doctors who knew him and his case history. His GP had a personal relationship with the consultants. We, his family, were in the community and had a good relationship with his carers. He had a local infrastructure which worked well. Those caring for him knew the context into which he was being discharged whether he was going home or to the nursing home. The GP, consultants, nurses, matron and assistant matron had personal knowledge of the people with whom they dealt.

This is an extremely important element, and one we take for granted. When that infrastructure is removed a new set of problems is created. It might not be relevant from a management consultant's point of view, but it is very much the case for the practitioner working on the ground. Nurses, GPs and consultants in Nenagh have emphasised over and over again to me the importance of maintaining the accident and emergency and acute services within a local setting in order to retain local infrastructure. One must support primary care in order for that to happen, and the Minister must take this into account.

The generation of large super hospitals in 12 centres throughout the country might seem like a solution. Putting people into one large accident and emergency department in a region rather than a series of smaller departments might also seem like a solution. However, that is not the case. Smaller accident and emergency departments feeding into a larger hospital is a better system of managing health care in a local setting because filtering occurs. A person may need to go to Dublin or Cork or might not need to go anywhere at all. Filtering goes on all the time in a local setting. By removing that process and locating everything in a central setting one is generating actions and necessary follow-ups. This creates more work and bureaucracy rather than delivering what we want which is the best possible quality of health care.

I agree with those speakers who said this crisis has existed for a long time and has never been tackled. I do not doubt the commitment of the current Minister, Deputy Harney, to tackle this problem. However, I question how this can be done without greater investment. I also question whether the care of the elderly in the community as mentioned by the Tánaiste can be managed by creating private facilities throughout the country. While these look good on paper, in my experience families are not happy that the quality of care that was available in the past is available in a commercial setting. While these are acceptable for those in good health, they are not suitable for those with any medical condition, in particular Alzheimer's disease. We need to do considerably more than providing private facilities into which people can put their elderly relatives. I question the Tánaiste's policy in that regard.