Maurice Hayes (Independent)

The Minister of State will be relieved to know I have no complaints for him. If I had, I would have to take them elsewhere. I offer some observations on the basis of experience in the field of health policy and management. We should listen carefully to many of the sensible statements made by Senator O'Toole. These are practical, although not quite straightforward, issues. I take some heart from the statement from the Minister of State, Deputy Brian Lenihan, earlier on, and I believe we are moving in the right direction. These are complex issues, and nobody can wave a magic wand to get a change overnight.

Investment is required in primary and community care rather than the hospital field. The problems in clogged accident and emergency departments arise from people presenting there who could be treated more appropriately elsewhere, and the fact that hospital beds are taken up by people who would receive more appropriate treatment in the community. Those two sides of the equation need to be reviewed. Investment, in the form of money and organisation, is necessary.

The HSE is correct to state that each hospital is different and needs to be approached differently. There is much to be said for the appointment of a "bed unblocker" in a hospital. Many of the reasons for people remaining in hospitals unnecessarily are administrative, there being a lack of staff to discharge them. If patients cannot be seen on a Friday they remain until Monday. There are a number of hospitals — I know of one in Manchester — where satisfactory triage at an early stage and the presence of a specialist accident and emergency nurse assists the flow of patients through accident and emergency units.

As Senator O'Toole said, the attendance of consultants must be reviewed. Most serious accidents happen late at night after the pubs have closed and when hospital staffing is inappropriate. There is much to be said for ensuring consultant cover and the availability of diagnostic services. There is no point in having CAT scanners, MRI scanners and operating theatres if they are only used for seven or eight hours a day. I remember an awful case in Belfast a few years ago where a man died within a mile of three scanners but none was open until 9 a.m.

I notice the term "rostering" was used. I hope it does not mean staff being on call-out or stand-by allowances but that it involves a shift system. That is necessary for laboratory technicians and radiographers, among others. Such personnel issues must be dealt with.

I am not against hospital league tables as long as they are used sensibly. Managers will say it is impossible to compare a particular hospital with others but the figures are useful if people use them to interrogate themselves and to ask why they are different this week from last week. A hospital may have good systems but it is important that a dialogue takes place.

The out-of-hours doctor service where I live is an enormous help and has transformed demand. A procedure called "NHS Direct", where people could telephone for assistance, was introduced in England a few years ago and is worth considering. People often bring a child to the door of a hospital in fear and want somebody to talk to, somebody who will tell them what action to take. If the child's condition does not improve they can bring the child back. It can be tremendously helpful.

I welcome the establishment of minor injury units and admission wards, which I take to be the "transit wards" mentioned in the statements today. These afford some breathing space for a hospital and allow it to adjust to an influx of people, especially early in the morning before beds can be cleared. Minor injury units have enormous potential because, according to all the studies I have read, some 80% of people presenting at accident and emergency units could be dealt with in properly staffed minor injury units. I would set up four such units in Dublin, one each in the north, south, east and west of the city. I would staff them with junior doctors and specialist accident and emergency nurses. That would take an enormous strain away from the system and would mean high tech hospitals, with heavy equipment to be used for real trauma, could be fully staffed on a 24-hour basis.

Drunks are an enormous problem for staff at accident and emergency units. Senators should visit an accident and emergency unit late at night and witness conditions under which nurses and other staff work. I am sure Dublin is no different from Belfast, with which I am more familiar. I do not think the answer is to keep drunks out. Drunkenness can very often disguise the symptoms of a serious head injury. Part of the answer is to have adequate portering and security staffing. Larger units in a city should be staffed by trained psychiatric personnel late at night because they are better used to handling such people. The people who work in these units late at night, particularly in urban hospitals, are heroic at times and deserve any support and help we can give them. The Minister of State is moving in the right direction and I wish him well.