Brian Lenihan Jnr (Dublin West, Fianna Fail)

The Tánaiste cannot come to the Seanad today and I convey her apologies to Senators. I am pleased on her behalf to set out for the record of the House some facts about the actions under way to improve patients' experience at the accident and emergency departments where there are problems and delays.

I reiterate to the House the Government's total commitment to achieve sustained results by working with the Health Service Executive to address the issues that cause problems at certain accident and emergency departments. These are complex problems which require to be addressed by a full spectrum of actions. The problems will be solved by a combination of reform and resources, management actions and improved efficiency, tailored to each individual hospital.

The Government must take responsibility to lead reform for real improvements and we are giving this our highest priority. We are providing all necessary funding, have empowered HSE management to act and are backing up its actions. We plan to recruit many new consultants in the coming years. We are providing funding for new beds in hospital wards, in accident and emergency departments and in the community.

Last year, more than 1.2 million people attended accident and emergency departments nationally, an average of almost 3,300 per day. On average, 75% of these patients are treated and discharged without the need for admission to an acute hospital bed. There are 53 acute public hospitals in the country. Some 35 of these have accident and emergency departments, between ten and 15 of which have experienced consistent problems. The problems can differ by hospital, and that is why the solutions must be identified on a hospital by hospital basis.

The Tánaiste said she wanted the accident and emergency situation to be treated as an emergency, to speed up the actions required to achieve better outcomes for patients. The HSE continues to implement the accident and emergency action plan which was introduced last year, and I will provide an update on the progress of the plan later. The HSE is implementing a number of other initiatives. The objectives are to reduce the numbers waiting for admission, the time spent waiting for admission, and the turnaround time for those who can be treated in accident and emergency departments and who do not require admission to an acute bed.

The HSE has set targets for each hospital to drive continuous improvement in waiting times. The immediate target is for nobody to wait for more than 24 hours to be admitted. The ultimate objective is to ensure that no patient will wait any longer than six hours to be admitted after the clinical decision to admit has been made. Our challenge is to support those hospitals which succeed in meeting the targets, to ensure they maintain this standard, and to bring all hospitals up to the same levels of performance.

The HSE is taking the following approach on a hospital by hospital basis. It is developing specific, time-based targets for accident and emergency and delayed discharges. It is putting in place financial and other incentives linked to performance and it is developing targeted initiatives aimed at delivering an immediate and sustained impact on attendances, delayed discharges and efficiency.

The board and the management of the HSE are fully focused on accident and emergency improvements as a priority. The board agreed that the allocation of hospital budgets for 2006 would include financial incentives linked to specific, time-based performance improvements. In addition, specific funding is being set aside for projects to advance innovation and reform in the areas of efficiency and throughput. Each hospital network manager has been instructed to treat accident and emergency as his or her top operational priority and to deliver a measurable improvement in services. It is intended that this will be reflected in the performance-related pay scheme.

The performance targets for individual hospitals relate to the number of patients on trolleys awaiting admission, and the time those patients spend waiting. The HSE will shortly publish the waiting times at accident and emergency departments so that improvement can be monitored and encouraged by all concerned. The hospitals will be assisted in achieving their targets by the task force which has been established by the HSE. The task force includes among its membership emergency department consultants, a consultant geriatrician, a respiratory physician, a director of nursing, a hospital chief executive as well as full-time representatives from the National Hospitals Office and primary, community and continuing care services. The task force advises on how improvements can be made to the effectiveness of some emergency departments, and will work with the individual hospitals to identify the specific issues which adversely affect accident and emergency performance so as to identify potential solutions.

We will also free up hospital beds by helping people leave hospital as soon as they are medically ready. We are providing more care in the community, in step-down beds and nursing home places. There is no question of discharging people who are not medically fit for discharge but those who are medically ready to leave hospital should be able to avail of appropriate care outside a hospital setting.

This year the Government is providing funding for the largest ever expansion of services for older people, amounting to €110 million in 2006, equivalent to €150 million in a full year. Under this funding, we will treble the number of home care packages, some of which will be used to assist older people who would otherwise have their discharge from hospital delayed. Care at home is still the preference of the vast majority of older people. Long-term nursing home care is also necessary for some patients after their hospital treatment.

The HSE is working to access as many public and private nursing home beds as required to free up beds for patients awaiting admission. The acute beds that become available as a result of this initiative will be ring-fenced for those patients awaiting admission in accident and emergency departments.

It is not just the number of patients on trolleys awaiting admission that is important, but the time those patients spend waiting. This is why targets for the individual hospitals are focused very much on waiting times. It is also important to ensure that patients' comfort and dignity are preserved while they wait for admission to a ward bed.

We are providing more appropriate facilities for patients awaiting admission. The 32-bed transit unit in the Mater Hospital has been operational since January of this year and is working well. Transit units are now being fast-tracked with capital funding in Tallaght Hospital, where a 40-bed transit ward is being developed, in Cavan General Hospital, Wexford General Hospital, at Our Lady of Lourdes Hospital in Drogheda and elsewhere. These initiatives are designed to provide immediate support to accident and emergency departments. However, it is essential that they are supported by significant changes, within and outside the hospital system, in capacity, the optimal use of capacity, practices and procedures, and non-acute hospital services.

There have been continual calls for more hospital beds as the solution to the accident and emergency problems. I will point out a few facts to the House. There are now 13,255 beds in public acute hospitals and 1,800 in private hospitals. Since 1997, the number of public acute hospital beds has increased by 1,528, up from 11,727 inpatient and day treatment places. Most of the increase — over 900 — comprised inpatient beds. The record of this Government is therefore nearly 200 more beds each year. This contrasts with just 33 beds per year in the years of the rainbow coalition Government.

Our five year capital investment programme for the future includes provision for 450 more acute beds. In addition, 1,000 new public beds in public hospitals will be created. With private investment, we will move existing private beds to new buildings and save €520 million in capital costs for taxpayers. It is interesting that Deputy Kenny condemned this proposal at the Fine Gael Ard-Fheis. He clearly is not committing his party to value for money solutions to the difficulties we face in the management of the public finances.

The HSE is currently reviewing the long-term acute bed requirement nationally and the outcome of this work will help to inform decisions on the future approach to be taken on this issue. We must broaden the debate beyond the need for additional acute capacity. We need additional acute capacity but we also need to ensure that existing capacity is utilised to maximum effect and, at the same time, determine the most appropriate configuration of services in both the acute and sub-acute sectors.

The HSE commissioned a process mapping exercise across ten acute hospitals. The project focused on the maximum utilisation of existing acute capacity and, in particular, the blockages, causes and potential solutions in the patient's journey through the hospital, from the decision to admit through to discharge. The exercise has shown that a patient arriving in an accident and emergency department with a letter from a general practitioner can have up to five separate contacts with medical personnel before eventually being admitted to a bed. Some hospitals have simplified this process with very positive results. We must examine the processes and procedures in other hospitals to make sure that they operate in the most efficient way to avoid wasting time and resources.

Difficulties in accessing diagnostic services outside normal working hours contribute significantly to delays for patients. The HSE is very clear that access to diagnostic facilities must be broadened so they can operate 12 to 15 hours a day as a rostered service. In addition, private sector diagnostics will continue to be used where they can contribute to faster patient services.

Consultants play a pivotal role in the efficiency of hospitals across virtually all departments. They are the senior decision makers and the importance of their clinical decision making skills in speeding up the patient's journey through the hospital system cannot be overstated. We must have far more consultants available at all times, both in accident and emergency departments and in hospital wards.

Hospitals cannot be the only setting for medical care. Many persons with chronic illnesses such as diabetes or heart disease regularly attend hospitals but could, with a well developed community service, get most of the treatment they need from their general practitioner and primary care team. With enhanced primary care services, patients can get local care from health professionals such as physiotherapists which otherwise would require hospital referrals. The HSE is establishing community intervention teams in Cork city, west Dublin, north Dublin and Limerick. These teams will provide services to enable dependent people to remain at home, rather than be admitted to hospitals or other care facilities. Nationally, all general practitioners have been invited to become involved with the HSE in the further development of primary care services and there has been a very positive response to this invitation.

I mentioned earlier the accident and emergency action plan which was introduced last year and which the HSE is continuing to implement. I will outline the progress that has been made under the plan. With regard to Action 1 of the plan, a number of new or significantly upgraded accident and emergency departments were commissioned in 2005-06, including those at Connolly Hospital, Blanchardstown, Cork University Hospital, St. Vincent's Hospital and St James's Hospital. These facilities provide for minor injury clinics to stream patients through accident and emergency, thus increasing the efficiency and effectiveness of the service provided to patients. Outside of Dublin, funding was provided for the expansion of minor injuries services at St. John's Hospital in Limerick and the provision of a minor injuries unit at Waterford Regional Hospital.

With regard to Action 2, a second MRI scanner is due to be commissioned in Beaumont Hospital by the end of 2006. Following a tendering process, interim arrangements with a private provider have been put in place. Additional capacity is also available at weekends to deal with urgent inpatients and 320 patients have benefited under this initiative since November 2005. Under Action 3, the planning for the provision of acute medical assessment units, AMAU, in Beaumont and St. Vincent's Hospitals is now under way. In Beaumont, a 29 bed AMAU is being developed to be ready for commissioning by the end of the year. In St. Vincent's Hospital, the AMAU is already partially developed. The aim is to have 20 beds fully operational by the end of June 2006.

With regard to Action 4 progress, a number of patients with very demanding care needs have been discharged to high dependency beds contracted from private nursing homes. Under Action 5, intermediate care beds were provided to allow the discharge of 560 patients from acute hospitals in 2005. A total of 302 patients have been discharged to intermediate care beds so far in 2006. Under Action 6, additional home care packages facilitated the discharge of 409 patients from acute hospitals in 2005. A total of 191 patients have been discharged with homecare packages to date in 2006.

Under Action 7, the HSE hopes to have an out-of-hours general practitioner service for north Dublin in place by the summer. Under Action 8, the first national hospital hygiene audit took place in all 54 acute hospital sites during July and August 2005. The audit was carried out by a UK based contractor and the report of the audit was published in November 2005. The second national hospital hygiene audit is currently under way, using the same methodology as last year. The results of the audit will be available in June-July.

With regard to progress with Action 9, palliative care services have been developed at Our Lady's Hospice, Harold's Cross, and have been in operation since early October 2005. Six palliative care beds have been commissioned at the Blackrock Hospice. Under Action 10, arrangements were put in place with private providers for the commissioning of CT scans and MRIs to facilitate direct access to diagnostics for general practitioners. During 2005, more than 1,000 CT scans and 100 MRI scans were carried out under this initiative.

Tackling the current difficulties in accident and emergency departments is the Government's top priority in health. The service being provided to patients in some accident and emergency departments is unacceptable and must be improved. The measures being examined by the HSE include improvements in the processes and procedures in hospitals to ensure they operate in the most efficient and effective way; the introduction of rigorous admission and discharge planning processes; the broadening of access to diagnostic facilities and the enhancement and development of primary and community care services.

By improving hospital processes and procedures, by providing additional step-down beds for those patients who do not require acute hospital care and by expanding and enhancing primary and community care services, I am confident we can achieve the sustained improvements in our accident and emergency services that patients and their families deserve. I urge all involved in medical and other organisations to contribute to the implementation of ideas and actions to improve these services.