Seanad debates
Thursday, 21 April 2005
Accident and Emergency Services: Statements.
11:00 am
Mary Harney (Dublin Mid West, Progressive Democrats)
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I am delighted to be in the Seanad to discuss accident and emergency services but first I wish to apologise for being late. I was under the impression I was due here five minutes or so later.
Mary Harney (Dublin Mid West, Progressive Democrats)
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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.
Fergal Browne (Fine Gael)
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I welcome the Tánaiste and her officials to the House. She referred to people being kept on trolleys overnight but her Government has been in office for eight years. It is very shocking that a person could present at an accident and emergency unit and leave in a worse state. This was highlighted in the report by the Health and Safety Authority. It stated that as a result of overcrowding there is a risk of violence breaking out between patients and that staff are under pressure. It is outrageous that a person could go to an accident and emergency unit with a minor injury such as a broken finger, be assaulted while there and come out in a worse state. This highlights the chaos which exists.
The Tánaiste referred to money being expended on the service but value for money is not being provided. There is a clear difference in quality of service in any of the countries mentioned by the Tánaiste. There is not value for money for the resources being invested. The health service is not lacking in money; the problem is how it is managing the money.
I made a telephone inquiry to the Department of Health and Children regarding the accident and emergency unit in St. Luke's Hospital in Kilkenny but my call was not returned. I question the sincerity of the Department on these issues. I commend St. Luke's Hospital in Kilkenny. There are no patients on trolleys, not as a result of its facilities but because of its management. The hospital has an excellent minor injuries unit and it maximises its very inadequate accident and emergency unit. The fire escape door is contained within a patient cubicle as was highlighted in the report. The unit is awaiting an upgrade. The staff are working under very difficult circumstances. In some hospitals patients are afraid to use the toilet in case their trolley or pillow is taken while they are absent.
Telephone calls to the "Liveline" programme last week were shocking in their content. Many people are angry. It is appalling that in 2005, in this prosperous country, yesterday 336 people were on trolleys, with neither dignity nor privacy being afforded to them. One is at one's lowest when sick. Patients cannot talk confidentially to doctors and may be exposed to the MRSA superbug. We should be looking after people far better than is the case.
The Tánaiste has been in Government for eight years and she is a member of the Cabinet which approved the now infamous primary care strategy in 2001. At that time the Government promised to spend €1.27 billion over ten years to provide 600 primary care centres across the country. Four years into that strategy, as far as I am aware, €15 million has been expended so far out of €1.27 billion and ten pilot projects are in place out of 600.
I ask the Tánaiste to consider her Government's record on medical card services. Currently 200,000 fewer people have medical cards compared with 1997. She has acknowledged this fact and has introduced GP-only medical cards. This is April so why are we still waiting for those GP-only medical cards to be distributed? I have spoken to the Health Service Executive but no guidelines have been issued on this matter. The legislation has been passed but when will those 200,000 promised medical cards be available?
The Tánaiste promised 30,000 additional full medical cards. How many of those 30,000 full medical cards have arrived? The Government's record is atrocious. The Tánaiste acknowledged in her contribution that the lack of a medical card is causing a problem because people are going to accident and emergency units instead of to a GP. I understand this is a significant problem in north County Dublin as is the shortage of GPs in that area where the ratio of GPs to the population is far lower than in south Dublin.
The report highlighted poor safety training and inadequate protection of health care workers from the risk of violence. It stated that overcrowding in accident and emergency units would lead to increased risk of violence and aggression, an increased risk of injury due to slips, trips and falls, manual handling, aggression, violence and increased risk of infection. It has the potential to compromise fire evacuation procedures and may increase the risk of stress among staff. A person could present in an accident and emergency unit and instead of coming home cured could come home in a worse state.
I suggest the Tánaiste should focus on value for money for the taxpayer. The issue of medical cards is very significant. Problems with accident and emergency facilities cannot be tackled in isolation. Primary care is key and it is time to refocus on the primary care strategy. Why are only ten pilot projects in operation out of the 600 that were promised? Why has only €50 million out of €1.27 billion in funding been spent?
The HSA's report should not be left on a shelf as is the case with numerous other reports. Action must be taken. We should have proper and safe accident and emergency facilities for the benefit of both patients and workers. Patients deserve dignity, privacy and confidentiality and this is not possible if they are accommodated on trolleys. There is plenty of food for thought on this issue. The Tánaiste has been a Cabinet member for eight years and has been in her current Ministry for almost seven months. It is not good enough that she should return to this House to outline the same difficulties in the health system.
Camillus Glynn (Fianna Fail)
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I welcome the Tánaiste and Minister for Health and Children, Deputy Harney, to the House and am grateful for the opportunity to engage in this debate. As the Tánaiste said, the situation in our accident and emergency units is unacceptable. It is important at the outset to consider the meaning of those two words, "accident" and "emergency". Those seeking treatment after an accident are patients requiring urgent attention as a consequence of an unplanned event. However, the word "emergency" seems to have been thrown in the dustbin in many cases.
The question of inappropriate usage of accident and emergency facilities looms large when this debate comes into focus. In the past a person who injured his or her finger or foot or suffered some other misfortune sought the assistance of a local GP and received the appropriate care. This no longer happens because GPs are understandably aware of the threat of litigation. GPs advise patients to attend the nearest accident and emergency facility because it can provide all the necessary resources. Many treatments such as suturing are now routinely performed in accident and emergency units rather than GPs' clinics.
There is a clear need for special training for GPs in providing these types of services. Senator Browne is correct that there is a problem in regard to the number of training places. However, I understand additional training places are being provided in the appropriate training facilities. There was a time when one would never see a non-national person in the position of non-consultant hospital doctor, NCHD. It is now the case, however, that most NCHDs are non-nationals. Where are Irish doctors going?
Camillus Glynn (Fianna Fail)
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Precisely. This is a problem and a debate for another day. Special training must be given to GPs, who have done a great job in the past in providing such services, and the appropriate insurance cover supplied. The MidDoc facility is an excellent service because it saves many visits to accident and emergency departments and ensures the patient receives prompt and adequate treatment and that the local GP has a quality of life which he or she did not heretofore enjoy.
The Tánaiste observed there are social reasons for delays in the discharge of hospital patients. I support her contention that follow-up services and support structures must be provided. Upsetting terminology has been used in respect of elderly patients availing of accident and emergency services. It is outrageous to describe those who have built this State and who are now in the winter of their years as "bed-blockers". Senator Browne referred to the special step-down unit for preparation for discharge in Kilcree, County Kilkenny. This is the way forward.
Members have referred to health and safety issues in accident and emergency departments. I was recently approached by a well-qualified health and safety officer who informed me there is a problem in this regard across the entire strata of working environments. There are people working as health and safety officers who do not have the appropriate training. This is a separate problem. Anyone with any knowledge of nursing and medicine is aware that the disposal of excreta is and always should be a nursing duty. Excreta must be disposed of in the proper way. If its disposal is the responsibility of those who are not aware of correct procedure there is a clear danger that highly infective organisms such as the MRSA bug may be transmitted to patients and cause the mayhem we have witnessed in our hospitals.
As a member of the Midland Health Board for many years, I am aware that accident and emergency consultants are employed in Tullamore and Mullingar hospitals and provide services in Portlaoise hospital. There is no doubt this has brought major improvements to patient services. However, one of the great abuses of accident and emergency facilities relates to the abuse of alcohol. Patients who are boozed up to the gills report to accident and emergency departments at night after being involved in an altercation with associates or as a consequence of an unprovoked attack arising from the abuse of alcohol. Such patients should be hit hard in the pocket because they cause mayhem not only in accident and emergency units but also in psychiatric hospitals.
The Tánaiste observed that in Leicester, a city of comparable size to Dublin in terms of population and in which I have worked on three different occasions, there is one accident and emergency facility. We clearly must focus on the use and possible abuse of our accident and emergency services. It is obvious there are people presenting in accident and emergency units who should be going elsewhere for treatment.
Significant resources have been invested in this area of the health service. In November 2004, for example, the Tánaiste announced additional funding of €70 million for current expenditure in 2005 to implement a number of initiatives to improve the delivery of emergency services. In addition, €10 million in capital funding has been provided in the context of the HSE's overall capital allocation. The plan to improve accident and emergency services includes the development and expansion of minor injury units, chest pain clinics and respiratory clinics to relieve pressure on hospitals' accident and emergency departments. Other developments are the provision of a second MRI scanner at Beaumont Hospital and the provision of acute medical units for non-surgical patients at Tallaght, St. Vincent's and Beaumont Hospitals.
In addition, there will be a transfer of 100 high-dependency patients to suitable private nursing home care and an active consideration of the scope for using greater numbers of private nursing home beds to alleviate pressure on acute hospitals. This is a sensible approach. Negotiations will take place with the private sector to meet the needs of 500 patients annually for intermediate care of up to six weeks. We must address the needs of elderly people awaiting discharge to nursing home care or their own homes with appropriate supports. Expanded home-care packages to support 500 additional older people at home will help in this regard.
A priority is the provision of more out-of-hours GP services in order to reduce people's need to attend accident and emergency units to a minimum. As I said, the MidDoc facility is providing a great service, especially in County Westmeath. Measures will be taken to ensure the efficiency of the dedicated cleaning service and security measures for accident and emergency departments. The further expansion of palliative care facilities and the proposed measures to enhance direct access for GPs to diagnostic services are extremely important.
The Department of Health and Children is liaising with the HSE to progress the implementation of the plan. New accident and emergency departments have been provided at Cork, James Connolly Hospital, Naas General Hospital, the South Tipperary General Hospital in Clonmel and Roscommon General Hospital. The accident and emergency unit at the Mater Hospital has also been refurbished. I could continue.
It is important to set up rapid access units. A model casualty unit was set up in Longford some time ago. "Casualty" is perhaps not the appropriate term today, but that unit has done tremendous things for the people of Longford. It has significantly reduced the number of people attending the accident and emergency unit in Mullingar. I acknowledge, however, that there is a situation that needs to be seriously addressed.
I remind Senator Browne that medical cards are an income-related facility. It has not been the practice to give people a medical card when they come into gainful employment. There have been people on the fringes, just outside the terms of qualification for medical cards, but that will be addressed through the doctor-only system, which has been an innovative proposal. I eagerly await——
Fergal Browne (Fine Gael)
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When are we going to have that system?
Camillus Glynn (Fianna Fail)
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It is never too late to do the right thing.
Fergal Browne (Fine Gael)
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It is April now. We are down 200,000 medical cards.
Paddy BurkeCamillus Glynn (Fianna Fail)
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Senator Browne talks about it; we just do it. That is the difference.
Camillus Glynn (Fianna Fail)
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I welcome the Tánaiste here today. I have no doubt she is on the right track. It takes time to resolve the current problems, as they have been around for a hell of a long time. Her party was in power previously, too. I remember, because I worked in the services and was a regular visitor on a professional basis to the accident and emergency department in Mullingar. The same problems obtained then, but they are being addressed now. That is the difference.
Mary Henry (Independent)
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I welcome the Tánaiste to the House. As she knows, I feel she should be given a purple heart for courage, for having taken on her current job.
Mary Harney (Dublin Mid West, Progressive Democrats)
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Or maybe a red heart.
12:00 pm
Mary Henry (Independent)
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I very much agree with the Tánaiste that the accident and emergency services situation is not in itself a problem; there is just an obvious manifestation of problems in the health service. We are spending an enormous amount of money on the health service. Sometimes, I wonder where on earth the money is going. I know that most of it has gone on pay for those working in the service, and their increases are well deserved.
The major problems in accident and emergency services have been brought to the fore because of the fact that, every night, so many people in hospitals around the country find themselves on trolleys. There is no gainsaying that fact. It is terrible for those people. At least they are being seen and someone knows their diagnosis.
There is greater concern about those who are waiting to get into accident and emergency units to be seen. That is a particularly dangerous time. I have asked some departments for figures to find out what has caused that to be the case. Has there been a significant increase in the number of people coming to accident and emergency departments? The answer is "No". Over the past four or five years, there has been an increase of just 1% in Tallaght, but there were 53 people on trolleys there last night. The real problem was the significant cutback in the number of acute beds introduced in the early 1990s.
Additionally, as the Tánaiste mentioned, we have a larger and older population, and far more sub-specialties are being dealt with at the hospitals concerned. For example, the number of oncologists in the country was minimal a few years ago. Now, there are quite a few of them. Many people with cancer are living much longer because they are now getting hospital treatment, and they must obviously occupy beds while getting that treatment.
The same applies to cardiology. We do not have people dropping dead with coronary attacks half as much as we used to. Patients are having stents put in, angioplasty and all sorts of other things done, and those people require beds. In a way, our success in those areas is promoting the problems in accident and emergency departments. The only thing we can do is increase the number of beds or, as the Tánaiste has rightly pointed out, do as Dr. Conor Burke said and ensure those who are fit for exiting the hospital do leave. His report was very worrying. I remember reading that about 30% of people in hospital were there inappropriately for too long.
As an aside, it is extremely difficult to get Dubliners to leave hospital on a Saturday. They will say, "Saturday's flitting is short sitting." It can be a matter of trying to shove people out the door at 6 p.m. telling them it is almost Sunday and asking them what they are worried about. That is a real problem.
My colleagues from accident and emergency departments tell me that minor injuries do not present that great a difficulty. It is a good idea to channel patients to minor injuries units within accident and emergency departments as quickly as possible.
I am concerned about the private minor injuries clinics being set up by VHI Healthcare, for example, and I have made my concerns known to the VHI. For a start, what if a person goes to a VHI minor injuries clinic and it becomes perfectly obvious that the injury is not minor and needs to be treated at an accident and emergency department? I have been told that people in that situation will be taken to such a unit by ambulance immediately.
I asked whether they would go to the top of the queue there. Some people seemed to think that that would be what would happen. I see the Tánaiste shaking her head: she is quite right to think that should not happen. Crucial time might be lost in serious cases if patients first go to a minor injuries clinic but then discover that their fall on the head has resulted in more than just a little cut, and that they have a subdural haematoma. They will then go into the waiting area, which is the area that all my colleagues say is the danger area in the accident and emergency department. There will be one triage nurse trying to decide whom to bring in fastest. People have to get their card, check in and so on. I do not like the idea of minor injuries clinics at all. People will simply lose time or an apartheid situation will set in, whereby those who have money and go to private clinics will end up at the top of the queue when they arrive at accident and emergency departments. I am sure that colleagues would not like that, but that is what could happen.
We might also end up with a dreadful leakage of skilled accident and emergency staff to the private minor injuries clinics. I looked at the charges proposed by the clinic in Galway. People must first go to their general practitioner. Let us say that will cost €40. They will then attend the clinic with their GP's letter and pay €120 to register. Then, treatment will start at €100. That means spending big money almost immediately, which will be impossible for many people. It would be far better to have minor injuries units within hospitals. I gather that is not a problem.
It is also well worthwhile to have acute medical units. I applaud hospitals such as the Mater Hospital, which has an asthma room, which people with acute asthma can attend. I was told that room only has armchairs and that the rule there is, "Don't let them get into a bed." The patients need to be kept in the armchairs and cured there. For the patient, reassurance is frequently the main thing, as asthmatic attacks are unpleasant. I applaud that initiative and I call for more such facilities to be set up.
The stress felt by staff in accident and emergency departments is a serious issue, and we must be worried by the health and safety report. Nursing staff are expected to deal with about three times the number of people they ought to be dealing with. I welcome the proposal that there should be more lavatories in accident and emergency departments, and the suggestion that could solve everything, but the patients are not there to go to the lavatory. They are only supposed to go to the lavatory while they are waiting or before going home. They are not supposed to be in need of those facilities on an ongoing basis. That sort of measure will not solve anything.
As Senator Glynn said, medical staff are now almost entirely non-EU staff. I suggest that we must be seen to be treating those staff in a better manner than has been the case, or we will not have any staff at all. A dreadful problem has arisen with anaesthetists, who were the cream of the crop in India and Pakistan, and who were brought here following the massive recruitment drive in 2000. They were told they did not need to sit the temporary registration examination. However, they now find they are being denied permanent registration unless they sit either the temporary registration or the fellowship examination.
I do not want to see the standards of people on our specialist registers downgraded in any way. However, if promises were made in the past in respect of them — I must re-examine the legislation under which they arrived — we must be fair to such people and not bring them here under false pretences. I was interested to see that the last accident and emergency consultant appointed in the country was a graduate of Karachi university. People from Ireland or the EU are not applying for these tough jobs and they are also not applying for orthopaedic jobs associated with accident and emergency departments. Not one EU graduate applied for the last consultant post in orthopaedics. That is also interesting.
I applaud all the Minister is trying to do to achieve better home care services for people. When I was working in a hospital as a junior we used to keep people in because of poverty at home. Now that does not happen, but we do have a different situation where the extended family is not close by. For example a mother could live in Ringsend but as the family could not afford a house there, they live in Gorey. It would be very difficult for them to drop in on her, as would have been the practice years ago. Very often it is not a lack of care or love on the part of the families, it is simply that they are not in a position to do anything. Home care services can be extraordinarily important in assisting people in leaving hospital.
I am glad the Minister for Health and Children acted so quickly on the Ballymun Health Centre. That was a disgrace. I do not understand the turf war which means the unit, which cost so much to build, has not been in action for two and a half years. While it is still not in action, at least something is being done. I am sure there were wrongs on every side but that should not mean fast action cannot to be taken to get a useful unit up and running. If similar situations exist around the country they should be dealt with as quickly as possible.
The Minister also referred to the national treatment purchase plan. It has meant people have been removed from waiting lists, which is good. The Minister also mentioned the fact that people attend accident and emergency units because there are such long waiting times to get an out-patient appointment. This happens all over the country and is dreadful. It is one of our worst scandals.
Making some hospitals available for elective surgery only is well worth while and Cappagh Hospital, which does elective work only, is a great success. I used to work in the combined Meath and Adelaide Hospital, where the only accident and emergency department was in the Meath Hospital as the one in the Adelaide Hospital was closed. Everyone in the Adelaide Hospital had their heads down doing elective work.
If a major accident occurs, such as a car crash involving a number of vehicles, it must be given priority. Theatres are taken over by such cases and the elective work is put back. This leads to problems rescheduling appointments. I am sorry that places such as Cavan and Monaghan cannot work like that, whereby, for instance, all elective work would be done in Monaghan. While there is a distance between Monaghan and Cavan, those involved might find after a while that they were getting a considerable amount of work done that would not otherwise be done.
I wish the Minister for Health and Children well in what she is trying to do. GPs are disappointed about the primary care units and I support Senator Browne's views on this. I also support the establishment of caredoc units, such as that in St. Luke's in Rathgar and as we may be able to do in Peamount. It means that people can contact a GP service as the units in question are not being used at that time of the day. Where they are in use they are successful.
John Minihan (Progressive Democrats)
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I welcome the Tánaiste and Minister for Health and Children to the House, and welcome the opportunity to contribute to this debate. There is no doubt that the health service, particularly accident and emergency departments, are to the fore of much recent political activity. Our health service needs to be focused and directed at patients, who must be at the centre of all actions and decisions we take.
Sir John Harvey Jones, the world-renowned industrialist and trouble-shooter is quoted as saying: "Managing the health service is a nearly impossible task and even if you did manage it nearly perfectly, I still think the system needs more money." Although he said that in 1992, his view today would be the same and all sides of the House would agree. People may say that nothing has changed. This debate will no doubt centre on one or both of the key elements referred to in that quote, management and money. However, there will be no reference on this side of the house to the impossibility of the task. Managing the health system and accident and emergency units is not impossible. It is difficult and testing but it can be done.
Much has changed since 1992. Over the intervening years we have built up economic success and the country has been transformed. At that time we felt many of the challenges we then faced were impossible to overcome. Many were the result of economic stagnation and recession. Today we have new challenges but I refuse to adopt a pessimistic view and would rather have to deal with these challenges, which arise from success rather than failure. In this regard, the Tánaiste is committed to seeing the fruits of our economic performance invested in the health care sector. This commitment is most apparent in the increased investment in services for people with disabilities and those with mental health problems.
It is time to apply the energy and methods that have served us in the past to our current challenges, which include accident and emergency units. I am glad that of the five priority areas outlined by the Tánaiste, accident and emergency units are top of the list. They perhaps pose our greatest challenge but it is not an impossible task.
People judge their experiences of our health service by their experiences in accident and emergency units. Over 3,000 people per day, that is more than 1 million patients per year, are judging our health service in this way. Success in tackling accident and emergency units will have real benefits for many people and health reform will also provide benefits for the 120,000 people working in the sector. That is a huge incentive to meet this challenge head-on.
The complexity of health service reform is continually recounted. I will park that idea for the moment, but before I do I will refer to a recent keynote address by the Tánaiste when she stated that she had brought forward a ten point accident and emergency plan for this year, that every action in the plan is being implemented now and if new action is needed it will be taken. She also stated that if new decisions are needed they will be made. This is testament to her commitment.
This sector is complex but we must, and thankfully do, have a pragmatic and determined starting point. That has not always been the case. Unlike in the past, reaching points at which difficult decisions must be made will not block progress. They must and will be overcome.
People are on trolleys at a time when others stay in hospitals for a weekend just to get test results. People attend accident and emergency units to access all kinds of services, including securing long-term care. I know at first hand the problems that exist. Last month the accident and emergency facility in Cork University Hospital had to close its doors to all but ambulance admissions due to overcrowding. Staff found that there were up to 30 patients waiting on trolleys.
These problems must be overcome. Sometimes taking on a challenge can set one back but we cannot shy away from this. Despite the negative comments from some quarters, the Tánaiste did not shy away when a prolonged problem in the health service had to be tackled.
She tackled the nursing home charges issue, she took on the challenge of the failure to implement properly the decision made by the Supreme Court 29 years ago. The State will honour its obligations, although the costs will be high. There is no doubt that the administrative and financial costs will divert energies away from tackling the accident and emergency services challenge, but we have to get on with things. If new actions are needed, they will be introduced. If new decisions are needed, they will be made. No one will shy away from those responsibilities. Encouraging people to leave acute beds to take up nursing home care has been made more difficult as a result of the current situation. However, this has not prevented the Tánaiste from tackling the nursing home issue and she will not be frustrated in tackling accident and emergency services. That is the committment she has made.
There are two aspects to this, money and management, which will be central to most statements in the House today. That is inevitable. Health spending accounts for a quarter of all Government expenditure and the Government has given top priority to this area by allocating €11 billion, an increase of 9.9%. The allocation of €2.8 billion for disability services is a powerful statement of the committment of this Government. The ten point accident and emergency services plan is fully funded. The Minister has allocated €70 million of current funding and €10 million of capital funding for accident and emergency services. Let us not get bogged down in figures though because they are scant comfort to those people on trollies or awaiting test results. However, they are evidence of the committment that exists. Every day we see evidence that real committment and dramatic action are needed.
I welcome the programme of inspection of the 11 accident and emergency units by the Health and Safety Authority, which began in March. I expect that the Health Service Executive will use the time given to it by the HSA to address the issues raised in the report. I also welcome the HSA's plans to visit four more accident and emergency units. The Health Service Executive, established in January 2005, has the responsibility to manage and deliver health services. People expect those health services, accident and emergency and other services, to be delivered in a safe manner and in compliance with health and safety law. This raises further challenges, but the Minister has shown throughout her career that she sees challenges as opportunities. I have no doubt she will embrace this opportunity to make progress on this matter, with clear planning, investment and determination.
I have had personal experience of the problems in the accident and emergency unit in Cork. However, because of planning, investment and determination, progress has been made in Cork. The new accident and emergency department became operational on Monday last. The unit, which is two and a half times the size of the old one, was developed at a cost of €11 million and will have the capacity to deal with 50,000 patients per annum. Before we listen to more negative comments from some quarters, I also point out that staffing has been increased by more than 70%. Planning and investment are making a difference. The project in Cork took eight years to complete. It is part of a €200 million expansion at Cork University Hospital. We are all working hard, no one more so than the Tánaiste, to ensure similar progress is made elsewhere. Problems must be acknowledged but so too must progress. Our objective is to make more progress and to do so quickly.
Historic problems have meant that facilities are inadequate or sometimes non-existent. Building new facilities takes time but they are needed now. That is why we are looking at new ways of addressing the issue. We know the old ways do not work. No matter what noises are made by other parties, we must face up to the challenge of providing facilities quickly in whatever manner is feasible.
Let us examine some of the facts. For the next five years the Government has set aside €2.5 billion for health capital investment, an enormous sum of money. Providing the physical buildings and equipment will result in that money disappearing very quickly. We need new ways to address this problem, ways which appear new in Ireland but are not new abroad. Combining public and private investment to develop health facilities has worked in Europe and Australia and there is no reason it cannot work here. There are people who are willing to invest money, at home and abroad, in sectors of demand. There is urgent demand in the health sector, for radiotherapy, BreastCheck and a new children's hospital. If private investment can be introduced in true partnership for the benefit of patients, we must make it happen.
Managing the health service is an almost impossible task and even if it were managed perfectly, it would still need more funding. That was the assessment of Jones in 1992. With the Tánaiste holding the Department of Health and Children portfolio, I have no doubt she will make certain the health service is managed as perfectly as it can be. The €11 billion budget provides more funding than ever before. The plans to introduce new sources of funding will ensure the system gets even more money.
The accident and emergency services challenge is a serious one. The lack of services causes distress and outcry, and rightly so. However, the challenge is being met head-on by the Minister and this Government. It is easy and opportunistic to point out problems for political or parochial gain, but the action the Government is taking is providing real benefit to patients. We are making progess. Thanks to our policies in the past, we now have more resources than ever to make progress. This is due in no small way to the work of the Minister and I welcome the fact that she addressed the House today.
Brendan Ryan (Labour)
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I can make thumping speeches as well as the next person. I intend to be a little more restrained on this occasion, although I do not intend to be any less critical.
In my final year in college I was taught there are four functions of management — planning, organising, staffing and controlling. My understanding always was that staffing, organising or controlling could never be achieved adequately without planning. If we were dealing with this crisis because of a sudden outbreak of an unusual disease or an epidemic of some kind, that would be understandable. However, this is not an issue that arose today or yesterday issue but dates to the cutbacks in health in 1987. The fundamental problem is that the Government recognised, in various strategy statements and in advice given to it, that the health service requires at least 3,000 extra acute beds. The Government has announced the provision of these extra beds on numerous occasions but it has only delivered 700. That is the fundamental problem. All of the other issues regarding expenditure and order go back to the fact that there are not enough beds in the system.
If one examines the OECD statistics, one can see that Ireland has one of the lowest levels of acute hospital beds in the OECD area. Speaking of statistics, I was disappointed the Tánaiste was disingenuous with the figures she quoted. It is possible to play with statistics, but our health expenditure, as a percentage of GNP, rather than GDP, is in the bottom half of the EU. According to OECD figures, the increase in expenditure of GNP in this country between 1997 and 2002 was no higher than in many European countries. We were attempting to patch up an almost failing health service from 1997 onwards. It was as if we were trying first to fill the potholes and then build new roads because the country needed more. However, now the potholes are filled we are surprised to find that the traffic is overloaded on the limited road service. Much of the expenditure simply prevented it from falling apart.
This Government did not do anything to address the under-capacity. One does not need to be an economist to realise that if one does not provide the basic capital infrastructure and starts to employ more and more people, squeezing them into the same inadequate number of buildings, one gets less and less return on the extra staff. That is rudimentary first-year economics.
Returning to the first requirement of management, there was a failure to plan in terms of the following: looking at the real problems and what was likely to happen with regard to population growth, aging and the young population; the consequence of a reduction in the number of the population with medical cards; and the declining number of GPs in many urban areas. None of these developments happened overnight. There was a blank denial of the country's fundamental needs. An objective evaluation would have demonstrated what was required, and has done since.
The Government made a peculiar decision to spend an enormous amount of extra money on the heath services from 1997 onwards. Having spent a lot of money, it then put a strategy in place which identified that more needed to be spent. The then Minister for Finance promptly said there would be no more money, as have his predecessors since. We are spending between 0.5% to 1% of GNP less on health care than most of the equivalent rich countries in Europe. We have a great deal of catching up to do and should, in the short term, be spending more than those countries to generate capital provision to build the hospitals, provide the beds and allow for an adequate number of nurses.
We should spend a bit more than other European countries, which spend between €1 billion and €1.5 billion or more per year. We must spend that amount on health care if we are to provide the beds and staff. No amount of management, window dressing or short-term thinking will get away from that fact. The crisis in accident and emergency services is a symptom of under-provision and will continue to be so. We need 2,300 extra acute beds. Once we get them, the pressure will begin to decrease. At the same time, we must put together a decent primary care service with adequate access for the less well-off. These two measures, taken together, would take the heat off accident and emergency departments.
We have spent eight years looking at this problem, the crisis has blown up every year and a new solution is suggested every year. However, the crisis blows up again the following winter because we will not deal with the fact that the service is under-resourced, under-funded and, in many cases, badly managed.
Kathleen O'Meara (Labour)
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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.
Geraldine Feeney (Fianna Fail)
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I welcome the Minister of State, Deputy Conor Lenihan, to the House. I have been looking forward to the debate and am pleased to be here. None of us can deny that the country's accident and emergency services are in serious crisis. The Tánaiste put up her hands and said so. I was shocked when she said that at least 1.2 million people visit accident and emergency departments every year. The media and the whole country seem to have little else to discuss. We all know that serious remedial action must be taken.
The Tánaiste has outlined some of the causes of gridlock in accident and emergency departments. The following factors also have an impact: Lack of investment and closure of hospital beds in the 1980s; increased population; increased life expectancy; curtailment of after hours service by GPs; and the increased level of self-inflicted injuries, particularly at weekends by younger people engaged in binge drinking, using drugs and acting violently. In a paradoxical way the crisis is partially due to increased prosperity which has resulted in rapidly increased population numbers, greater life expectancy and more spending power. The Government, the Health Service Executive, and the medical and health professions must all work together to urgently deal with this grave situation.
Last year in this House I suggested the possibility of doctor-only medical cards and I am pleased that the Government, in its wisdom, announced the provision of such cards in last December's budget.
Geraldine Feeney (Fianna Fail)
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While my colleague on the Opposition benches is smiling now, I did so. Fine Gael claimed the credit when the party announced a similar initiative after I did so. I understand the cards are almost ready for issue. All sensible people must agree this is a very positive step, which will help many people on marginal income and considerably alleviate problems in the accident and emergency services.
Unfortunately, some GPs seem to be behaving like spoilt children. They want to make policy without seeking election instead of implementing good policy initiatives of a duly elected government. Of course, they really want more money. They are wrong and should not hold up this initiative. Moreover they should not be allowed to get away with it. People should condemn this small number of GPs for their action. Equally, some consultants are making threats of non-co-operation and strikes. Professor Niamh Brennan was aghast when she reported on the consultants' contracts. I was pleased to read this week that the consultants' contracts are now being reviewed and I hope this leads to change.
If we wish to make serious improvement in the health service and in particular in the accident and emergency service, politicians, the Health Service Executive and the various professional bodies must try to forget personal often greedy needs and work together for the common good. The HSE has a new chief executive, Professor Brendan Drumm, whom I congratulate. Somewhat like the late Pope, I have only heard good of him. He has the added advantage of coming from my area of Sligo where he grew up and received his education. I wish him well in the hard task ahead of him. His reputation goes before him and I am sure he will do an excellent job.
Accident and emergency services at the Mater Hospital received much media attention last week, particularly on Joe Duffy's radio programme. Various businessmen phoned in to offer items free of charge. However, for some reason these had to be turned down. Arising from that programme it has emerged that the Mater Hospital has sought additional funding to help its accident and emergency department. I hope such funding will be made available. Given the crisis in accident and emergency services and the genuine concern of the public, I ask the Tánaiste to consider that case and try to give it additional funding.
The VHI is to establish minor injury clinics, one on the south side and one on the north side of Dublin. Senator Henry has problems with these and has asked what would happen to a patient with major trauma if that condition were not identified. I believe this will be a positive development. They will handle minor injuries and will alleviate the strain on accident and emergency departments.
I was pleased to hear the Tánaiste confirm she supports older people staying in the home setting and where possible keeping older people at home. I am a member of the National Social and Economic Forum. Senator Kate Walsh and I are members of a sub-committee for care of the elderly. Some very innovative ideas are coming from that group. It is good to know that the Tánaiste and Minister for Health and Children is supportive of that work.
I welcome the inspection report from the Health and Safety Authority on accident and emergency departments. More reports are to follow which is good. When I was a member of the health council we inspected accident and emergency departments. We were very critical of many of them and praised the ones that deserved praise. The inspections are done in the interest of safety and I am glad to see them happening.
The Tánaiste mentioned that we would spend €1 billion more on the health services this year than we did last year. It is worth mentioning that on a per capita basis we are ahead of countries like Germany, Italy, Belgium and France, to name a few. The Tánaiste stated that less than 10% of people who access accident and emergency departments end up on a trolley for more than 24 hours. She related a nice story from a man who told of his mother being in and out within two hours. While we often hear of the tragic stories we seldom hear the good stories. As I have said before in the House, St. Luke's Hospital in Kilkenny, under the stewardship of Dr. Gary Courtney, has a wonderful blueprint for accident and emergency departments and this should be considered for other hospitals.
John Paul Phelan (Fine Gael)
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I am interested in the Senator's last comment about St. Luke's Hospital in Kilkenny. This morning I spoke to the doctor in charge of the accident and emergency department and he did not have such a rosy——
Geraldine Feeney (Fianna Fail)
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Did the Senator speak to Dr. Courtney?
John Paul Phelan (Fine Gael)
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I spoke to the doctor in charge of the accident and emergency department.
John Paul Phelan (Fine Gael)
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I know Dr. Courtney and I have spoken to him several times about the facilities in the hospital. Several of those in charge of the accident and emergency department of St. Luke's Hospital to whom I spoke this morning expressed serious reservations about the facility and noted significant problems with it. I will address these a little later.
I am surprised and disappointed that the emphasis of Government Senators appears to be on the amount of money being spent on the health service. Senator Feeney, for example, listed a number of countries which spend less per capita on health than Ireland. Despite this, our health service is much worse than that of the countries mentioned. We have spent more per capita than other countries for several years but place no emphasis on achieving value for money or obtaining a return on investment.
All Senators have heard horror stories about accident and emergency units and this debate offers a welcome opportunity to raise the serious issues involved. The problem in our accident and emergency facilities revolves around overcrowding, as mentioned already, which is a function of the increase in the number of patients visiting the units, and blocked access, which is the problem of finding beds for incoming patients. These two separate issues are sometimes confused or no distinction is made between them.
In preparing for this address I spoke to several people who work in the health service in St. Luke's Hospital in Kilkenny and Waterford Regional Hospital. I was impressed by one doctor who referred to the system of key performance indicators operated in Australian and New Zealand accident and emergency departments. Once patients have seen a triage nurse, they are graded according to the gravity of their condition and placed in one of five categories. A period of time is indicated for each category within which patients must be seen by the doctor on call. A similar approach could be adopted here with great effect. The so-called Manchester system introduced in some Dublin hospitals to grade patients has not worked to date.
The time patients must wait before being seen in accident and emergency units is a serious problem. Thankfully, the last time I attended an accident and emergency department was a couple of years ago. Even then, however, I had to wait several hours before being attended to. My secretary told me this morning that she attended the accident and emergency facility in St. James's Hospital around two years ago and spent two days, most of it attached to a drip, sitting on a chair in the waiting room. This occurred during the first crisis in accident and emergency departments which struck in the winter of 2002 or thereabouts. Unfortunately, the problems experienced in hospital accident and emergency units each winter have not been satisfactorily addressed by the Government.
I admit that when the Tánaiste, Deputy Harney, was appointed Minister for Health and Children I was confident she would achieve change because I regarded her as the right person for the job. I expected action following the years of dillydallying under the previous Minister. After eight months with the Tánaiste in charge I regret that little action has been taken.
Geraldine Feeney (Fianna Fail)
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The Government has another two years.
John Paul Phelan (Fine Gael)
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I am also disappointed by some of the comments on the problems in the health service. Senator Minihan's statement that money continues to be the major problem is incorrect. While I acknowledge that health expenditure has increased considerably, the main problem in the health service is not funding but the absence of value for money and service improvements. It is clear the health service has disimproved in the eight years in which Fianna Fáil and the Progressive Democrats have been in office.
The Tánaiste may have occupied her current position for just eight months but she has been at the Cabinet table for eight years of unprecedented economic growth, during which many billions have been spent on the health service. The service has deteriorated at a time when significant improvements should have been expected. While I hope the Tánaiste will be able to reverse this trend in the coming months, I am not convinced by anything she has said in recent weeks, including her speech this morning.
Senator Feeney is correct that St. Luke's Hospital in Kilkenny is run by a dedicated group of medical practitioners. The hospital is largely a victim of its own success in that issues and problems which arise are addressed quickly before they can become national issues. During a conversation this morning, one of the hospital's doctors described the five cubicles in the accident and emergency unit. Only two of the cubicles are suitable for use in an accident and emergency facility because one has no equipment, a second, the resuscitation unit, is equipped solely for resuscitation purposes and an emergency fire exit is located in the corner of a third, a highly unsatisfactory position given that trolleys may block access in the event of an emergency. Urgent action is needed to solve this specific problem. All is not rosy in St. Luke's Hospital. Despite the best efforts of staff, a serious problem remains as the facility is hopelessly outdated and overcrowded. The accident and emergency unit, which deals with almost 30,000 patients per annum, has only five cubicles, just two of which have dedicated equipment. This is wholly inadequate in this day and age.
The doctor to whom I spoke is not Irish and worked for many years in the Australian health service. When I asked him to compare facilities in St. Luke's Hospital with those in Australia he told me the former were about 15 years behind the latter. Much work needs to be done and many hard decisions taken. While I extend my best wishes to the Tánaiste and Minister for Health and Children in taking these hard decisions, I have not been impressed by what I have seen and heard thus far.
Geraldine Feeney (Fianna Fail)
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On a point of order, I was not referring to the accident and emergency department of St. Luke's Hospital. I was misquoted.
John Paul Phelan (Fine Gael)
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I apologise if I misinterpreted the Senator.
Cyprian Brady (Fianna Fail)
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I am grateful for an opportunity to debate the issue of accident and emergency services and welcome the Minister of State to the House. I congratulate the Tánaiste and Minister for Health and Children on putting herself forward for a portfolio which everybody accepts is particularly difficult.
As is evident from the contributions, Senators on all sides accept and realise that problems remain with regard to the lack of progress in tackling the issues surrounding accident and emergency services. This issue must be considered in the context of the health service as a whole. The accident and emergency service is just one piece of a complex jigsaw. If one piece is missing, we do not have a complete picture.
Major strides have been made in recent times to resolve the problems in accident and emergency units and I welcome Senator John Paul Phelan's admission that money is not the problem. In recent years, major changes have taken place in the health service in general, with improvements in cancer and cardiac services, provision of enhanced mental health services and community rehabilitation units as well as additional respite day and long-term day places for the physically and intellectually disabled. Ireland is recognised worldwide for its efforts in research and development. All these developments have occurred over time.
The accident and emergency service is the first port of call for most people. It is the coalface of our health service and therefore its most important element. A vast number of dedicated, committed, highly-skilled people work in the health service, particularly in trauma treatment and accident and emergency services. In general, these workers want to provide a top-class service to the public and it is our task to assist them to do so. All efforts made, and I refer again to the efforts made by the Tánaiste and Minister for Health and Children in the short time she has been in the portfolio, have been directed towards enabling workers in the health service to provide that service.
A number of Members have mentioned that financial, accounting and resource management are the key to the provision of such a service. Demands on the health service have changed. People now live longer. If we are to provide an adequate service, there must be future planning. This is a key issue. The Brennan report stated there was "a managerial vacuum at the centre of the health service" and "an absence of a system of structured accountability".
These are the issues we must tackle. The provision of staff, facilities and adequate backup systems are also issues, but we must plan for the future. Senator Ryan pointed out that we are in our current situation with accident and emergency services in particular because no forward planning was carried out back in the 1980s. Things were tight and decisions which have proved to be inadequate were made based on the situation at the time. We are still playing catch-up, despite the huge investment over the last number of years and the commitment of this Administration and its predecessor to tackle the problems. Previously, successive Governments had failed to tackle the problems head on and failed to provide adequately for them.
I welcome the establishment of the Health Service Executive from 1 January 2005, which was another recommendation from the Brennan report. It will go a long way towards centralising responsibility and will concentrate on the day to day administration of the health service without becoming involved in policy or future planning. That is the responsibility of the Minister and the Department of Health and Children. The Health Service Executive will provide adequate facilities and backup for the day to day running of the health service.
Senator Feeney pointed out that more than 3,300 people per day or 1.2 million people per annum are treated by our accident and emergency services. The Tánaiste highlighted a number of steps which are worth repeating. For example, she mentioned the 500 step-down places in private nursing homes, which is a major issue. Every hospital in the country will admit there are people in hospital who should not and do not need to be there. Tackling this issue is only one part of an overall strategy. The GP out-of-hours service is another issue. I could not believe that the GP service stops at 5 p.m. People have no alternative but to go to accident and emergency departments at the weekend. There is nowhere else to go. I am glad the Tánaiste's discussions with the consultants on working hours are continuing. She is also continuing her discussions with nurses and nursing unions. Great efforts are being made and all these elements are essential.
I welcome the health and safety report on hospitals. It is a positive and progressive step because it points out the inadequacies in the system. Over the years, I have heard people say that the winding down of the involvement of religious orders in staff training and day to day running of hospitals is an element of the problem. Our approach and the demands on the system are changing. Huge resources are being put into major cleaning contracts in hospitals. Cleanliness is an important issue, as we can see currently in the UK.
As Senator Feeney has stated, major issues exist, which we could debate for a longer period. While everyone accepts there are still problems, major steps are being taken to resolve them. No one should be left in the position currently faced by some people. We hear the horror stories but not the good news. For example, last Saturday night, there were four people on trolleys at one stage in the Mater Hospital in Dublin. We heard no mention of that. This is a priority for the Government which it will tackle.
David Norris (Independent)
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I will not pretend I have the wisdom to resolve this problem, but I have some comments to make. I welcome the Minister of State at the Department of Foreign Affairs, Deputy Conor Lenihan, to the House. In particular, I wish to show some solidarity with the Tánaiste and Minister for Health and Children, Deputy Harney. She has shown great courage in seeking this job for herself. Politically, it is regarded as a poisoned chalice. She is a remarkable woman who previously made inroads into other complex and difficult areas in a very practical manner. I hope she is also able to do this with the health service.
It is clear that the health service needs structural reform so that the taxpayer receives value for money, which I do not believe we are getting at present. The health service needs to be examined in a structural fashion because there is a kind of systemic failure therein. I believe the Tánaiste and Minister for Health and Children used a similar phrase. The service requires radical examination and overhaul.
There is also a political dimension to this matter about which politicians have not shown courage. We have the Hanly report and know perfectly well that its recommendations are the way forward. There is no question or doubt about it. However, every local interest pops up to say "not in my backyard" and that the local hospital should not be affected. Undoubtedly, this is a vote-getter, and one has hospital candidates as a result. As far as the voters are concerned, it is perfectly understandable. Their fears are encouraged and whipped up for electoral advantage, which is a mistake. We must rise above that and look at the entire system. If radical measures are necessary, they should be taken.
An entire series of issues exist such as, for example, the inappropriate use of facilities because of pressure on the system. Many elderly people are held as long-term chronic patients in hospital. It is unfair and wrong to call them "bed-blockers", which is insensitive language, but that is the effect. One of the matters we should examine is getting people into the most appropriate area and facilities for their proper treatment.
The issue is receiving great public attention and I have referred to this in its political dimension. The media are also involved and sometimes they do a good job by highlighting particular issues. Sometimes however, it can be overdone and I must say that Joe Duffy's radio show did so, with its offers of trolleys from Ben Dunne. It is a pity Maureen Potter is no longer with us. I am sure that she could have had quite a few——
Rory Kiely (Fianna Fail)
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The Senator should leave personalities out of the debate.
David Norris (Independent)
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She is deceased. We can talk about her because she is dead. I am only saying good things about her.
Rory Kiely (Fianna Fail)
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We should leave her name out of the debate, dead or alive.
David Norris (Independent)
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Maureen Potter would have had great play with Ben Dunne and his trolleys.
David Norris (Independent)
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I also wish to say that we now have very high expectations. We appear to have forgotten we are perishable goods and have some degree of responsibility for our own behaviour. Apart from issues with facilities, staffing and safety precautions, one of the critical problems for accident and emergency departments is the atrocious and unacceptable behaviour of people who are high as kites on drink and drugs. Such people will not stay where asked, will not co-operate with medical procedures and attack the nursing staff. That is unacceptable.
David Norris (Independent)
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People who cause a fracas and consequently cause danger and risk to other seriously ill patients should be arrested and charged.
1:00 pm
David Norris (Independent)
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I have damn-all sympathy for them. There is a question of our own behaviour as citizens. The health service has changed. I listened to the Tánaiste on the monitor in my office and she mentioned the time when one used to ring up and ask which hospital was on call. It would have been either the Mater Hospital or St. Vincent's Hospital, in the north and south of the city. Now there are six hospitals on call. Much of this is the result of riotous behaviour at the weekends, which must also be addressed.
There are safety issues in accident and emergency departments that need to be addressed. I am aware that the issue of safety is problematic and that accident and emergency departments should be there for traumatic situations where there is perhaps a justified panic on the part of the patient or relatives. These are precisely the circumstances in which safety issues must be managed. The idea of having locked doors, barred access or trolleys clogging up accident and emergency departments is ridiculous. What would happen if there was a fire or if an armed individual under the influence of drugs managed to get in? Hospitals would definitely need to be able to clear passageways and evacuate people then.
Somebody remarked — it could have been a slip of the tongue — that 1 million people per day visited accident and emergency departments. If that figure was true, it would be mind-boggling. I think it is actually 1.25 million people per year. Even that is——
Conor Lenihan (Dublin South West, Fianna Fail)
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The figure is 25% of the total population per year.
David Norris (Independent)
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The Minister of State stole my point but he is very welcome to it. It shows that he is on the ball. To think that one in four citizens visits accident and emergency departments is, to quote Seán O'Casey, "unnatural". Something must be amiss for there to be so many people visiting accident and emergency departments. One of the reasons for it is the way the entire system is structured. When I was younger, GPs were on call at all hours of the day. It was very stressful for GPs and their families but people could phone them at 11 p.m. and they would attend to them, even on a Saturday night. There is now very little GP cover, particularly in working-class areas, so people have no alternative but to visit accident and emergency departments for inappropriate complaints. This issue needs to be addressed.
I support the Tánaiste and believe she is a woman of considerable courage. She has taken on the job of Minister for Health and Children with a sense of mission and purpose. If anyone can do something with this very difficult situation, it is probably her and I wish her well. In tackling this situation, she will have my support and the support of most Senators.
David Norris (Independent)
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I remember within approximately three weeks of the Tánaiste assuming the post of Minister for Health and Children, she was questioned very aggressively about why there were still flaws in the health service. The problems facing the health service will not be solved instantly and easily. It will take time to seriously tackle these problems. While we are correct in monitoring the Minister's progress, it would not be fair to try to issue a final report on her performance until she has had a reasonable amount of time to allow her to address problems. People like myself who are lucky enough to be independent and not susceptible to the vagaries of a rural constituency with a hospital interest or hospital candidate will stand up and state that if the Minister wishes to try to implement things like the Hanly report, she will receive the strongest possible intellectual commitment and support from us.
Margaret Cox (Fianna Fail)
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I welcome this opportunity to debate the issue of accident and emergency services as it gives us an opportunity to mention a number of other issues regarding the health service. The first issue I wish to address is the complaint that the health service is either overfunded or that health service funding is being improperly spent. If we were to examine health system funding today and what we get out of it and compare that with what was spent and received in the past, we would see the additional services throughout the country that we are paying for and recognise that we have a high quality health service. For example, ten years ago, very few people survived cancer. Today, people can survive cancer or extend their life expectancy when diagnosed with cancer due to the full range of oncology services. There is also a full range of support services for cancer patients and their families.
Cardiology is another area where great progress has been made over the last ten to 12 years. Ten or 12 years ago — I know this from personal experience — the prognosis for people who suffered heart attacks was bleak. The situation is much brighter today with advances in cardiac surgery. Cardiac surgery is now available in the west, which was not the case three years ago. A range of services is now available throughout the country which means that those who are seriously ill receive the best care available, better than they would receive anywhere else in the world. I challenge anyone who says that cardiology, oncology and radiotherapy services are better in the United States or anywhere else to produce the proof. We have an excellent health service. It is incorrect to say it is a black hole that drains and misuses funds. While it is heavily funded it produces top quality services.
However, the health service needs more funding. It is time for the Department of Finance and the Department of Health and Children to realise that the system has been cut down to its very bones. There is no fat left to trim. When things go wrong in the health system, it is only possible to provide band aid solutions to problems because there is no excess funding to fix problems. Two or three years ago, there was a problem with an operating theatre that was used for orthopaedic procedures in a hospital in the western health board area. Orthopaedic surgery demands complete clean room environments because of developments in surgery. There was insufficient funding to provide the proper systems in the hospital in question so a quick-fix solution was found. Something then went wrong and the health board wound up spending €300,000 fixing it. If that money had been spent on the original problem it would have been properly solved. However, nothing was heard from the Department of Health and Children because the money had to be obtained from the Department of Finance.
Time and time again, quick fix solutions are used that cause more and more problems and waste money. This happens because there is no opportunity for local management, which understands the real issues, to find solutions that it knows will save money in the long term. Due to lack of access to funding and lack of power to direct where the money is spent, local management is forced to resort to half-hearted measures that never solve problems.
Health service funding must be ring-fenced. Among other things, we are now providing excellent oncology and cardiology services. These services have benefited from strategies that were put in place by various Governments over the last ten years. Not only should funding be ring-fenced, the decision as to how to spend it should be decided at local level. This is my main problem with the Health Service Executive.
While I recognise that we needed reform in the way that the health service is being run, centralised control is not the answer. Decisions need to be made at local level. I understand that the executive's budget has not been agreed, or if it has been agreed, this has only happened in the past few weeks. This situation is unacceptable. When I was a member of the Western Health Board, we worked around the clock from mid-December to 23 January to establish our service plan, agree our budget figures and decide our plans for the year. Why can this local control not continue? Why do these decisions now have to be made by one organisation? I wish to draw the Minister of State's attention to employment levels within this service. While we should not employ people who are not nursing and doctoral staff, we have a significant problem with front line medical staff being unavailable. What will happen at hospital level when we do not have enough people to provide a service to patients?
Hospitals are forced by the cap on public sector recruitment to hire agency nurses or examine other solutions. I will explain how the charging for agency nurses functions. First, they are paid at a premium as they work on a part-time, on-call basis. Second, the agencies must also make money because they maintain a service and cover their people with insurance. This service is invoiced to the hospitals. The cost to the hospital includes the following: the payment to the nurses at a premium; the margin to the agency provided to the nurses at a premium; the PRSI that must be paid as the employer also pays; and 21% VAT. Of hospital budgets, 21% of expenditure in these circumstances on top of PRSI is paid back to the Department of Finance. Has the Minister of State ever heard anything so ridiculous in his life? This makes no sense. For every product bought by the hospitals, such as a €3,000 defibrillator, VAT is paid at 21%. Where does this go? It goes to the Department of Finance. From where does the Department of Health and Children receive its funding? It receives it from the Department of Finance. We are going around and around making jobs for accountants and administrators when we moan and groan that there are too many administrators in the public sector.
It is important to be parochial on these occasions. We do not have BreastCheck in the west. People whose lives could be saved if BreastCheck were available are dying from breast cancer. There is no reason it is not. The Merlin Park Regional Hospital is falling apart due to a lack of capital funding. We have a paediatric unit from the dark ages and there are no plans for continued development and investment in UCHG. This is unacceptable in this day and age. We must have continual planning. I fear the regions are losing out because they do not yet have representation or a public voice in the HSE.
Sheila Terry (Fine Gael)
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I welcome the Minister of State to this important debate. No one here hopes to get sick or hurt or to have a family member with a need to go to an accident and emergency unit this coming weekend, whether in Dublin or elsewhere. If we are unfortunate enough to need such units, we may as well bring our weekend cases with us. We will be there for as much as a day and a night. If one sprains an ankle, requires stitches or falls seriously sick, it is a weekend job.
The overcrowding in our accident and emergency units is in a state that would not be found in a Third World setting. Dublin is the worst, Beaumont Hospital and the Mater Hospital in particular. How can we address this problem? I accept that the Tánaiste has a difficult job and has inherited a bad situation and I wish her well in trying to deal with it. We must examine some of the causes and solutions. One significant cause is that there are 3,000 fewer hospital beds in Dublin now than in the late 1980s. They were taken out of the system and have not been replaced. We must consider our increased population, elderly and otherwise, and address this urgent problem.
The number of elderly people occupying beds in hospitals through no fault of their own was mentioned. We must look after our elderly and I respect that the Tánaiste is trying to do so. However, 400 elderly patients in Dublin hospitals should not be there. They need long-term institutional care. Many could go home if services were available, leading me to another issue. There are no institutional long-stay provisions or community services to allow some of these patients to return home. The lack of community care services is wrong and must be addressed.
Home help hours have been cut in some of Dublin's health districts. An elderly person now receives home help for two hours per week. I do not accept this as enabling a person in hospital who requires home care to go home but this is all some people are getting. I was surprised to learn from a public health nurse this morning that patients are asked to contribute whatever they can towards the costs of the two hours, be it €5 or €12. What type of country is this when we ask people to do this for two hours per week? It is difficult to get home helpers but there are excellent home help workers out there. We must employ and keep them with us but if we cut their hours or cannot employ more people, they will get jobs in other areas. There are 27 elderly people on a waiting list for two hours per week of home help in south inner city Dublin. Community services must be improved if we are to return some of these people to their homes.
We need minor injuries units to alleviate the problems in our accident and emergency services. There is no point in taking up a place in an accident and emergency department if one sprains one's ankle or needs a stitch in one's finger if sitting beside a person with a heart condition, high blood pressure or suffering an asthmatic attack. It was mentioned that acute medical units will be set up in two hospitals but I am unsure what these units will constitute. Will the Minister of State explain what they are? Are they assessment units for minor injuries or sport injuries? Are they acute medical admissions units? A decision has been taken to introduce them into two Dublin hospitals. Will the Minister of State tell us where they will be located?
If the acute medical units will be similar to the unit established in St. James's Hospital, they will be a waste of time. The unit in St. James's Hospital could only transfer patients into an acute medical ward if they stayed there for no more than one week. This reverted to being a long-term ward. If we are to ring-fence units and beds, we must ensure they are available for their intended purpose. I invite the Minister of State to examine the matter of palliative care beds. I support the establishment of special oncology units in two Dublin hospitals because we must provide services for patients who need palliative care. The service is unacceptable at present.
Staffing of nurses in our accident and emergency units is another issue. It is not fair on the patients or the present staff when agency nurses are brought in. I spoke to somebody last night who told me about a friend who was feeling very ill who, for eight weeks, went around different hospitals in Dublin and its environs but was not admitted to any. She went to Beaumont Hospital twice, to the Royal Victoria Eye and Ear Hospital twice, because the problem related to her ears and head, and to two private clinics in Clane and Tullamore. Finally, her sister, who happens to be a nurse, brought her to Blanchardstown hospital and insisted the woman was seen and admitted. She is seriously ill and will spend some weeks in hospital in Blanchardstown. Our diagnostic services leave a lot to be desired. I wish the Tánaiste well and hope she will be able to make improvements.
Brendan Daly (Fianna Fail)
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I join in the good wishes to the Tánaiste and wish her well in the onerous task she faces. The situation is critical but it is not necessary to get hysterical and emotional about what is happening. The problem must be dealt with in a planned and positive way. Investment is required to enable it to be dealt with and it is available now more than ever. It was a joke to hear Ben Dunne on "Liveline" with Joe Duffy saying he would give €30,000 for a prefab. If he had said €30 million, I would have taken him seriously. He seems to have much money to give away but that is a side issue.
I wish to make a case for the accident and emergency unit in Ennis General Hospital. A working plan for Ennis General Hospital was prepared by the former health board, the Department of Health and Children, the consultants and the people of Ennis. After many years work, the control plan for Ennis General Hospital was approved by the Department in December last. The Department has sent the detailed plan, which took professional people many years to prepare and which has been costed, to the Health Service Executive. The top priority in the plan for the phased development of Ennis General Hospital is for immediate action to be taken to deal with overcrowding and the critical situation in the accident and emergency unit in the hospital.
The Shannon Doc service is working very efficiently in Kilrush and other parts of County Clare and it should be possible to establish and attach small minor accident units to such services. Much of the overcrowding, especially in the regional areas, such as Limerick and Ennis, could be resolved if some of the minor injuries people suffer on building sites or otherwise were dealt with in a local acute unit attached say to the Shannon Doc service, one of the general hospitals or one of the hospitals for the elderly. This would alleviate the pressure on accident and emergency units.
Approximately 80% of people who present at accident and emergency units are discharged. Some attend with minor injuries and may need further attention. If a minor injuries unit were attached to the Shannon Doc service in Kilrush, people injured in Moneypoint, Kilrush or in west Clare could get immediate treatment. In most cases, it would only necessitate some bandaging or minor work and would alleviate much of the pressure on the accident and emergency unit in Ennis General Hospital.
It is critically important to push ahead with the development of Ennis General Hospital. The outline development plan is available, the costing has been done and the detailed specifications and so on have been set out in the plan which is to be phased. It is long overdue. The priority in the plan is to deal with the current staffing and accommodation issues in the accident and emergency unit in Ennis General Hospital. I would like the Minister of State, Deputy Parlon, to convey that to the Tánaiste. I wish her well and I hope immediate action is taken on some of these plans which have been in the Department for some time.
Tom Parlon (Laois-Offaly, Progressive Democrats)
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I thank Senators for their good wishes and join with them in wishing the Tánaiste well in the challenging job she faces. There was a suggestion that 1.2 million people attend accident and emergency units each day. Thank God, that is not the case. Some 1.2 million people attend per year. In fairness, the majority receive quite an efficient service but of course there are difficulties, as outlined.
Senator Terry asked about the acute medical units. Comhairle na n-Ospidéal's report on acute medical units published in October 2004 examined the role, organisation and staffing at acute medical and assessment admission units. Acute medical units will be put in place in Tallaght, St. Vincent's and Beaumont Hospitals and the hospitals are finalising proposals for the Health Service Executive.
It should be clear that the Tánaiste has put accident and emergency services at the top of her and the Government's agenda. The Government is committed to improving the public's experience of accident and emergency departments and improving conditions for staff therein. It is extremely important that highly qualified and specialised staff continue to be attracted and retained in this most important frontline hospital area.
Accident and emergency services present a particular challenge to hospital managements. In many instances, an accident and emergency unit is the only area in which the public experiences hospital services. As such, hospital managements must regard accident and emergency departments as the shop window for the hospitals. A much more customer-oriented approach must be adopted by hospital managements, consultants, nursing and other professional and support staff.
Delivery of hospital emergency services is interdependent on the inpatient elective service, day and outpatient care and on community services. The effective delivery of emergency services, therefore, cannot be dealt with in isolation from the delivery of all hospital-based services. The key to addressing the current problems is a whole systems approach which addresses people's needs on a timely basis in the most appropriate setting.
The need for additional acute beds in the hospital system has been well documented. The Government is well on the way towards building up the acute bed capacity in the acute hospital system. It is committed to increasing acute hospital bed capacity, as set out in the health strategy. Since the publication of the health strategy in December 2001, funding has been provided to hospitals to open an additional 900 beds.
A number of new units in acute hospitals throughout the country are in the process of coming on stream. New accident and emergency departments have also been provided under the capital investment programme. For example, a new accident and emergency department opened recently in Blanchardstown. On Monday last, the new accident and emergency department at Cork University Hospital opened. St. James's Hospital in Dublin will have a new accident and emergency department shortly. These developments, together with new day facilities, theatre and diagnostic capacity, will result in improved patient flows through the hospital system and make better use of existing beds.
The Health and Safety Authority, HSA, has completed its programme of inspections of 11 accident and emergency departments. The authority acknowledges that resolving problems in the delivery of accident and emergency services requires a system-wide response. However, the work of the HSA raises many issues for hospitals. The HSA has, however, acknowledged that the hospitals are fully engaged in the process of addressing health and safety in their accident and emergency units.
I am confident the actions being taken by the Government and the Tánaiste, including the provision of new beds will, over time, generate an appropriate, multi-faceted and multi-dimensional response to the problem in accident and emergency units. The Tánaiste outlined her action plan to improve the delivery of accident and emergency services, which will bring about significant improvements in patients' experiences of accident and emergency services.
I trust I have demonstrated that improving the delivery of accident and emergency services is our priority. We will continue to work in the best interests of patients and staff. I am confident we will improve the delivery of accident and emergency services so that patients receive the appropriate treatment as quickly as possible.
Pat Moylan