COMMITTEE of PUBLIC ACCOUNTS debate -
Thursday, 3 Jun 1999

Vol. 1 No. 9

1997 Annual Report of the Comptroller and Auditor General and Appropriation Accounts (Resumed).

Vote 41 - Department of Health and Children.

Mr. J. O'Dwyer (Secretary General, Department of Health and Children) further examined.

Chairman

We will now proceed to the Vote of the Department of Health and Children. I want to focus this discussion. Why is it that, despite the fact that the State is spending 50 per cent more than it did five years ago on health, people are still lying on trolleys in waiting rooms for 48 hours, often with the added humiliation caused by the presence of drunks and drug addicts? Why are dental costs so much higher than in Northern Ireland? Why are there such queues for treatment? We will also deal with the £20 million moved by the Department from one year to another.

Mr. O'Dwyer and I have met many times and the Department has produced interesting documentation which I read carefully. Throwing money at the problem is not the only answer to the queues in accident and emergency wards which so humiliate and irritate people. Is there a problem with hospital administration which leads to this constant difficulty? The number of people using accident and emergency wards has risen since 1994 from 1.13 million to 1.14 million, a growth of 8.3 per cent. Is there an explanation for this? What are doing to get rid of these queues which annoy people so much?

Mr. O’Dwyer

We sent a great deal of material to the committee and tried to put the questions posed in a wider context. As the Chairman acknowledged, there has been an increase. There are numerous factors, such as the demography of the population. There are probably more genuine accidents as a result of changes in society, not least with the increase of cars on the roads. If we look at it in wider terms we can see have the beginning of a significant increase in older people, particularly the over 80s. The interaction between the general practice system and the hospital system is an area which could be contributing to this.

The other issue that arises is the extent to which we have not got the right balance - which we are now seeking to address - between the investment in the different levels of service, particularly investment in facilities which would take the pressure off acute hospital beds. There are two elements to this issue. What is the best way of taking the pressure off our acute hospital beds? Do we need to invest in more acute beds and, if so, what is the nature of them? I mentioned this problem the last day I was here and it is part of a review we are carrying out.

For a number of years we have consistently attempted to improve the management of accident and emergency departments with a variety of initiatives. We provided a number of observation beds. We have also provided a system where an experienced nurse sorts out people into the different categories of immediate or other requirements in terms of trying to enhance both the medical and nursing input to the service.

I readily acknowledge that at particular times there are problems. We are moving into a situation where, in co-operation with the Department of Finance and as part of the strategic management initiative, the two major services that will be reviewed this year and next year are acute hospital services and services for the elderly. These services are being deliberately taken together because they are interdependent.

A review of mental handicap services and dental services has been completed and now we will review the two services I mentioned. In advance of the completion of that review there has been continuing investment. I imagine this issue will continue to receive attention in the Estimates for the year 2000 and beyond. It is a pity from everyone's point of view, the hospital, the patient and the Department, that this does occur. While an investment is required there are other matters which must be considered, including the whole process, the interaction between the general practitioner and the hospital and the extent to which people appreciate the ways in which different problems can be resolved. People appreciate that it is not necessary to go to the accident and emergency department first.

Chairman

People often complain that when they go to an accident and emergency department they have to wait on trolleys for as long as 38 hours. My daughter had an accident last week. She was brought to hospital at 8 p.m. but was not seen to until 2 a.m. the following day and I know many people have to wait to be attended for a lot longer. This department also admits people with behavioural problems. When people are sick they cannot cope with people who are drunk or suffering from drug addiction. Can a separate room be provided for drunk people, etc., to stop them annoying sick people waiting for attention?

Mr. O’Dwyer

In any hospital the accident and emergency department has been designed in accordance with certain operational policies. If we want to pursue the Chairman's initiative, future accident and emergency departments would have to be looked at in a different way. We would also have to examine to what extent we could restructure the existing departments. The Chairman would accept that this is the ultimate open door and whether a person travels by ambulance, car or walks, once a he or she goes in the door, the hospital has to cope with them as best it can.

Chairman

I know that but if a drunk entered a church or an office he would be handled in a different way to quiet people waiting in hospitals. Two years ago I was sitting in a waiting room and two drunks were trying to diagnose my illness. It was not funny at the time and it is not a funny situation to be in.

Mr. O’Dwyer

In this instance the person dealing with it at first hand is damned if they do and damned if they do not. You cannot assume that if a person is drunk they are not in need of medical attention. They may be in need and they often are.

Chairman

I do not dispute that drug addicts or drunk people who are in waiting rooms are there for medical attention. People who are sick will be even more aggravated and upset if, having been already worn out waiting for hours to get attention, they have the added humiliation and annoyance of dealing with people with behavioural problems. That is not the only aspect of this problem. The long hours is the real problem. Why do people have to wait hours for treatment in accident and emergency departments when we are spending 50 per cent more on the health service than we did five years ago? That is a 40 per cent increase in real terms.

Mr. O’Dwyer

People have to wait because, if it is decided that they ought to be admitted, there may not be a bed available for admission. We are trying to cope with that problem. We have just completed a development in Beaumont Hospital which Members have probably read about. In that hospital we tried to provide observation wards or holding facilities but it may not always be possible to do that without major reconstruction work.

The second issue that arises is being able to provide a sufficient level of service. For example, if you have one or two teams on hand and you are unfortunate enough to get two serious trauma cases at the same time, then obviously the team will give their attention to those cases and, as a result, the laboratory, X-ray and other departments can get blocked up very quickly. I can reassure the committee that we are trying to deal with this issue. Every Dublin hospital and major hospital in the country is anxious to do things which would improve the situation. Tallaght Hospital was the last hospital we opened. When designing the hospital we took account of some of the factors the Chairman mentioned, particularly in relation to disruptive patients.

Chairman

I will tell my wife.

Mr. O’Dwyer

I cannot give the Chairman a guarantee that it is operating on that basis. He has raised this issue with me but I do not have the precise information with me.

A possible key to solving this issue is to take account of information we already have. We could free up a number of existing beds and try to make them available as much as we can or we could make a further investment. If we decide to make a further investment it has to be based on the type of bed that will be most effective for that purpose. Both issues are being addressed.

Chairman

If this problem can be solved by investing more money then let us get more money. I am sure my view is shared by the committee. I do not want to throw more money at a problem but end up with the same result, that is, long waiting times. Is there a need for better administration, more streamlining or management at a more senior level of accident and emergency units?

Mr. O’Dwyer

I think you have to be open to looking at that. If we take any one of the hospitals the issue arises as to what is the appropriate number of medical people to have in at any one time. One of the issues we are looking at in a wider sense is the whole question of the future structure of medical manpower within hospitals. When you sit down and talk about this, one of the areas that everybody mentions where we should try to get a start in any new initiative is in relation to the accident and emergency departments. For example, St. James's Hospital has undertaken a number of initiatives in this area, including involving general practitioners. Hospitals have also brought in experienced doctors on a part-time basis and so on.

A combination of three things has to be done. First, investment has to be made in alternative facilities to improve existing facilities. Second, staffing out of hours of the accident and emergency departments will have to be strengthened. Third, the processes which are necessary to underpin it could be further improved. For example, one area that could be looked at is the question of having clerical staff in a support capacity in these areas out of hours, not 24 hours, but perhaps for a longer period than at present. In some cases the tracking and recovery of records etc., the interconnections between the x-ray, the lab and the treating position could be accelerated. Of all the people who attend an accident and emergency department a relatively small percentage have to be admitted. Once a decision is taken to admit them the issue arises as to whether a bed is available.

Chairman

From my own knowledge and experience sometimes there is a bed but the communication between the ward and the accident and emergency department takes a few hours because there is no co-ordination. Is there a need for a general manager in accident and emergency departments who co-ordinates everything and oversees all situations?

Deputy Rabbitte

I cannot answer the Chairman's question and with all due respect I am not sure Mr. O'Dwyer is answering it either. Is there a system whereby the accident and emergency departments report to the Department? Has Mr. O'Dwyer reliable data and information on how bad the situation is?

Mr. O’Dwyer

We certainly have information on an ongoing basis from the major Dublin hospitals. There is a co-ordinating committee for accident and emergency departments under the chairmanship of the Eastern Health Board. It meets on a regular basis and deals with many issues, including sharing of the work between hospitals and so on. We get regular statistics with regard to admissions, length of delays, pressure on beds and so forth. We have quite good information. I do not think it is a question that has been neglected but rather a certain amount of work has been done for a number of years. Between 1994 and 1998 accident and emergency increased from 1.137 million cases to 1.231 million, which is 8.3 per cent.

Chairman

In four years?

Mr. O’Dwyer

In four years. The proportion of people admitted remains relatively steady except at particular times of the year when for medical cases the rate of admission is much increased and there is tremendous pressure on medical beds. This is usually from old people who have particular conditions.

Deputy Rabbitte

What about the primary care and the contribution of GPs? I presume some of those would be repeat cases. Is Mr. O'Dwyer suggesting that a third of the population end up in accident and emergency wards in any given year?

Mr. O’Dwyer

No. The figures I am giving are the accident and emergency attendance. What I am saying is this——

Chairman

What Deputy Rabbitte has said is correct. Some 1,231,593 cases represents one third of the entire population.

Mr. O’Dwyer

That is the number of attendances. There are two problems: accommodating those who have to be admitted——

Chairman

Ireland must be the most accident prone country in the world.

Mr. O’Dwyer

I am not in a position to say whether we are or not. All I can say is that the problem of pressure on accident and emergency departments is a widespread phenomenon. I do not believe anybody has fully cracked it. That is not to say we do not need to improve; of course we need to improve and we are trying to improve.

Deputy Rabbitte

Deputy Durkan put a question earlier in which he made a passing reference to Tallaght Hospital. Mr. O'Dwyer was very quick to correct the record and said it was not a question of funding and so on. I expect my colleagues will bear out the fact that we have had an opportunity to be exposed to more people in the past two weeks than normal. The situation is appalling. There is no other description for it. In the famous election ten years the then Taoiseach said he did not realise how bad it was. I think we are back in that situation. It is difficult given the Chairman's point about expenditure to explain why that is the case. I will give one example. A 62 year old man living alone was referred to Tallaght Hospital with blood clots. The doctor told him it may be life threatening and, therefore, he had better go in immediately. He was left waiting for eight and a half hours unattended to and a fellow patient took him home. They contacted the doctor on his return. The doctor became extremely agitated and intervened with the hospital. He was sent back and seen after two and a half hours. There is a range of anecdotal evidence but I can produce names and testimonies of the people concerned. How can a system operate where a man on his own in life, with no partner and no family, left for eight and a half hours unattended to, frustrated, hungry and in need of going to the toilet is brought home?

Mr. O’Dwyer

That ought not happen. In that case I would like to know if he had any communication from his GP with him, whether the GP made any contact with the hospital before going to the emergency department. If a GP comes across somebody who has a life threatening condition, my understanding is that the GP takes it upon himself or herself to make direct contact with the appropriate person in the hospital and at the very least gives him a letter which makes it clear this person has a serious condition.

Deputy Rabbitte

I cannot answer that question. All that would have meant is that he would jump the queue.

Mr. O’Dwyer

One of the things we have been trying to do all the time in the accident and emergency departments is to sort out - this is where the experienced senior nurse comes in - when the initial screening is done, those who must be attended to immediately, followed by the next serious and so on. It is not unusual for people who have relatively minor, if irritating and worrying conditions, to have to wait for a long period. In this case the admission to hospital has to be on the basis of clinical need. If, in this case, the person had a life threatening condition, whatever it was, they should have been treated on the basis that they might have one, and all the necessary tests should have been done as an emergency.

Deputy Rabbitte

Even if one's suspected illness is imaginary, is one unattended for half an hour while one waits? Is that acceptable, even if one's illness is minor?

Mr. O’Dwyer

No, I said it is not acceptable. I would have thought that, at the very least, there would have been an initial interview with the person, that certain critical information would have been got from him or her and that the situation would have been explained to them.

Deputy Rabbitte

Is it proposed to do anything about the issue of the postponement of operations at the hospital because of the absence of intensive care beds? I do not want to be too specific because the areas covered include procedures for cancer. However, I can give Mr. O'Dwyer details of individual cases where people were sent back without being operated on because of the absence of an intensive care bed at the end of the procedure.

Mr. O’Dwyer

The number of intensive care beds provided in a hospital is based on people's experience and expectation with regard to the number of beds required. I am not aware, for example, that we had any dispute with Tallaght in relation to the number of such beds provided in the new hospital.

Deputy Rabbitte

Is Mr. O'Dwyer saying that he does not have information from the hospital, for example, from the professor of oncology and the senior consultant, about the situation in Tallaght in this regard?

Mr. O’Dwyer

I am trying to deal with the question the Deputy asked about intensive care beds. I was trying to explain that one must go back——

Deputy Rabbitte

It was explained to me that the situation is determined by the availability of intensive care beds.

Mr. O’Dwyer

First, a decision is made with regard to how many intensive care beds are initially put into a new hospital. There is then a further number of beds, which are referred to as high intensity beds. These are just below intensive care beds. I am open to correction but I am not aware that there was any serious difficulty between the Department and the hospital in relation to the provision which was made in that regard.

The second point is that peak demands can arise. There are times when, for a variety of reasons, the particular number of high intensity or intensive care beds is not enough and the situation must be managed. The third thing which can cause a problem is the availability of staff. In this case I do not know whether it was a question that they had the staff but they did not have enough beds or they had enough beds but they did not have the staff. I do not know.

Deputy Rabbitte

Are there not unopened intensive care beds? Is there not unused technology generally in the Tallaght hospital? Mr. O'Dwyer said there is no shortfall of funds. Is it not the case that there are facilities, in the widest meaning of that term, underutilised or not utilised at all because of the financial situation?

Mr. O’Dwyer

The agreement the Department has with Tallaght up to this day is that we opened the hospital on a certain basis. It is disputed whether the amount of money given to support that was enough or otherwise. I would take one view but, obviously, other people take another view. It was agreed, relative to the total capacity of the hospital, that the further services would be phased in over a short number of years. There was no dispute about that.

The position at the moment and the agreement with the board of the hospital is that as soon as the troika or three people whom the Minister appointed to the hospital indicate that the hospital is ready to move onto the next phase, there would be agreement with the hospital on a prioritised basis with regard to how the further services would be brought onstream. It is a question of agreeing that the hospital has got itself into a situation where it is comfortable with the management of the existing facility. There would then be an agreement covering a two or three year period in respect of a small amount of it where the additional facilities that are physically provided for in the hospital would be brought onstream.

Deputy Rabbitte

Is the hospital comfortable? I presume Mr. O'Dwyer saw the public statement last week from Professor Ian Graham.

Mr. O’Dwyer

Yes.

Deputy Rabbitte

That scarcely conveys comfort. It conveys the most serious discomfort and alarm about the situation from a person who commands authority in the hospital.

Mr. O’Dwyer

I can only respond to my dealings with the board of the hospital. Professor Ian Graham was speaking on behalf of the Adelaide Society.

Deputy Rabbitte

I understand that, but does it make his views any less valid?

Mr. O’Dwyer

I am not making any comment on whether they were valid or invalid. I am just making the point that, as of now, the Department has agreement with the board and management of the hospital on a service plan for this year. Everything that was agreed between the Minister and the board in relation to support has been or is being put in place. They are in the process of recruiting a new chief executive. The expenditure is broadly in line with the service plan. The activity level is somewhat higher than in the service plan as of now. The situation is that as soon as the troika, which is helping the board to put the hospital on its feet, indicates that it is time to move onto the next stages, that will be done. That is the position.

Deputy C. Lenihan

I do not know if Mr. O'Dwyer is aware - if talking to people on the doorsteps is anything to go by, this is the case - that the issue of the accident and emergency service is a huge one. One hears many stories. As Deputy Rabbitte said, we are receiving complaints from people at clinics. I am aware of the complaint to which Deputy Rabbitte referred about a person who had a fatal condition. I know of a similar story which is also centred on the Tallaght hospital.

Mr. O'Dwyer mentioned that survey information is available to the Department about the actual levels of delays in the accident and emergency departments of the acute hospitals. Will he make that information available to the committee in terms of the delays people are likely to experience if they visit the accident and emergency departments of the different hospitals with different categories of illness or injuries? I would be interested in that information because these complaints are an enormous source of frustration to all Deputies given the large amount of money being spent on the health services.

One regularly meets people who say that their child went to a hospital because of a sports injury and they waited eight hours before they were seen. I do not suggest these people should get priority over people with head injuries etc. However, it appears nobody in the accident and emergency unit screens people, assures them that they are in a priority order and they will be seen at a particular time or gives them some form of basic medical advice that they should not panic. It appears there is a communication problem.

In the past year I have accompanied people to some of the units. As the Chairman said, it is completely ridiculous that drunks, drug addicts and occasionally people with serious psychiatric difficulties or complaints are running wild in the unit and causing huge disruption to the medical staff who are doing their best and to people who are seeking treatment. It is madness in this day and age that this simple issue of disruptive people in accident and emergency units at busy times, such as weekends, cannot be solved. If that problem cannot be resolved, there is no point having a health service. It is a simple issue and I do not understand why it cannot be sorted out.

Chairman

Given all the talk about the Celtic tiger, people do not understand why this problem is not under control.

Deputy C. Lenihan

It is important to get the information about delays from the Department. Mr. O'Dwyer said he had very good information on the actual delays for the different Dublin hospitals. I would like to see that accurate information.

Chairman

We should seek a report on each of the major accident and emergency services in Dublin, the southern regional hospital in Cork and University College Hospital, Galway. This problem is so acute that the committee may want to hear from people in the hospitals. Perhaps we should go there ourselves to see what the problems are.

Deputy C. Lenihan

I agree.

Chairman

An increasing amount of public money is being spent - 50 per cent more than five years ago, with a real growth rate of 7 per cent per annum or 40 per cent over the five years - yet we have all these problems. We should go behind this. We will write to each of the major accident and emergency hospitals in Dublin, Cork, Galway and Limerick asking them what they think are the problems and solutions.

Deputy Rabbitte

Do Irish hospitals have a management problem? On its face it is difficult to match the increasing expenditure over the last ten years to the public perception of a worsening hospital service.

Chairman

We need a breakdown of the figures also. The figure of 1.23 million is one third of the population.

Mr. O’Dwyer

In the material we gave you, Chairman, we tried to explain the various factors in the increase. I think it is important to bear in mind, in the context of the discussion we are having, that a great deal of the additional investment has gone into services other than hospitals. The pressure has been on us from many quarters, not least the social partners, to try to ensure that other services are brought up to certain levels and developed. As can be seen from the figures we have given, that certainly has happened. I cannot say to Deputy Rabbitte whether there is a management problem but I can say we probably have the same difficulties and opportunities regarding management as any other large system.

It is also important to understand that a main reason, but not the only reason, for the medical manpower forum is to bring about a form of staffing by fully trained doctors that will ensure that any patient in a hospital who requires it has available to him or her at any time of day, 365 days a year, the services of a fully trained doctor. The position at the moment - I think it is important to mention it in this context - is that there is a high dependency in the hospital system on non-consultant hospital doctors, these are doctors who are still in training from a full professional point of view. A great deal of the burden of work falls on those doctors while they are in their training. In the forum the Department is in discussion with all the interests involved, looking at the changes taking place in a lot of areas. We are essentially trying to get an agreement which will produce a structure that ensures we have far less reliance on doctors who are still in training and a far greater number of fully trained doctors. The ongoing argument is not whether we need to achieve that but the best way in which that can be done. We are at a stage where a decision in principle will be reached, I hope, in a matter of months.

In answer to the Deputy's question I would identify a medical issue to be addressed. If a patient goes in at 1 a.m. or 2 a.m., we should be able to ensure a fully trained doctor is available to look after him or her and to ensure all the right things are done. We must also make sure that the necessary support is available to nurses and doctors and we must look at that. The other area is the physical requirements needed to assure safety and comfort to the patient and to give doctors and nurses the best possible chance of doing that.

Going back to Tallaght, a lot of thought went into the design of the A and E department and we would have thought that all the issues which the medical and nursing people raised with us, and experience abroad, were brought to bear on it. I can say that in relation to the physical provision but, specifically in relation to Tallaght, I cannot say how it is being operated. I have no problem making available to the Committee the information to which the Deputy refers, and also the developments which are under way and the proposals for further developments in A and E. That should complement the information which we are proposing to give.

Deputy C. Lenihan

In that data could the Secretary General provide a percentage breakdown of the 1.23 million people?

Mr. O’Dwyer

Speaking from memory, about 20 per cent of those who come to an A and E department require to be admitted, if not long-term perhaps overnight.

Deputy C. Lenihan

Deputy Rabbitte feels the same as I do about Tallaght Hospital. As Deputies we have made inquiries of the management but we get short and cryptic replies, on issues such as the gentleman who spent eight hours there, mentioned by the Deputy. I draw that to the Secretary General's attention. We get curt replies which are far from transparent.

Chairman

I want to summarise. We are perplexed as to why the State is spending 40 per cent more in real terms on health than it did five years ago, yet the services to patients seem to be deteriorating, including accident and emergency and dental services and waiting lists, although there have been improvements on some waiting lists. In respect of accident and emergency services we must go behind the figure and I propose to the Committee that we ask the major accident and emergency hospitals in Dublin, Cork, Limerick and Galway to send us within a month a summary of the problems and solutions as they see them. We will then call witnesses from the hospitals and perhaps we will decide to visit them. Too much money is being spent with too little service to patients, who are usually at their most vulnerable when they visit these hospitals at these times. Specifically, we want to address the question of what special arrangements can be made so that patients are not annoyed, aggravated or have their problems added to by other patients presenting with behavioural problems, whether those are psychiatric or are a result of drink or drugs.

Some 1,231,000 people presented to accident and emergency departments in 1998, which is an increase of 100,000 over four years. We want a breakdown of the categories to see what has led to this increase. How does this compare to the norms in other EU countries for people presenting to accident and emergency departments? Is this an accident prone country or are too many people going to accident and emergency departments who should not go there? We also want to know more about how accident and emergency wards are managed and whether there is room for improvement. I think that is a fair summary of what the committee wants.

Deputy Rabbitte

It would be helpful if there were comment on the role of GPs. Has quality of life or have lifestyles changed so dramatically that GPs are not obtainable and people who should have been treated by their GPs end up in accident and emergency departments, or are referred there by GPs for trivial reasons?

Chairman

We must look at those questions. I asked about dental costs. Why are young children waiting years for orthodontic treatment and eventually people go to the North and get if for half what it costs here?

Mr. O’Dwyer

I wrote to you on 30 April and gave as much information as I could. In terms of moving it forward, in that letter I explained that the chief dental officer in the Department has had a number of discussions with the economics department in UCD to explore the feasibility of a study which would first, establish and compare the prices charged for dental treatment in the Republic and Northern Ireland and, second, establish and evaluate the factors which are contributing to higher prices in the Republic.

Chairman

The prices are not just higher; they are twice the price.

Mr. O’Dwyer

They are higher. We hope to get that initial study undertaken anyway and to have the results by the end of this year.

Chairman

Excellent. You will report to the committee when you get those results. At least we are getting the matter studied and creating pressure to get it addressed. We cannot have such long queues for orthodontic treatment because the costs here are so much higher than in Northern Ireland without an explanation.

Mr. Kenny, on the question of the £20 million which the Department of Health and Children, in breach of all the procedures, transferred from one year to another, the committee wrote to the Secretary General of the Department of Finance on 15 March and he has not replied. We asked him what penalties were contemplated to deal with this sort of situation in future and we asked him for a reply within a month.

Mr. Kenny

The reply is being prepared in the Department at present. We apologise for the delay. I do not have any information as to what will be put in place but the Department will come back to the committee on it.

Chairman

We asked on 15 March for a reply within a month. The committee expects Departments to reply on time, as it has made clear repeatedly. We ask the Secretary General of the Department of Finance to come before the committee on this day fortnight to respond personally. He should tell the committee what proposals there are to introduce penalties where financial procedures are breached by Departments or Accounting officers by transferring money from one year to another.

I propose that the committee notes the accounts of the Department of Health and Children. Notwithstanding that, we will return to the question of accident and emergency services in a month when we receive the replies from the hospitals. In any event, we can discuss this further under the general health sector report of the Comptroller and Auditor General.

Mr. O’Dwyer

I want to make two requests. In view of the new arrangement, I would like to see as soon as possible a transcript of the proceedings.

Chairman

It will be supplied to you as soon as it is available.

Mr. O’Dwyer

I feel that perhaps I would be in a position to be more helpful to the committee if, even a day or two beforehand, I could get some notice of the issues. I certainly would like to be better prepared. I would appreciate if that can be done on any occasion. Thank you, Chairman.

Chairman

It is hard to anticipate the questions which will arise.

Mr. O’Dwyer

Not the questions but the broad issues.

The committee noted the Vote.

The witnesses withdrew.

The committee adjourned at 12.15 p.m.