I thank the Chairman for the invitation to attend the Committee of Public Accounts to discuss matters arising from the 2009 Comptroller and Auditor General Special Report No. 70 on emergency departments. We look forward to working with the committee and extending to it every co-operation and assistance in its work.
I introduced my colleagues but in view of the significance of this issue and the public debate that surrounds it, Dr. Cathal O'Donnell, medical director for ambulance services and a consultant in emergency medicine, Professor Gary Courtney, national lead on the acute medicine programme, Mr. Brian Gilroy and Mr. Sean McGrath, national directors, are also attending and are available to the committee.
These are challenging times for our health care services. Demand for services continues to grow year on year and exceeds our capacity to meet it. At the same time we are implementing almost €1 billion in budget reductions in 2011. For example, more than 588,000 inpatient treatments were provided in 2010, which is an increase of 47,000 or 9% over our planned activity, almost 730,000 day case treatments were provided in 2010, an increase of 60,000 or 9% over the 2009 outturn, and there were more than 3.5 million attendances in our outpatient departments, an increase of 200,000 or 6% over the 2009 outturn. During 2010 there were just over 1.1 million individual presentations in the country's 33 emergency departments. Almost one third of those who presented, 369,000 patients, were subsequently admitted to hospital. Data for the first four months of 2011 show an increase of 5,614 presentations and 4,535 emergency admissions when compared to the same period last year.
There are considerable challenges in our emergency departments. It is not acceptable that patients are waiting on trolleys for long periods. The Comptroller and Auditor General's report raised a number of important conclusions on more streamlined hospital processes, community initiatives, the relative cost of emergency department attendances, acute hospital services and regional centres. In my introduction, I will comment briefly on each of these areas.
The national clinical programmes have been established to drive improvements in how services are delivered. These programmes, which are being led by Dr. Barry White, have been established over the past year. The two most significant programmes in this context are the acute medicine programme, which is focused on the management of medical patients who represent the majority of cases requiring admission by emergency department, and the emergency medicine programme.
The focus of the first programme is on implementing key solutions which have been shown to drive major improvements in the care of patients with emergency presentations. This includes standardised protocols, early access to senior decision makers, rapid access to diagnostics, availability of community intervention teams and home IV services and seven day per week discharge planning. This programme will commence implementation in 12 hospitals by the end of 2011. The acute medicine programme document which outlines these interventions was published within the past six months. During 2010 and 2011 there has been renewed focus on implementing a range of service improvement measures and initiatives, such as reducing the length of time people stay in hospital, increasing the numbers of patients receiving day surgery, increasing day of surgery admission, putting in place additional ward rounds by consultants, increasing the number of senior clinical decision makers and putting in place early discharge policies to ensure patients are discharged by 11 a.m.
The programmes include plans to recruit 14 new consultant posts in emergency medicine and 34 new consultant posts in acute medicine to support implementation in 2011 and 2012. The future development and recruitment of advance nurse practitioners will also form part of a comprehensive workforce plan for emergency departments. We have set out in appendix 1 to our submission details on service performance improvements and performance metrics in emergency departments and my colleague, Ms McGuinness, can take members through these. The appendix also summarises the key interventions for the national clinical programmes for 2011.
In regard to regional centres and safety of small hospitals, a critical factor is ensuring that our hospitals and all the services they provide are safe and comply with the appropriate clinical standards. The safety of care must be central in our planning for the role of smaller hospitals within our acute hospital networks. We are regulated by the Health Information and Quality Authority, which set out very clear recommendations in its reports on Ennis and Mallow hospitals in regard to what is safe or unsafe when delivering care in hospitals of this size. We are required to implement the HIQA recommendations to ensure that the standards of care delivered in smaller hospitals are as high as possible and that the type of care provided is appropriate to the clinical setting and the needs of patients. An implementation process has been established which involves all the relevant national clinical leads in critical care, emergency medicine, acute surgery, acute medicine and the ambulance services. The clinical leads have set out what type of patient should go to smaller hospitals, taking account of the level of specialist cover and the volume of care provided in each hospital. The clinical advice of the national clinical leads is consistent with and reinforces the HIQA recommendations for smaller hospitals.
The HSE recognise that changes to the role of smaller hospitals must be accompanied by the commensurate development of our ambulance emergency services. In recent years, the HSE has invested significantly in training ambulance paramedic staff and the number of advanced paramedics has increased from 14 in 2005 to 220 to date. Appendix 2 sets out an assessment of the implications of the HIQA reports on Ennis and Mallow for the delivery of services in our smaller hospitals. Dr. Philip Crowley, director with responsibility for quality and patient safety, can speak further about this key section of the document. Appendix 3 sets out a briefing note on the ambulance emergency service.
Community services and primary care also play an important role in relieving the pressure on emergency departments by providing services in the community which prevent unnecessary hospital admissions and provide hospital patients with appropriate services once they are discharged from hospital. At the end of April 2011, 368 primary care teams were in place. Approximately one third of these teams are well developed and offer a range of services including falls prevention, diabetes and asthma programmes. The remaining teams are in earlier stages of development. Our service plan target is to have 527 teams in place by the end of 2011.
The GP out-of-hours service plays a very important role in pre-hospital emergency care. In 2010 there were more than 899,000 contacts made with the GP out-of-hours services. The HSE carried out a national review of the service in 2010 with a view to driving down costs and achieving greater efficiencies. The recommendations arising from this review are being implemented in each of the four regions. Appendix 4 sets out additional information on these initiatives and performance data associated with them.
I come to the cost of emergency department attendances. The report of the Comptroller and Auditor General found there were significant variances in the cost per attendance at emergency departments nationally. The Comptroller and Auditor General also noted some issues in deriving the costs used and made recommendations such as: the need to distinguish EDs that have diagnostics from those that do not; the need to filter out costs associated with additional services such as chest pain and endoscopy; the need to review cost treatment of streaming units; and the need to review the accuracy of cost capture and design an overhead allocation model.
These conclusions we support and they are being addressed in our approach to costing service in the acute setting and the clinical programmes. ED costs represent on average 7% of total hospital cost. The HSE has adopted the approach of costing all inpatient, day case and ED attendances and has implemented and is implementing full costing on a diagnosis related groups basis, which is called DRG, with the support of the Economic and Social Research Institute, ERSI. This is a standard method of defining inpatient and day case work used internationally. This costing approach takes into account the full cost of treatment, including ED attendance. The output from this costing process is used to influence the funding of the 39 hospitals involved. This costing approach includes the development of a standard cost allocating model for all overhead costs as referred to by the Comptroller and Auditor General.
There has been no common classification of ED activity. The work undertaken in EDs varies from minor injury to major trauma. In some instances ambulance bypass protocols are in place to ensure patients go to the most appropriate facility. The ED programme is looking at the classification of activity in these settings to allow for appropriate comparative analysis and appropriate internal and external benchmarking.
The HSE has undertaken a patient level costing exercise in both 2010 and 2011 as a precursor to moving funding to the patient level. In 2011 the HSE will introduce a pilot project in orthopaedics which involves payment per treatment from July 2011.
The committee will be aware that our hospitals are facing challenges in recruiting sufficient non-consultant hospital doctors across a range of hospital specialties. This is despite a major overseas recruitment drive. There are 4,660 NCHD posts in the Irish health system and, as of 11 July, 80% or 3,750 of the 4,660 posts will be part of structured training schemes run by the postgraduate training bodies and funded by the HSE. The postgraduate training bodies have indicated that they have largely filled - in excess of 97% - posts on their training schemes. The remaining 19%, 910 posts, are service posts and not training posts. The key issue is the extent to which this complement of posts is filled. As of 5 July, 172 posts remain unfilled and as of yesterday, 6 July, that has reduced to 158. While the full impact of any vacancies will not be known until the next rotation commences next week, we are aware that there will be shortages in a number of EDs, especially in smaller hospitals. Hospital management is working with clinical directors in a planned way to develop and devise contingency arrangements which can be implemented if and when required, to ensure any resulting impact on services is minimised and patient safety is maintained. Appendix 5 sets out a full and detailed report on the current non-consultant hospital doctor situation and we can update the committee in the question and answer session.
Members of the committee will be aware that the programme for Government committed to the establishment of a special delivery unit in the Department of Health. The unit, under the leadership of Dr. Martin Connor, will initially focus on the areas of reducing trolley waits in emergency departments and on cutting inpatient, day case and outpatient waiting lists in our health system. Dr. Connor has also been appointed to the board of the HSE, and a dedicated committee of the board has been established to support the implementation work of the special delivery unit.
This concludes my introduction and, together with my colleagues, we will be happy to take questions.
