Ceisteanna—Questions. Oral Answers. - Elective Hospital Procedures.

Ivor Callely


6 Mr. Callely asked the Minister for Health the total number of elective procedures that had to be cancelled due to insufficient bed availability in 1995; if he will give a breakdown of this number; and if he will make a statement on the matter. [11720/96]

Limerick East): Elective admissions have had to be cancelled at times due to an upsurge in the numbers of people seeking in-patient beds admitted through the accident and emergency department. This has been a feature of the acute hospital services over the past few years. Casualty admissions by their very nature are unplanned, and while some admissions through the accident and emergency department can be anticipated, it is not possible to predict when the peaks and valleys will occur.

While full figures are not readily available on a national basis, indications are that no more than one to two per cent of admissions to hospitals nationally would have been cancelled because of non-availability of beds in 1995. This figure would be much the same as in 1993 and 1994.

The hospital service has encountered problems in the provision of accident and emergency services, particularly over the winter period, in the past number of years. This is not a problem confined to Ireland but is a feature in other developed countries also. The causes of the problems which arise have been well documented. The ageing of our population has contributed to the difficulties in accident and emergency departments. The winter period brings its own set of problems for our elderly population. This in turn can lead to an upsurge in the number of patients present in accident and emergency departments requiring admission to hospital. Many elderly patients require acute hospital care initially but much of their recovery period could be spent in step-down sub-acute accommodation.

The shortage of sub-acute beds, particularly in Dublin, has caused problems in that acute hospitals have not been able to discharge patients in sufficient numbers, and quickly enough, to cater for new patients seeking the services of the hospital. This in turn has led to the cancellation of elective admissions to hospitals at times, medical priority being the determining factor. There is nothing new in this. This has been the position for quite some time and has faced successive Ministers for Health.

The successful management of the accident and emergency difficulties includes tackling a number of areas including services for the elderly, services for the chronically disabled and services provided by the acute hospitals which, when taken together, provide a comprehensive and integrated response. I have set out in written replies to Deputy Callely on 8 February 1996 and on 13 March 1996 measures which I took to tackle the accident and emergency difficulties during the winter of 1995-96.

I am concerned that any elective admission to acute hospitals should have to be cancelled and I am confident that the measures recently put in place will reduce the need for such cancellations. In cases where elective admissions are cancelled I understand that hospitals endeavour to reschedule these patients for admission as soon as possible.

I thank the Minister for his response. However, I asked him for the total numbers. I hope he will be able to supply them to me at a later date if he does not have them now. The Minister indicated that problems were due to peaks and valleys which were unpredictable. He also referred to seasonal aspects, particularly winter time and the problems this brings in the context of the elderly. There are several issues relating to this question which I would like to touch on. One is whether there is a clear pattern relating to demands on beds in hospitals. Am I right in saying there is usually a greater demand during the winter months? I understand there are insufficient hospital beds to meet the requirements in the Dublin area — as the Minister has indicated, I have tabled questions on this matter in the past — and this is leading to serious difficulties in accident and emergency departments and in relation to elective procedures. Care of the elderly is also a serious problem. I accept there are recurring difficulties but does the Minister have proposals to address the issues? Surely he will have innovative remedial ways to address this.

He is very sensitive today.

Jack Bourke said you were a great health board member.

(Limerick East): I thank Deputy Callely for his very complimentary remarks.

I will speak to him later.

Has the Deputy checked with the Whip to see if it is party policy?

(Limerick East): As the late father of Deputy Burke, a respected colleague of Deputy Callelly, once said, “strange things are happening in our times”. There is not a contradiction between what I said about accident and emergency admissions to hospital causing disruption and at the same time older people putting pressure on services during the winter months. If an accident occurs in the greater Dublin area and 12 or 15 people with multiple injuries are taken to the Mater Hospital, consultant staff will have to be drawn down to deal with the crisis and there is a possibility that elective surgery scheduled for that day will be cancelled. The policy is to reschedule it as quickly as possible. It is not possible to avoid that and to staff against that eventuality. That superimposed on seasonal difficulties gives us a picture of the difficulties to which the Deputy has referred.

The population is ageing and as the number of people over 65 years of age increases there will be a greater need for health services for the elderly. Many elderly go to accident and emergency units as their first encounter with the health services, others go to their GPs who will seek to have them admitted to hospital. I am not saying that elderly people do not need acute hospital beds during the winter months but their condition can be stabilised very quickly, in a matter of seven or eight days. However, they may need a further week because they may not be quite fit to go home. They do not need the services of an acute hospital but there is no step-down facility.

Last year we addressed this problem and the Deputy will be aware that 200 sub-acute beds were provided in Dublin. Together with better scheduling and ensuring that accident and emergency is a consultant driven service, with better bed management and more movement from acute hospitals to sub-acute services and with the provision of a dedicated unit for the chronically ill young who are inappropriately maintained in hospital year in year out in acute beds, we brought about a situation where patients were no longer on trolleys in hospital corridors and there were not major problems in accident and emergency units in major Dublin hospitals last year. It went close to the brink on a couple of occasions because it is a very difficult problem.

I am not saying that hospitals were not under pressure but there were strategies put in place last year which improved the situation dramatically throughout the country, with the exception of Galway. University College Hospital Galway seems to have a particular set of problems. Officials from my Department have been in consultation with the Western Health Board to see if some of the strategies which were applied in Dublin would be appropriate for Galway. We are evaluating that with a view to applying them in Galway.

I gave the Deputy the percentage of total admissions. The answer to his final supplementary question is between 1 and 2 per cent of that. If I can get the figure I will communicate with the Deputy later.

Has the Minister figures for the percentage of acute hospital beds occupied on an annual basis by patients who should be in step-down facilities or in respite care?

(Limerick East): It is very hard to be definitive. If you ask the patient's opinion he will certainly believe that he should be in Beaumont or the Mater. A GP or relative may think he should be there as well but a consultant will be aware that somebody in greater need needs to be admitted and may believe the person should be allocated a bed in a sub-acute unit or a nursing home. Starting in mid summer last year we examined the situation and it transpired that better managed hospitals had shorter patient stays for treating similar conditions. We were trying to put best practice in place. It is an increasingly litigious society. What happens in practice is that a junior hospital doctor on accident and emergency duty late at night will tend to admit rather than to send a person home, whereas a consultant is more likely to admit people whom he or she considers to be in need of admission and may send others home advising them on appropriate action. In a pilot scheme at St. James's Hospital we brought senior GPs into the accident and emergency department and found that because they had more experience than the junior doctors admissions were reduced considerably because there were fewer inappropriate admissions.

In my view there is no one strategy which will alleviate the problems in accident and emergency departments but a series of initiatives tried in Dublin last year proved effective. I am not saying we will not have difficulties next year but we will be trying out other initiatives and doing more of the same. One bout of flu among older people could have all accident and emergency services in the major Dublin hospitals and all around the country in great difficulty over a period. Before Deputy Harney took steps to eliminate the Dublin smog problem people were admitted to hospital not only in January and February but in November with pneumonia, asthma and problems that were smog related.

I think we have a very good idea of the problem but it is difficult to put a figure on how many people are in inappropriate beds in hospital. Chronically ill young people need to be in dedicated units. If a young person who has had an accident is in a coma for years on end he or she is better off in a unit with dedicated staff and there is a movement in that direction. We did it in Dublin last year and we are trying to extend it to other parts of the country. Some specific patients are in the wrong place and would be better looked after elsewhere. It would be to everyone's advantage if they were moved to more suitable accommodation as this would lead to the full use of acute beds in acute hospitals. In other cases it is a question of medical opinion as to whether an older person should be discharged from hospital after eight days or 12 days. Doctors differ but we try to keep moving forward. We have pinpointed one of the major difficulties and we need to plan in the summer to make sure that we will not be very hard hit in the winter.

Given that the Minister travelled from Dublin to the west, will he come to Cork? A review of accident and emergency services has been carried out by the Department and the Minister would obviously be very concerned about the lack of space, overcrowding and the inadequate number of beds which lead to cancellations. What does he propose to do to alleviate the very serious situation at Cork University Hospital? Under the health amendment Bill additional demands will be placed on the health services. Chief executive officers will not be able to meet seasonal demands and will have no option but to curtail services due to the lack of financial resources.

Part of that question is rather specific.

(Limerick East): We have a devolved system in this country in terms of the delivery of the health services. The first responsibility is on the health board. The health boards are big enough, they meet often enough and there are enough managers to do the job. I do not take kindly to Deputies acting as messenger boys for health boards and telling the Minister about the terrible problems in Cork and the fact they need more money. The first responsibility is on the people of Cork to sort it out.

The consultants are outlining the position to the Minister.

(Limerick East): I am prepared to look at the situation in the major hospitals in any of the health board areas. There are 66,000 personnel employed by the health board services. It is not possible or proper to run them by diktat from my desk. I will alleviate the demonstrated need but I will not get involved in a Dutch auction between health boards. A problem is emerging in Galway where we have allocated extra funds. However, I do not want the other seven health boards shouting for funds, whether they need them or not.

I accept what the Minister said about the social aspects of people being discharged from hospital as well as the need for hospital admissions. Will the Minister agree there are insufficient beds in the system, whether they are in accident and emergency departments, the hospital system or in step down facilities? There is a need to improve the total number of beds available.

(Limerick East): The old fashioned way of measuring the effectiveness of hospitals was to do a bed count. The output of hospitals is more important now, whether from the day care side or the end patient side. If we created another 500 beds in Dublin or throughout the country they would be filled. However, that does not mean they are necessary. There are mismatches in different parts of the country. Extra beds are probably required in some areas but there are probably more beds than are necessary in others, which will always be filled. This might change as the extended family becomes more of a rarity and people rush to put aged relatives into care. However, if beds are free they will be filled.

I ask that my question be kept on the Order Paper for the next day of oral questions.