Vol. 561 No. 1
93 Ms O. Mitchell asked the Minister for Health and Children the measures being planned to deal with the withdrawal of recognition for training purposes of the accident and emergency departments of many of the State's hospitals; and if he will make a statement on the matter. [3515/03]
The standards applying to the training of postgraduates are being reviewed on an ongoing basis. As changes to these standards have implications for service delivery, I established the Inter Agency Care Health Forum to allow those who set standards and those who deliver service to discuss emerging issues. The IAHCF meets quarterly to discuss various issues of concern, including the implications of the implementation of new training standards. The forum is chaired by the chief medical officer at my Department. Comhairle na nOspidéal, the health boards, the Medical Council, the Postgraduate Medical and Dental Board and the training bodies are also represented at the forum.
In June 2002, the Irish Surgical Postgraduate Training Committee of the Royal College of Surgeons of Ireland published guidelines for the recognition of training posts in accident and emergency departments of acute hospitals providing such services. These guidelines state: "The accident and emergency department must be under the clinical and administrative control of one or more emergency medicine consultants devoting the whole or major part (eight or greater sessions) of their clinical time to the day to day supervision and training of the junior medical staff". I am advised that the health boards and the training bodies have, through the inter-agency forum, come to interim arrangements which will allow for hospitals to continue to provide services while arrangements are being put in place to meet the standards required. In general, both the colleges and the Medical Council have adopted a flexible approach when approached by the boards with realistic efforts to meet the standards set. Discussions on the guidelines are also taking place between Comhairle na nOspidéal, the Medical Council and the RCSI.
I would like to have been a fly on the wall when the Royal College of Surgeons in Ireland was persuaded to change its mind from a position where the guidelines were essential to one where they were merely the ideal towards which it would work. Will the Minister outline the interim arrangements to be entered into and how long it will take to put them in place? Will he also indicate if it is intended that every hospital without an A&E consultant will have one? Is it intended that all such hospitals will retain a full A&E service? If some will not, will they be informed and will members of the public be advised or will they be left to ascertain the position in the same way as those in County Monaghan, when insurance cover was withdrawn from Monaghan General Hospital for similar reasons?
Interim arrangements are entered into by health boards and respective individual hospitals in certain locations and they make arrangements with the colleges. From my experience, having met with the Medical Council and the colleges on these matters, once realistic efforts are made by the hospitals concerned to respond to the standards set out in the guidelines, the colleges and the council generally take a flexible approach in terms of the maintenance of services. In some areas, and especially since the appointment of a significantly greater number of A&E consultants in the last two years, they have generally played a supervisory role over hospitals in specific regions. In its review of A&E services last year, Comhairle na nOspidéal recommended that existing surgeons within acute hospitals could also play a role in the supervision of training. Comhairle is currently in discussion with the Royal College of Surgeons in Ireland in terms of the guidelines that have been published in view of what appears to be different perspectives by the Comhairle review and the guidelines issued by the college.
The interim arrangements are decided upon at local level between the boards and the colleges. On a national level, the work of the Hanley committee, the National Task Force on Medical Manpower Planning, will be important in terms of the more medium to long-term scenario that will unfold regarding the configuration of hospital services.
There is no medium or long-term future for the health service unless the Hanley report is speedily implemented. We all know what has been signalled by the committee, indeed what is required has been known for the best part of ten years. The Minister rightly says more consultants have been appointed.
A question to the Minister.
Does he accept that all the problems affecting the health service are concerned with the fundamental question of the appointment of consultants, including where they are to be appointed and in what specialities? The Minister will have to make political decisions on this. If he defers dealing with them he will effectively condemn the health service to collapse. He cannot say they are local decisions between health boards and hospitals because they form part of the fundamental reforms he must implement.
We have run out of time and I ask the Deputy to allow the Minister to make a brief final reply.
I am overseeing these fundamental reforms. It is important to note that the Deputy appears to support the recommendations that might emerge from the Hanley report.
The Minister need not ques tion my support, but let me be appraised of the recommendations before he can presume it.
Almost the entire Fine Gael parliamentary party was instructed to ask questions about A&E units around the country. It appears to be an attempt to play politics with both hands, at local and national level.
It is not too much to ask for this information. The Minister should come clean on his plans for hospitals throughout the country.
That is the subject matter of another question which I will answer later today. We all know that the National Task Force on Medical Manpower Planning has not completed its work. I hope it will be completed next month. I will publish the task force report in full because it will set the agenda in terms of the transition from a consultant led to a consultant provided service, which should be done.
In the short-term.
Yes.
94 Ms McManus asked the Minister for Health and Children his views on the findings of the CAPITA report in regard to the crisis in accident and emergency departments, commissioned by the Health Service Employers Agency and the nursing organisations; the steps he intends to take to address the serious deficiencies identified in the report; and if he will make a statement on the matter. [3516/03]
In early 2002, action was taken by nursing staff in accident and emergency departments of hospitals providing such services. Proposals put forward by the Labour Relations Commission aimed at resolving the dispute included an independent review of the bed management function in acute hospitals providing A&E services. The review was commissioned by the Health Service Employers Agency and the unions representing nursing staff in A&E departments. Its purpose was to help to establish some of the causes of weakness in the system and to provide guidance on how these difficulties might be addressed. The CAPITA report, referred to by the Deputy, is the product of this independent review and was completed on 27 January 2003.
While the report is critical of certain aspects of bed management it found, in general, evidence of good bed management practices around the country. The report is designed to ensure the development of enhanced and uniform bed management practices across the hospital system. Its recommendations are at present being considered by the management and staff sides in the context of the continuing implementation of the LRC proposals.
Improved bed management is one of a range of measures being taken to improve A&E services arising from the LRC proposals. Management structures and procedures have been strengthened, a staffing review is nearing completion while a review of security practices was conducted and its recommendations are being implemented.
A comprehensive range of measures has been taken by the Government which is designed to enhance further A&E service provision. This includes a €41 million investment package in 2001 which provided for the recruitment of additional A&E consultants. Seventeen of these posts have now been filled and the recruitment process is continuing in respect of the remaining posts. It also includes the provision of capital funding in respect of the development and upgrading of A&E facilities in hospitals throughout the country. This will total approximately 14 A&E facilities across the country. New A&E departments will be built or there will be significant extensions to existing departments. It further includes the provision of a chest pain service at St. James's Hospital and minor injury units at Beaumont, the Mater, James Connolly Memorial, St. James's and Tallaght hospitals; the recruitment of discharge planners and patient liaison personnel; and the development of deep venous thrombosis treatment at Beaumont Hospital. These initiatives are designed to improve the delivery of services in A&E departments.
Comhairle na nOspidéal has undertaken a detailed review of the structures, operation and staffing of A&E departments while last year I established an accident and emergency forum to identify urgent measures which could be taken to enhance A&E services in acute hospitals, consistent with the commitment in the national health strategy. The work of the forum helped to build on the existing and proposed policy framework for A&E services as set out in the strategy. A number of short, medium and long-term actions aimed at alleviating service pressures were identified and these are now being advanced by the National Partnership Forum through the involvement of partnership groups at local level.
Will the Minister indicate if he is filled with a deep sense of shame that, yet again, there has been a crisis in A&E departments with the result that patients have greatly suffered? In one instance an elderly woman was treated in an ambulance outside an A&E department because the situation at the department was so grave. Others were made to wait 17 hours before they received the treatment they desperately needed. This is now a perennial experience for patients under the watch of the Minister for Health and Children. I wonder if he is aware that there are reports in today's newspaper about pressure on the accident and emergency department of the Mater Hospital because of bed blocking. Will he not come clean regarding what the report actually stated rather than skipping over what is clearly its most important conclusion – because it is the first – namely, that the lack of rehabilitation or step-down beds is the cause of much of the difficulty, stress and strain in our accident and emergency departments? What has the Minister done about this? It is great to talk about provisions in the future, but where are the significant increases in the numbers of step-down and hospital beds?
There is very clear criticism in the report of the fact that community care services finish during standard working hours and that there is no out-of-hours provision. Has the Minister done anything about that or what does he intend to do?
The criticisms in the report of consultants' practices in hospitals raise issues to which the Minister should respond, especially in regard to the discharge policy of some consultants and the current pressures on consultants to discharge patients early when they are probably not ready to be discharged. Will the Minister address the issue of the high return rate of patients?
I have responded to hospitals that have come up with initiatives to try alleviate the stress on accident and emergency departments, particularly in the Dublin region, which has had acute problems. A significant part of the problem emanates from historical under-provision of post-acute, rehabilitation and continuing care beds. The budget for nursing home subvention and contract beds, for example, has increased dramatically from approximately £38 million in 1998-99 to approximately €102 at the end of 2002. This represents immediate action the Government and I took to try to absorb capacity in the private sector to put spare beds in place.
Many of the district hospitals in the Dublin region closed throughout the 1980s and early 1990s, resulting in a dearth of public sector community nursing unit beds in the eastern region and, to a certain extent, the southern region. We have commissioned a public private partnership to try to get 850 beds on stream within the next two years to increase public sector capacity. Last year we commissioned 50 more beds in the eastern region. That is a key issue and nobody is underestimating in any way its centrality to the overall problem of bed accommodation.
95 Mr. Gormley asked the Minister for Health and Children the reason he has failed to address the crisis in hospital accident and emergency departments despite the setting up of a task force a year ago; and if he will make a statement on the matter. [3777/03]
Last year I established an accident and emergency forum to identify urgent measures which could be taken in order to enhance accident and emergency services in acute hospitals, consistent with the commitment in the health strategy. Participants included hospital management, members of the medical and nursing professions, paramedical and non-nursing personnel, staff representative associations and unions, patient advocacy groups and other interested parties. The work of the forum helped to build on the existing and proposed policy framework for accident and emergency services, as set out in the strategy. A number of short, medium and long-term actions aimed at alleviating service pressures were identified and are now being advanced by the National Partnership Forum through the involvement of partnership groups at local level.
In 2002 action was taken by nursing staff employed in accident and emergency departments in hospitals providing such services. The Labour Relations Commission made a number of recommendations aimed at resolving the dispute. These included the undertaking of a full security assessment in each accident and emergency department in hospitals providing such services; the establishment of a national accident and emergency nursing staffing structures review group to carry out an immediate examination of existing structures and staffing levels in accident and emergency departments; and a review of the bed management function in acute hospitals providing accident and emergency services.
The staffing review is almost complete. A security review has been conducted and its recommendations are being implemented, and the report of the bed management function has recently been completed. That report is designed to ensure the development of enhanced and uniform bed management practices across the hospital system. Its recommendations are being considered by the management and staff sides in the context of the continuing implementation of the LRC proposals regarding accident and emergency service provision.
Improved bed management is one of a range of measures being taken to improve accident and emergency services arising from the LRC proposals. Management structures and procedures have been strengthened, a staffing review is nearing completion and a review of security practices was conducted, the recommendations of which are being implemented.
I outlined in my previous reply a comprehensive range of measures which are designed to further enhance accident and emergency service provision. The measures include the use of chest pain clinics and minor injury units, as we have established; the re-organisation of diagnostic services to ensure increased access to and availability of services at busy times in accident and emergency departments; the appointment of advanced nurse practitioners in acute hospitals; the use of admission protocols to ensure emergency patients will be the only patients admitted to hospital through accident and emergency departments; the appointment of additional personnel to liaise with patients while they await diagnosis and treatment at accident and emergency departments; and the introduction of information systems that record comprehensive, comparable and reliable data on activity in accident and emergency departments. Last year, for the first time in a decade, we increased successfully the bed capacity by 520 beds in the acute side, which was sought for a long time by all involved.
Additional informationI will continue to support initiatives designed to further enhance services and facilities at accident and emergency departments. I am satisfied that the range of measures I have outlined represents tangible evidence of the continuing support by this Government of the development of front-line hospital and emergency services.
Does the Minister accept that he has failed to address the accident and emergency crisis properly? In his reply, he mentioned bed management. Why does the CAPITA report state that only five of the 23 hospitals visited had detailed plans for bed management? Surely that is an indictment of the Minister's policy.
I put a parliamentary question to the Minister about the treatment purchase fund and he indicated that, of the €6.6 million spent on the fund in the last six months of 2002, approximately 17% or €1 million related to indirect payments, indirect patient care and travel. Given that the total sum is $31 million, about €5 million will be spent on travel arrangements etc. The Minister may say the figure does not amount to €5 million, but that is my calculation. What sort of bed capacity could we get for that money? Does the Minister accept that this is a waste of money?
I cannot understand how anybody could say that providing the opportunity for a person who is waiting for longer than 12 months to have an operation is a waste of money, particularly when some people have to wait for over two years.
What about travel arrangements?
The people are not all travelling. Of the 600 patients travelling per month last year, only 200 would have been travelling abroad. The remaining 400 would have been provided for within the private sector in Ireland. The chief executive officer of the treatment purchase fund team is clear that value for money is being attained. The projected estimate for this year is that we will achieve about 7,200 operations through this mechanism.
In terms of the public sector, we have had bed occupancy of anything up to 95%, which is too high. That is why we put in 520 beds last year and provided the necessary funding. Since I became Minister for Health and Children, everybody in the public sector was saying that their premises were full up, they could not take any more patients and could only do so much. Many consultants were saying to me that their capacity to do elective work was undermined by the almost 100% occupancy levels, particularly through medical admissions. Therefore, what we are doing through the treatment purchase fund is identifying capacity in the system, albeit in the private sector, and utilising it for the benefit of public patients who are waiting for more than 12 months for operations.
I am glad to say that many health boards have more or less achieved that target within the 12 month period. In the eastern region we have not yet reached it, but some hospitals in the region are beginning to use the fund quite effectively.
In terms of accident and emergency provision, if we did not take the steps we took over the past three years, in terms of the winter initiative of 2000-01, the additional facilities we put into the major acute hospitals or the additional money that went towards nursing home subvention and contract beds, we would have had an extraordinary collapse in our hospital system.
We must try to deal with the interim and immediate problems, which we have been doing. More importantly, the medium and long-term problems involve the development of a strong post-acute patient capacity response.
