Dáil Éireann debate -
Tuesday, 10 May 2005

Vol. 602 No. 1

Private Members’ Business.

Accident and Emergency Services: Motion.

Dr. Twomey

I move:

That Dáil Éireann recognises the:

—work of nurses, doctors and staff of accident and emergency units who work under severe pressure each day;

—recent report published by the Health and Safety Authority, Health and Safety Authority Inspection Programme in Accident and Emergency Units March-April 2005, which stated that "the health sector, and more particularly accident and emergency units, is at major risk" of workplace violence and that "the current arrangements for protecting workers from this risk were inadequate";

—increasing problem of intoxicated persons turning up in our accident and emergency units; and

calls on the Government to:

—implement health and safety procedures for staff and patients within the hospital environment;

—deal with the escalating alcohol fuelled aggression and abuse that is becoming endemic in our accident and emergency units with the following measures:

—introduce separate "wet rooms" where those found simply to be drunk, following a medical assessment, but not ill or injured are isolated from the other patients and medical personnel and left to sleep off the effects of their drinking;

—have extra gardaí present in accident and emergency units on Friday and Saturday nights when the throughput is highest;

—introduce a new offence of "threatening, abusive or insulting behaviour in or around an accident and emergency unit" which would be subject to an on-the-spot fine of €200, to be imposed by the gardaí on duty in the accident and emergency units;

—remove hangers-on who are under the influence of alcohol from the accident and emergency unit, as these add significantly to the tension and stress; and

—double the charge for visiting an accident and emergency unit for those who are found simply to be under the influence of alcohol and are not actually ill or injured.

I propose to share time with Deputies Pat Breen, McCormack, Crawford, Olivia Mitchell, Deenihan and Hayes.

I thank the Ceann Comhairle for the opportunity to debate this important motion. Tonight's debate continues Fine Gael's determination to jolt Fianna Fáil into action on the ongoing crisis in our accident and emergency departments both in Dublin and countrywide. On this occasion I will not focus on the overcrowding issue whereby thousands of patients annually receive their full course of medical treatment on trolleys in accident and emergency units. Nor will I dwell on how this overcrowding contributes to the lack of hygiene and the difficulties in cleaning up vomit, faeces, urine and blood in accident and emergency departments. I will not deal with the medical assessment units, minor injury units or MRI facilities, which have become so important to the Tánaiste and the Government as they put a spin on their efforts to deal with the crisis in the hospital sector.

In focusing on the role alcohol plays in contributing to the accident and emergency crisis, I begin by observing there is no problem with those persons who enjoy a sociable few drinks on a weekend night. Problems emerge where alcohol leads to violence, aggression and abuse. Patients semi-comatose or aggressive as a consequence of excessive drinking terrify staff and other patients in accident and emergency facilities, especially children and the elderly. The taxpayer, meanwhile, is left with a bill of €600 million at the end of every year.

The recent Health and Safety Authority report shows the health sector, and accident and emergency departments in particular, face a high risk of workplace violence and that current arrangements are inadequate. The HSA is only responsible for the health and safety of workers. The Minister and the Government are responsible for the terrified elderly patients and the sick children scared out of their wits when they have the misfortune to require the services of an accident and emergency facility, especially on weekend nights. The Government has done nothing to prevent the escalation of this crisis.

Families and elderly persons can avoid going into city or town centres late at night but they cannot avoid going to accident and emergency units if they are ill or injured. The treatment they receive there is an absolute disgrace and a poor reflection of the Government's inaction on this matter for the last several years. This Government has refused to face up to its responsibilities on many issues. We have seen the debacle taking place in Dublin Airport with passengers queueing for long periods to pass through security checks.

Minister of State at the Department of Finance (Mr. Parlon)

Has Deputy Twomey checked the waiting times today?

Dr. Twomey

This is another example of the Government's failure to act.

Mr. Parlon

The Deputy is straying from the issue at hand. The waiting times are similar to those in any international airport.

An Ceann Comhairle

Deputy Twomey should be allowed to continue without interruption.

Mr. McCormack

The Minister of State could not say the same about hospital waiting lists.

Dr. Twomey

They will not be published until next year.

Mr. Parlon

It is Deputy Twomey who began speaking about the airport.

An Ceann Comhairle

Deputy Twomey should be allowed to speak without interruption. The Minister of State will have an opportunity to respond.

Dr. Twomey

Since this issue has arisen, does the Minister of State suggest the Government now believes there is no need to build a second terminal in Dublin Airport?

Mr. Parlon

I was at the airport today and was informed by the new general secretary that the waiting times are normal.

Dr. Twomey

A second terminal is required. I merely ask if the Minister of State agrees.

An Ceann Comhairle

I ask the Minister of State not to interrupt when Deputy Twomey addresses the House. The Deputy should ensure what he says is relevant to the terms of this debate. That way, he may avoid provoking the Minister of State.

Dr. Twomey

I thank the Ceann Comhairle and assure him I will extend the same courtesy to the Minister of State when his time comes to speak.

I am sure he and other Government speakers will have much to say on our proposals. I hope no Minister ends up in one of the proposed wet rooms. The measures we propose are necessary to tackle the effect of alcohol abuse on accident and emergency facilities. Nothing is being done in this regard and I hope the Minister of State will address this failing when he gets his opportunity to speak. Alcohol consumption has increased by 40% in the last ten years and the small minority who abuse alcohol has also increased in that period. The problematic effect of such persons' behaviour is evident every night in accident and emergency departments.

Some Government Members may claim wet rooms such as we propose are medically unsound but this would only be the case if they were poorly planned, executed and manned, failings evident in many health facilities as a consequence of Government policy. Fine Gael in Government would ensure such services are properly designed, operated and medically supervised. As it stands, many patients in accident and emergency departments must ask a relative to mind their trolley while they go to the bathroom. What is the Minister of State's view on this?

Mr. Parlon

The Deputy ostensibly exaggerates.

Dr. Twomey

I remind the Minister of State of the case of a patient with lung problems whose condition was aggravated by the presence of a man who was smoking in the accident and emergency department.

Mr. Parlon

There are 1.3 million accident and emergency patients every year. The Deputy points to only one case.

Dr. Twomey

When this patient's relatives asked the man to extinguish his cigarette, he responded with a threat to do so on the patient's neck. Two laws were broken in this instance in that the aggressor was smoking in a confined public place and threatening and abusing other persons. Why are patients exposed to intimidation, violence and aggression in accident and emergency departments? Such has become almost standard behaviour but the Minister of State responds only with glib remarks about the number of patients.

Mr. Parlon

The experience of one patient out of 1.3 million is hardly representative.

Dr. Twomey

I am well aware of the number of patients who avail of accident and emergency services. Unfortunately, far too many complain about those facilities.

Mr. Parlon

Thankfully, the vast majority are satisfied with the treatment they receive.

An Ceann Comhairle

Deputy Twomey should be allowed to continue without interruption.

Dr. Twomey

The Tánaiste has promised to implement her ten-point plan and to consider the recommendations of the HSA. The Government has pledged to support the Minister for Justice, Equality and Law Reform in his efforts to tackle public order offences. He has come up with quite novel ideas about how he will tackle alcohol abuse in society by encouraging people to sit around wooden tables and partake in a café society. There is something of Marie Antoinette in the notion of us all eating ravioli and crostini while society breaks downs around us.

Mr. Parlon

Is the Deputy not aware of the introduction of anti-social behaviour orders?

Dr. Twomey

The Minister for Justice, Equality and Law Reform has also proposed increasing the fine to €300 for anybody who sells chocolate liquors to a child under 16 years of age. These are hardly ground-breaking and effective measures to tackle alcohol abuse. Perhaps the Minister of State will be able to offer some that make more sense when he responds.

The only report the Government has commissioned which has any reasonable recommendations to deal with the violence and aggression of patients who have abused alcohol is that of the national task force on alcohol. None of those recommendations has been implemented. They are far more important to citizens than the many other nonsensical reports, 148 of which have already been published. It is time to bring forward some simple proposals and make them work.

The HSA's report states:

While all departments in a health care setting may potentially be exposed to workplace violence, some are at higher risk than others. Such risk should be assessed having regard to the specific situation and conditions in which each department operates with special attention paid to those departments that are located in highly populated and high-crime areas; small and isolated; understaffed; under the strain of reform and downsizing; working with insufficient resources, including inappropriate equipment; and functioning in a culture of tolerance or acceptance of violence.

Of the 39 hospitals in the country, will the Minister of State, Deputy Parlon, name those on the list which do not fulfil those criteria? Will he name hospitals which are large, well resourced, do not have problems with violence and are not understaffed? Almost every accident and emergency department, many of which I have visited, face these difficulties. All we hear day in, day out is about a ten point plan drawn up last November, yet nothing has been done on behalf of patients.

Patients are my primary concern, but if one looks at the Health and Safety Authority's report and asks who are the potential victims, it states that although all professionals in the health sector are potentially at risk of workplace violence, some appear to be at special risk. Nurses and ambulance staff are at extremely high risk, doctors and support and technical staff are at high risk while all other allied professionals are at risk. If all these people are at risk, patients are in a very dangerous position.

Tomorrow night I hope to have some figures for the Tánaiste on which she can reflect over the weekend. In the past month, 80% of staff in accident and emergency departments said they were exposed to some form of verbal abuse, 56% said it was threatening verbal abuse and 18% of nurses said they were exposed to what they would consider significant sexual harassment while carrying out their job. As I said, I might have other figures tomorrow night, but in the meantime the Tánaiste can dwell on those figures and outline what the Government is doing about this issue.

Mr. Parlon

The wet room will sort all that out.

Dr. Twomey

We would be more than happy if the Minister of State would discuss the proposals with us. We would like him to consider the people about whom we are talking, the 1.3 million people who pass through our accident and emergency departments each year and the 3,500 people who the Government keeps saying use accident and emergency departments each day, in whatever proposal with which he comes up. I am sure people will be delighted to hear the Minister of State does not believe there is a need for another airport terminal.

Mr. P. Breen

I am disappointed the Tánaiste is not here for this debate.

Mr. Parlon

She will be here.

Mr. P. Breen

Good. I welcome the motion which recognises the extraordinary work accident and emergency staff do in difficult circumstances at the best of times, not to mention when they have the added stress of having to deal with drunkenness and abusive behaviour. While the problems of major hospitals are often highlighted, accident and emergency departments in smaller hospitals are also filled to capacity. The same issues apply to smaller hospitals, except they are compounded by a severe shortage of funding. Those hospitals must deal with drunkenness, particularly at weekends, and their security resources are stretched. Indeed, it is only a few years since Ennis General Hospital had to add security people to its staff, which shows a great change in society.

These extra stresses extend to patients. Those who are deserving and in need of the best treatment often face long ambulance journeys to the nearest regional hospital due to the unavailability of a sufficient number of staff and of basic equipment. While patients on trolleys in the Mater or Tallaght hospitals face extreme discomfort, it is small comfort to know that at least they are in the hospital where they will be treated and which has facilities. However, the discomfort of patients on trolleys in smaller hospitals, such as that in the constituency I represent, Ennis General Hospital, is compounded by the fact they may have to remain on a trolley for a few days and then be referred to Limerick, enduring an ambulance journey and a further queue to get the appropriate CT scan. In some instances, there is an emergency case and they must go home and face the same journey the next day.

In the context of the extraordinary and damning wastage of taxpayers' money highlighted in last night's "Prime Time", I am confident the Tánaiste will give a positive response in the next week or so on the capital funding programme for Ennis General Hospital. The hospital has 88 beds. Six of these are in day wards and most of them are filled with in-house patients because of overcrowding in the hospital. Surgery is often cancelled. I spoke to a doctor this evening who told me two patients had their day surgery cancelled on Monday last. I assure the Tánaiste that moneys spent on services for the accident and emergency department in the hospital will be well spent.

Apart from the severe pressure staff must endure in the hospital, they must put up with increasing demands and ongoing threats from the Department of Health and Children to downgrade the hospital, as recommended in the Hanly report, and even to close it. It is no wonder staff and consultants are frustrated by promises in recent years.

According to the most recent figures for 2003, staff dealt with a 5% increase in accident and emergency cases despite the great work done by Shannon Doc and the out of hours GP services in the mid-west region. A CT scan is essential in this hospital so that patients do not have to travel to the Mid-Western Regional Hospital in Limerick, which is over an hour away. As the Tánaiste is aware, the outline development plan for the hospital has been prepared. I hope she will have positive news when she announces the capital programme next week.

Three weeks ago the Tánaiste met a deputation from the hospital committee which included consultants, staff members and Oireachtas Members. They presented a very compelling case in regard to patient safety, which forms part of this motion. The consultants at the hospital were very concerned about patients given the conditions and equipment in the hospital with which they must deal. As we know, patient safety is paramount for a consultant and a doctor.

The deputation also highlighted the population growth in the region and the fact that much of the population is dependent, ageing and needs a considerable amount of care. I do not know if the Minister of State's Department was included in last night's "Prime Time" on the waste of money but I hope funding for the hospital amounting to approximately €20 million will be included in the Tánaiste's announcement of the capital programme next week. I remind her that the hospital manages its budget efficiently. It is a well run hospital and meets the criteria for funding laid down by her Department. She recognised that at the meeting three weeks ago. I remind her of remarks she made that any hospital run efficiently would be rewarded, and Ennis General Hospital has a strong case. I urge the Tánaiste when she announces the capital programme in the next few weeks to think of Ennis General Hospital and the words of Dr. Hennessy at the meeting that patient safety is vital.

Mr. McCormack

Like Deputy Pat Breen, I am disappointed but not surprised that the Tánaiste is not here, as is her duty, to respond or listen to this debate on a very serious topic.

Mr. Parlon

She will be here in approximately ten minutes.

Mr. McCormack

She could have got one of her €1 million per year advisers to stand in for her in whatever she is doing.

Mr. Parlon

I assure the Deputy I will inform her of whatever he raises.

Mr. McCormack

She should be here to listen to the debate and to give this serious matter the attention it deserves.

Everyone recognises that since the Tánaiste became Minister, the situation in accident and emergency departments has got considerably worse. Many people are on trolleys overnight and sometimes for up to 30 to 40 hours. At University College Hospital, Galway, the situation has got progressively worse since the Tánaiste took office. There has been much public relations, spin and ten point plans but no improvements in the health services. The illusion is being created by the Government and, indeed, the Tánaiste that there is no problem or that something is being done to solve it. However, nothing is being done about this intolerable situation and the service for patients has got considerably worse.

People are scared if they have to go into hospital. They are scared of being left on a trolley. Even if they are lucky enough to get a bed, they are scared of contracting the hospital bug which is being contracted by a large number of patients in many hospitals. Two Members of this House contracted the hospital bug in recent months after a short stay in hospital.

This is the situation we face. The Tánaiste and Minister for Health and Children, who took on the job, has done nothing to alleviate people's fears. Lately, she has advocated putting more beds into wards to relieve people on trolleys. Nurses and doctors are already at their wits' end trying to cater for hospital patients. Recently, the businessman Ben Dunne made an offer on Joe Duffy's radio show to provide portacabins to relieve overcrowding in Dublin's hospitals. The solution is much easier than that. The last time I checked, 68 beds were left unused at University College Hospital Galway. More than 30 beds in St. Mary's ward and 20 beds in St. Finbar's ward were empty, as were eight beds in coronary care and St. Pius's ward as well as seven beds in St. Dominic's ward. I have checked on a regular basis and over the past year, an average of 60 beds have remained idle at University College Hospital Galway, while the intolerable situation continues with people on trolleys in the accident and emergency unit. I have called on the Tánaiste and Minister for Health and Children, Deputy Harney, to provide the necessary funds to have those beds commissioned. It would take the equivalent of 50 full-time staff to operate the University College Hospital Galway at its full capacity, which would relieve the situation.

Recently, I put down a question to the Tánaiste and Minister for Health and Children about this matter. This is a tragedy and I am sorry the Minister is not present to hear this. She fobbed off my question. I asked her if she would commission approximately 50 full-time equivalent staff to open the beds at the University College Hospital. She replied that she established the Health Service Executive on 1 January, which has the responsibility to manage, deliver and arrange the beds and that she would pass the question on to it. She simply passed the buck to the Health Service Executive. As there are no health boards anymore, we do not have the opportunity to raise those matters at that level. The Tánaiste and Minister for Health and Children is not taking her job seriously even as far as dealing with a legitimate parliamentary question is concerned. She pretends she wants to put people into wards and that she wants to open St. Bricin's military hospital. I have the solution for her at University College Hospital Galway. All she must do is commission the 50 necessary staff to open 60 beds that are closed every year on average.

Mr. Parlon

The Tánaiste and Minister for Health and Children must also get the money for it.

Mr. McCormack

Yes. So she has stated. However, she also states the country is awash with money. She spends €1 million a year on public relations advisers and other public relations people. She spends €135,000 on one public relations person alone. I do not know what those people are doing. It would be far better if that €1 million was allocated to relieve the situation at University College Hospital Galway and at other situations. The Tánaiste and Minister for Health and Children cannot hide behind a public relations team anymore. I call on her to open those beds.

Last week, I noted that the Minister for Defence was making St. Bricin's Hospital with up to 100 beds available to the Tánaiste and Minister for Health and Children to relieve conditions in accident and emergency departments. In Galway, we have the beds and all we need is the goodwill or a ministerial decision to commission the beds and provide the necessary funds to open them. I note the scandal whereby the Taoiseach and the Tánaiste spend more than €5 million every year on advisers and public relations. That money would do much to open beds at University College Hospital and other hospitals.

Mr. Parlon

They run the country and need the best of advice.

Mr. McCormack

There is no point in interrupting me. I do not know if the Minister of State is the Minister for decommissioning, decentralisation or something else. He is certainly not the Minister for Health and Children.

Mr. P. Breen

He is getting there.

Mr. McCormack

The Tánaiste and Minister for Health and Children continues to preside over the scandal. I want her to check the figures I have provided. One ward, St. Enda's ward, remained closed for a full year, supposedly for painting. The paint should be dry after a year and it is now time to open it.

Mr. Crawford

I welcome the opportunity to say a few words on this very important issue. Last week the Taoiseach assured us there were no people on trolleys in Monaghan General Hospital's accident and emergency section. He is correct. This is because for two and a half years, the Government allowed the hospital to be closed down completely for on-call purposes. It is now on-call for medical procedures but it is still unclear as to who should or should not go there. Certainly, patients who should be treated there are being brought past Monaghan hospital. I make no apologies for stating that. However, it has a so-called treatment room, which I understand will now be called a casualty room that was due to be opened in February. The last action of the previous Minister for Health and Children, Deputy Martin, was to hold a press conference telling us of all the good work the Government did in Monaghan. That treatment room is still not open. In spite of the fact that the Tánaiste and Minister for Health and Children has €11 billion, the funds have not been made available to staff that treatment or casualty room.

Only this week at an inquest, the coroner stated clearly that it was possible the failure to open the treatment room for a patient from just outside Monaghan town could have been the cause of his death. Moreover, a good friend of mine lived at the bottom of the hill beside Monaghan hospital. As entry to the hospital by ambulance was not allowed, he was taken to Cavan and he died on the way there. The Tánaiste and Minister for Health and Children spoke here about real life crises. I want to ensure that whatever Government is in power, the services to which local people are entitled are available to them within the hour. I would be equally critical if the Minister was from my own party. Yesterday, it was stated clearly in the coroner's inquest that whatever chance Mr. Courtney might have had if he been seen to immediately, he had no chance when he went to Dundalk.

When people get into Monaghan General Hospital, they receive a tremendous service. We wish to ensure that the resources are provided and the commitments given are fulfilled. There is no point in having fancy press conferences and making statements if, when one asks a question, one is informed that the politician is not responsible but that the Health Service Executive is responsible. I am delighted the Tánaiste and Minister for Health and Children had joined us in the House, because it is vital that we no longer pass the buck. We should take a hands-on approach. I know that the Minister cannot be everywhere at the same time. There is no point in stating that responsibility rests with the staff or management of Monaghan General, Cavan General or the Health Service Executive. If the staff are wrong at any level, they must be held accountable just as if they worked in Dunnes Stores or anywhere else. We should not retain people who are incompetent and are unable to fully utilise the available services.

Thanks to the Ceann Comhairle, I will speak about Monaghan General Hospital on the Adjournment. On the motion before us, the staff in accident and emergency units do an extraordinarily good job. They deal with a very difficult situation. If one takes Cavan General Hospital, which has suffered because of the——

An Ceann Comhairle

The Deputy's time has concluded.

Mr. Crawford

I have a couple of seconds left.

An Ceann Comhairle

It would be better if the party itself divided the time because according to my——

Mr. Crawford

I have only spoken for three minutes.

An Ceann Comhairle

The Deputy used four minutes. However, it would be better for the party to divide the time for itself.

Mr. Crawford

I am shocked at this intervention. However, I am not surprised. In any event, the fact is that drunks go to accident and emergency units. As I stated earlier, in Cavan, 14 patients were on trolleys and beds this week. In Cavan, the room used to deal with drunks late at night is the children's play area to which the children must come the following day. This is not right and no matter how one tries to clean it, this is impossible. We must change the situation and deal with the problem of drunkenness but we must also provide the facilities in wards where drunk patients can be dealt with. There are only two toilets in Cavan General Hospital so one can guess what the situation for staff and patients is like. I support this motion and I will address other issues later.

Ms O. Mitchell

It is a measure of what accident and emergency departments have come to that we must put forward a Private Members' motion to deal with this problem and protect staff and patients in them. The Tánaiste and Minister for Health and Children volunteered for the post and said her tenure in the Department of Health and Children would be judged on her success in resolving the crisis facing accident and emergency departments. In many ways, accident and emergency is the only part of the hospital service where we know what is going on because it is the only area where we can see the queues and the problems. Everything else has disappeared from view and gone below the radar since the abolition of the health boards and the removal of democratic accountability.

Given that the Tánaiste and Minister for Health and Children set herself this target, it is very surprising that she has not focused on a major part of the crisis in accident and emergency departments, namely, aggressive, recidivist drunks who add to the cocktail of problems facing staff at weekends. It is an unnecessary and unacceptable addition to problems staff face. People who join the Garda, Prison Service or Defence Forces expect to have to deal with aggression but people who join the caring professions do not expect to deal with aggression and should not have to tolerate it. This motion will not take people off trolleys in accident and emergency departments but it will protect them from the indignity of being vomited on by drunken patients and this is why Deputy Twomey's motion is so necessary. Society is in a sorry state when doctors, nurses and patients require a Garda presence to protect them from drunken individuals and when the issue of the chaos caused by drunken patients has to be addressed in the Dáil. However, it has come to this because the days of the harmless, garrulous drunk are over and in its place is the 21st century drunk who represents the sons and daughters of my generation and for whom we must bear some responsibility. This new drunk is hyped up on energy drinks and a mix of alcohol and illicit drugs and is driven way beyond reason and his or her normal disposition.

If drunken individuals are sick, they should be treated. However, if their presence in accident and emergency departments endangers staff or patients or affects staff's ability to treat other patients, they must be consigned to wet rooms away from their friends and placed under secure supervision, if necessary. All reports indicate that the same drunks return to accident and emergency departments month after month and they will continue to return if we tolerate it. We have been excessively tolerant of drunkenness. Drunken patients have been led to believe that their activities have no consequences and we must have a new policy that communicates to them that their behaviour does have consequences. Although they might not see the brain and liver damage they are inflicting on themselves or the damage, distress and inconvenience they are causing in accident and emergency departments, the spartan and lonely conditions in wet rooms and double hospital charges might have some effect on them. Parents of underage drinkers should be informed of and brought to hospitals to see the condition of their children. If we are to change this culture of drunkenness and tolerance of drunkenness, somebody, be it the child or the parents, must take responsibility.

I urge the Tánaiste and Minister for Health and Children not to ignore this motion because it is dealing with a serious problem.

Mr. Deenihan

The staff at Tralee General Hospital must be complimented on their dedication and commitment to patients over the years. The staff possibly do not face the same problems as staff at hospitals in urban areas. The main issue in Tralee Hospital is the safety of patients. The report by the Health and Safety Authority refers to the safety of patients in a number of sections and it clearly states that senior medical coverage is essential for a 24-hour, seven-day week. This finding was also confirmed by the Cavan report some years ago on the death of Frances Sheridan. In Kerry General Hospital, senior medical coverage is only provided for eight hours a day, five days a week. There is neither a consultant nor a registrar present. Many people, including I think the Tánaiste and Minister for Health and Children, believe the problem can be solved with the current ceiling of staffing. It might be the case in the bigger teaching hospitals but it is not the case in Kerry General Hospital. There must be a basic staffing requirement to ensure patient safety. A junior doctor, for example, who requires a second opinion must receive it from a senior medical officer immediately; there is no point in telephoning someone.

I understand that Kerry General Hospital has written directly to the Tánaiste and Minister for Health and Children highlighting its basic needs but has received no response. I ask the Tánaiste and Minister for Health and Children to increase accident and emergency medical staff numbers to a safe level. Seven HSOs and three registrars is not an unreasonable figure upon reflection as this is the medical staffing level in similarly sized units around the country. There needs to be an increase in nursing numbers in Tralee General Hospital to reflect the continued demand on accident and emergency departments. While the Tánaiste and Minister for Health and Children was given a warm welcome in Kerry last week and I was delighted to be present when she opened the new nursing units, it was unfortunate that she did not visit the accident and emergency department to see for herself the circumstances that both nurses and patients have to endure.

Mr. Hayes

Everyone must acknowledge that there is a real problem in the health service in dealing with the difficulties people are encountering. The public's real concern is that it is being told over a long period of time by the Government that change is due following the publication of a variety of reports. This change has not occurred despite the plethora of reports. I acknowledge that bringing about change is difficult.

I wish to highlight the crisis which has developed in South Tipperary General Hospital over the last ten years. A split service has been run on a Cashel-Clonmel site. If the Tánaiste and Minister for Health and Children does one thing in the next capital programme, it should be give the constituency I represent a service that has been promised by successive Governments over the last number of years. I know she understands the desperate situation and that many have made pleas to her.

Tánaiste and Minister for Health and Children (Ms Harney)

I move amendment No. 1:

To delete all words after "Dáil Éireann" and substitute the following:

—recognises the pressures on some of our accident and emergency departments and acknowledges that the abuse of alcohol is a significant contributory factor;

—supports the Tánaiste and Minister for Health and Children in her determination to bring about improvements in the accident and emergency services available to patients;

—welcomes the steps being taken by the Health Service Executive to implement the ten point plan announced by the Tánaiste and Minister for Health and Children to improve the delivery of accident and emergency services;

—notes the recommendations made by the Health and Safety Authority following its recent inspection of certain accident and emergency departments and calls on hospital staff at all levels to work together on their implementation; and

—supports the Minister for Justice, Equality and Law Reform in his efforts to tackle public order, particularly as it impacts on staff who deliver emergency care.

I welcome the opportunity in responding to this motion to underline once again the Government's commitment and actions to improve patients' experience of accident and emergency services in our hospitals. I will address later some detailed points about alcohol abuse and accident and emergency services, and the actions we are taking in this area. I will first take a wider view of the challenge of improving accident and emergency services, a perspective that is somewhat lacking in the Opposition motion.

A recent analysis of our accident and emergency issues by a non-political body stated:

Across the world the pressure on accident and emergency services has been increasing. In Australia 80% of patients waited for more than four hours at accident and emergency in 2004, while in Canada 6% of patients waited 24 hours or more for admission in 2002. The Canadian Association of Emergency Physicians has described their overcrowding problem as a ‘national epidemic'.

The writer continues:

Ireland's problems are not insoluble. There are viable solutions to the accident and emergency crisis. Two recent reports on accident and emergency services in February 2002 and acute medical units in October 2004, both published by Comhairle na hOspidéal, offer clear recommendations which, when implemented, will have a significantly beneficial effect and should prompt appropriate and efficient management of emergency hospital referrals.

This is the Irish Medical Organisation's view and I concur. We have taken all the reports and the analysis and we are now implementing solutions. The IMO goes on to say about the actions we are taking: "The ‘whole system' approach and the underlying strategy . . . is correct; to reduce demand and increase the efficient use of current facilities."

To improve all patients' experiences of accident and emergency units, we must deal with the medical and care needs of the people comprising 1.2 million attendances per year, 3,300 patients per day on average, at our accident and emergency departments. This is not a simple matter for Ireland or elsewhere. The ten-point plan for accident and emergency services is a beginning, not an end.

Mr. McCormack

The plan has not begun yet.

Ms Harney

It has begun and many patients have been moved out. The plan captures many of the actions that must be taken to address the problems. We have allocated priority funding of €80 million this year, clearly not as a total investment in accident and emergency solutions but on top of substantial funding for hospitals, long-term care, home help, primary care, GP co-operatives and so on. Our actions are also being implemented in conjunction with our capital investment plan of nearly €3 billion up to 2009. Additional actions are needed that are not about funding but more about management, work practices and processes in hospitals, which the Health Service Executive will address.

No plan can work without people implementing it. Health is all about people, about the patients, their needs and the people who have the expertise, training and commitment to deliver services. We cannot achieve improvements in accident and emergency services without change. More of the same, even a lot more of the same, will not work. More beds, hospitals, nurses, consultants, resources and pay on their own are not the solution. When the IMO and others rightly say we need a whole system approach, this means whole system change, not just a wholly bigger system. Would any of us tell patients that the existing system is fine, it just needs to get bigger?

I am urging all of us involved to embrace change to make things better for patients. Doctors, nurses, politicians, administrators, hospital managers, cleaners and caterers are all involved. We can each play our part in delivering that change. The health system is not an anonymous machine to which we are all subservient. It amounts to the way we work together, the rules, processes and procedures that have grown up and are perpetuated. The system is ultimately under our control, not just mine as Minister, not just this consultant or that nurse, this manager or that chief executive, but all of us working together.

Mr. McCormack

The buck stops with the Minister.

Ms Harney

That is true. We must recognise that the way we work together, our practices, our rules and our procedures——

Ms McManus

Unless the issue is nursing home charges.

Ms Harney

I did not hear Deputy McManus's comment.

Ms McManus

I said unless the issue is nursing home charges.

An Ceann Comhairle

The Deputy should allow the Tánaiste to continue without interruption.

Ms Harney

We need to recognise that the way we work together, our practices, rules and procedures can change and can be improved for patients' sake. We must also recognise that change does not threaten us or require us to be compensated. If we all agree we want to improve care for patients, should we not reward and incentivise innovation, ideas and new ways of working that do so? Rather than reward the squeakiest wheels, we should reward the most effective work for patients by the most effective hospitals.

This is the context in which I believe we should follow the recommendations of the Health and Safety Authority to move patients from accident and emergency trolleys to additional beds in hospital wards at certain times. That is why hospital consultants and other groups can better work for patients with better round the clock rostering and why speedy access to diagnostics and GP services round the clock must be the norm. These are just some examples of how we can change our system to improve accident and emergency services for patients. This is not about quick fixes or command and control from the centre, it can only work if we all focus on achieving better outcomes for patients.

Looking at it this way, our accident and emergency services and health generally have many parallels with the economic challenges we faced in the 1980s and early 1990s. The partnership process helped all players to lift their heads above the trenches to see that we all had a stake in the whole economy working much better. We took ownership and responsibility for how the whole economy worked, and we can do this for health. Just as we proved that the economy was under our influence and control, so too we can show that our health system is under our control and can be improved by change and reform together.

Mr. McCormack

Fine words.

Ms Harney

I have already welcomed the Health and Safety Authority's report arising from its assessment of 11 accident and emergency departments. The National Hospitals Office has separately analysed assessments of risks carried out in all hospitals and the actions taken to deal with such risks. I stress that this is the first nationally co-ordinated analysis of all accident and emergency departments. Therefore, it is critical that action is taken to follow through on the recommendations emerging from both the HSA and the NHO assessments.

All hospitals inspected by the HSA have been issued with a report of the inspection. The HSA has directed the hospitals in question to submit a comprehensive plan to address these issues, including time scales for corrective action. The HSA acknowledges that the hospitals are fully engaged in the process of addressing health and safety in their accident and emergency units.

The HSA recommended that the HSE should determine on a hospital by hospital basis, after undertaking the necessary risk assessment and staff consultation, whether extra capacity can be achieved within the existing system. The NHO has advised hospital managers to examine the potential for using the total hospital capacity, including inpatient wards, for patients who require admission. Each individual hospital must exercise its own judgment on how to reduce risk. In doing so, hospital managers have been asked to have regard to international best practice in areas such as improving work-flow issues and increasing the use of more appropriate community-based interventions to reduce pressure on accident and emergency services.

The NHO is seeking tenders from companies which are expert in the area of work-flow management to carry out a review of ten hospitals to identify the efficiencies that can be achieved to improve patient services and reduce overcrowding. This is an approach that has contributed significantly to improving accident and emergency services hospital by hospital in the UK. I look forward to the practical steps taken by many hospitals here as a result of this audit work.

One of the issues raised by the HSA was a fragmented approach to health and safety that was exacerbated by the fact that there is no senior clinician in charge of accident and emergency units on a 24-hour, seven day a week basis. While the number of accident and emergency consultants has increased from 14 in 1997 to 52 at present, the HSA has indicated the need to address the extent of senior clinician cover for accident and emergency units. I understand the NHO will invite the IMO and the Irish Hospital Consultants Association to discuss this issue for hospitals with two or more accident and emergency consultants.

Both the HSA and the HSE reports have found violence and aggression to be one of the main risks in accident and emergency departments. Much of this relates to the prevalence of cases of alcohol and drug misuse presenting at accident and emergency departments. An alcohol and injuries study, commissioned by the health promotion unit of the Department of Health and Children, has been expanded nationwide to include six major hospitals and a full report is being prepared. Preliminary results from the wider study of accident and emergency departments appear consistent with the Mater Hospital study that showed 30% of male admissions, 10% of female admissions and almost 25% of all accident and emergency attendances met diagnostic criteria for alcohol misuse or dependency. The full results of the expanded study are being processed and should be available by mid-2005.

The HSE has recently carried out an examination of patients attending accident and emergency departments with psychosocial conditions with a view to developing appropriate care pathways and referral processes for such patients. An action plan is being finalised to include initiatives such as the identification of appropriate care settings at community level and the development of triage arrangements at hospitals with accident and emergency departments to enable more appropriate assessment and treatment of persons with psychosocial issues.

The National Hospitals Office has requested the immediate implementation of guidelines issued by the Health and Safety Authority on dealing with violence and aggression in the workplace. It has also written to each trade union or staff association requesting that the accident and emergency issue, including the issue of health and safety, should be dealt with by way of a working partnership group between management and the trade unions rather than through the normal industrial relations process.

We would all agree that it is totally unacceptable that front-line health care workers might be subjected to threats or abuse. The Minister for Justice, Equality and Law Reform is determined that everything possible should be done to tackle disorderly behaviour and, in particular, assaults on emergency workers such as the staff of hospital accident and emergency units.

The Minister is providing in the Criminal Justice Bill for a fixed charge procedure in regard to certain public order offences. Section 29 of that Bill, which is on Second Stage in the Dáil, provides for such a procedure in regard to disorderly conduct in a public place and in regard to intoxication in a public place. In addition, the Minister is examining the current position in regard to assaults against emergency workers with a view to providing for a specific offence in this respect by way of an amendment to the Criminal Justice Bill. I hope the House will join me in fully supporting the Minister's work in this regard.

Everyone who has taken time to understand the accident and emergency issue in any country will recognise that many factors cause the bottleneck in accident and emergency departments and that each has to be addressed if we are to solve the problem. The Government is confident that accident and emergency services can be substantially and radically improved if people come on board for change.

The issues include alcohol abuse as one factor causing difficulties and discomfort for patients and staff in accident and emergency departments. It is one of many issues, but it would be a mistake to expect short-term actions on alcohol abuse to solve wider problems. Clearly, tackling alcohol abuse will not improve rostering to ensure patients are seen, diagnosed, treated and discharged quickly. It will not supply better out-of-hours GP services so that people do not have to resort to having to go to a hospital in the middle of the night for medical worries or minor injuries. It will not make diagnostic tests available round the clock without long delays for patients.

The Government is determined to make visible improvements for patients in accident and emergency departments and elsewhere throughout our health services. Our economic strategy is working to provide massive resources for public services. The Government has invested unprecedented new resources in health care. However, what is required is not simply a matter of providing more resources. The time has come for all of us, including the Deputies opposite, to acknowledge that the priority now is for all those involved in the delivery of our health services to work together to ensure that these resources are used to deliver much better services for patients.

Regarding the implementation of the ten-point plan, the HSE has identified many of the high dependency beds that we put out to tender and patients will be moved to those beds over the coming weeks. We have also put in place a home care package. Many elderly people in particular and some younger people who are disabled are availing of the home care package to return to their own homes. We have acquired facilities for 500 patients in the intermediate care area, particularly, but not exclusively, in the greater Dublin area. These, together with independent access to diagnostics, the AMU units that will be put in place at three of the main hospitals in Dublin and provision in regard to some of the issues around care of the elderly, will have a dramatic impact on accident and emergency services.

However, above all else we need changes in hospital practice. As I said on other occasions, Dr. Conor Burke from Blanchardstown hospital stated in a paper he produced recently that if every patient at that hospital could be discharged when he or she was medically fit to be discharged, there would be no problem in the accident and emergency department of that hospital. What is required is the daily discharge of patients, consultants working together, people not being admitted to hospital for diagnostics when that can be done on an outpatient basis and the provision of more services for elderly people, particularly in urban areas.

The controversy around the charges issue has added to the problem this year. Many people who may have moved to a nursing home environment have not been prepared to do that because of the controversy. The confusion around that issue is not the cause of the problem but it has delayed the discharge of many elderly patients from some units in our acute hospital system. There are close to 400 elderly patients in main hospitals in Dublin, which is an unusually high figure for this time of the year.

The difficulties and pressures in accident and emergency departments are a priority for the Government. We are determined to put in place all the necessary policies to ensure that we deliver a solution. I believe that by next winter we will see a remarkable improvement in the vast majority of patients' experience of accident and emergency departments.

We need additional bed capacity. It is not secret that the new Mater Hospital will have additional bed capacity. I have plans to provide additional bed capacity at public hospital facilities throughout the country because at present 2,500 public beds are used for private patients. For private patients, there are alternatives to using the facilities in our public hospitals. Those measures, together with many aspects of the ten-point plan, will have a major effect on ensuring that the public hospitals are used efficiently.

We need to ensure there are appropriate work practices and rostering in place, particularly 24-hour consultant cover at accident and emergency departments. Many patients are not discharged if the consultant is not on duty to discharge them and they end up staying in the ward from 6 p.m. until 8 a.m. the next morning when they could have been discharged within an hour or two of having seen the consultant if he or she had been on duty. These work practices have to be changed in the interests of patients and they are a number one priority.

I should have stated at the outset that I wish to share my time with the Minister of State, Deputy Tim O'Malley.

Mr. McCormack

There are 60 beds in a facility in Galway which the Minister should commission.

Minister of State at the Department of Health and Children (Mr. T. O’Malley)

It should be clear by now that the Tánaiste has put accident and emergency services at the top of the Government's agenda. The Government is totally committed to improving the public's experience of accident and emergency departments.

Accident and emergency services present a particular challenge to individual hospital managements. In many instances, accident and emergency departments are the only areas in which the wider public receive hospital services and, as such, hospital managements must regard the accident and emergency departments as the shop window for hospitals. While the accident and emergency service is but one aspect of acute hospital services, people judge our health services by their experience of accident and emergency services. While it is not a complete measure of health services, it is understandable that people view accident and emergency services in this way. A much more customer oriented approach must be adopted by hospital managements, consultants and nursing and other professional and support staff.

The actions to improve the delivery of accident and emergency services take a wide-ranging approach and are aimed at improving access to accident and emergency services, improving patient flow through accident and emergency departments, freeing up acute beds and providing appropriate longer-term care for patients outside the acute hospital setting.

Delivery of hospital emergency services is interdependent on the inpatient elective service, day and outpatient care and 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 in addressing the current problems is a whole systems approach which addresses the needs of people on a timely basis in the most appropriate setting.

The safety and security of staff in accident and emergency departments has been and is a continuing priority for health service management. An independent review of security arrangements in accident and emergency departments of all hospitals in the State providing accident and emergency services was undertaken in 2002. The review recommended the introduction of a range of measures aimed at enhancing security arrangements in accident and emergency departments. The Department of Health and Children provided €2.35 million in 2002 to the then Eastern Regional Health Authority and the health boards towards the cost associated with the enhancement of security arrangements. Earlier this year all hospitals with accident and emergency departments were contacted regarding the review of security that took place in 2002. The review showed that the recommendations made in 2002 were largely in place. One of the key recommendations of this review was that all acute hospitals should actively participate in the Garda hospital watch programme.

The recommendations on security included closer liaison with local gardaí in regard to advice on security measures. Modern hospitals have good accessibility and provide services on a 24-hour basis. Because of their sheer size and openness there is potential for crime to take place. Crime committed in a healing and caring environment can be doubly traumatic for patients, visitors and staff, and hospitals are making every effort to prevent and reduce the opportunity to commit crime.

The hospital safety and security programme known as hospital watch is similar to neighbourhood watch. It acts as a crime prevention programme, using the knowledge and alertness of staff, the development and introduction of good security practice and regular communication between the staff and the local gardaí to minimise the opportunity for crime within hospitals. This programme helps make these vital and vulnerable hospital environments a safer and less stressful place for everyone. I am happy to report that the majority of acute hospitals now have a hospital watch programme in place where there is ongoing liaison with local gardaí.

The Government set out to improve the physical infrastructure of acute hospitals, particularly accident and emergency departments. 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. Last Monday the Tánaiste officially opened a new purpose-built accident and emergency department at Cork University Hospital. New accident and emergency departments and new hospital buildings were also provided at Connolly Hospital, Blanchardstown, and Naas General Hospital at a total capital cost of €100 million and €75 million, respectively. A new accident and emergency department was provided at Roscommon General Hospital at a capital cost of €6 million. New accident and emergency departments are expected to open this year at St. James's Hospital, Dublin, and at South Tipperary General Hospital, Clonmel. Major capital projects at Tullamore General Hospital and St. Vincent's Hospital, Dublin, will also result in new accident and emergency departments being provided. 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 inpatient beds.

The need for additional acute beds in the hospital system has been well documented. The Government is now well on the way towards building up the acute bed capacity in the acute hospital system. Since the publication of the health strategy in December 2001, funding has been provided to hospitals to open an additional 900 beds.

For the benefit of the House, I will set out the current status of the initiatives under the Tánaiste's ten point plan for accident and emergency services. First, on the development and expansion of minor injury units, chest pain clinics and respiratory clinics in hospitals to relieve pressure on accident and emergency departments, the HSE eastern region has had very positive discussion with both public and private sector providers for the development of additional minor injury facilities in Dublin. The HSE eastern region has initiated an exercise due for completion this month to assess minor injury attendances at accident and emergency departments and the potential of having these patients treated elsewhere. The results of this exercise will inform decisions regarding the scope of minor injury and diagnostic initiatives and also the evaluation criteria.

Second, it is expected that the second MRI for Beaumont Hospital will be available by the autumn. Third, there will be provision of acute medical units for non-surgical patients at Tallaght, St. Vincent's and Beaumont hospitals. The relevant hospitals are finalising their proposals for the HSE. The national hospitals office is in the process of seeking tenders from companies expert in the area of workflow management to identify how processes for patient services can be improved and made more efficient. Final decisions on the design of the acute medical units will be taken in light of this work so that resources are used most effectively, hospital by hospital.

Fourth, 100 high dependency patients will be transferred to suitable private nursing home care. The tender process for the provision of high dependency beds for 100 patients in private nursing homes is in the final stage. The essential site inspection visits have been completed. Decisions on which nursing homes to be awarded contracts will be taken shortly.

Fifth, there will be negotiation with the private sector to meet the needs of 500 people annually for intermediate care of up to six weeks. The tendering process is completed and successful applicants have been notified. A total of 90 beds have been procured nationally to allow an annual throughput of 500 patients. Some 64 patients from hospitals in the eastern region and 23 patients in the Cork region have already been discharged as a result of the intermediate beds being available.

Sixth, there will be expanded home care packages to support 500 additional older people at home. Additional home care packages for patients in each of the six major acute hospitals in the Dublin area have been made available. An additional 100 home care packages have been allocated to hospitals outside of the eastern region. To date, some 51 patients have already been discharged from acute hospitals in the eastern region and discharge arrangements are being finalised for a further 45 patients.

Seventh, there will be provision of more out of hours GP services to keep people's need to attend accident and emergency to a minimum. Some 150 GPs on Dublin's northside have agreed in principle to the establishment of out-of-hours services. Discussions in this regard are progressing positively.

Eighth, there will be dedicated cleaning services and security measures for accident and emergency departments. The director of the national hospitals office is finalising arrangements for the establishment of a national audit and an inspection process to measure cleanliness in all acute hospitals. Funding is available to hospitals to improve security measures and to take whatever measures are necessary to ensure patient and staff safety. The director of the national hospitals office has written to all hospitals in regard to the report of the Health and Safety Authority in this regard.

Ninth, there will be further expansion of palliative care facilities. An additional six palliative care beds will be made available in Blackrock Hospice, Dublin, as soon as the necessary staff are recruited.

Tenth, there will be measures to enhance direct access for GPs to diagnostic services. It has been agreed to explore entering into local arrangements with the private sector to match capacity with needs. Negotiations are ongoing. In regard to inpatient diagnostic services, discussions are advanced with two private hospitals in the eastern region on MRI and CT.

I am confident the actions taken by the Government, including the provision of new beds and capital investment under the Capital Investment Framework 2005-09 will, over time, generate an appropriate, multi-faceted and multi-dimensional response to the accident and emergency problem.

The problems of alcohol abuse are very real and go much wider than their impact on accident and emergency services for patients. Unfortunately, the Opposition's motion is not real in regard to this aspect. It displays no evidence of practical thinking about the practical realities of dealing with people with alcohol-related problems at accident and emergency. To ask Dáil Éireann to approve a motion calling for "hangers on" to be "rounded up" shows no real appreciation of the legal, medical or civil rights requirements.

Dr. Twomey

What are the requirements?

Mr. Howlin

The PDs will be agreeable to rounding up——

Mr. T. O’Malley

I am confident the Tánaiste's action plan to improve the delivery of accident and emergency services will bring about significant improvements in patients' experiences of accident and emergency services.

Mr. J. Breen

What about Galway and Clare?

Mr. T. O’Malley

Improving the delivery of accident and emergency services continues to be a priority. We will continue to work in the best interests of all patients and staff. I am confident that we can and will improve the delivery of accident and emergency services so that patients receive the appropriate treatment as quickly as possible.

Ms McManus

I wish to share my time with Deputy Howlin. I have a sense of déjà vu about this debate. The accident and emergency crisis was debated in this House on a number of occasions. What is different now is that we have just come through the worst crisis and the worst winter in terms of the situation in our accident and emergency departments. There are also other differences. When the Minister for Health and Children initially referred to her plan, she suggested that by March-April this year we would see a significant improvement. She later changed it to autumn. She stated tonight that it would be winter before we would see improvements. This does not auger terribly well.

One aspect of this motion deals with an extreme facet of the accident and emergency crisis, namely, the drunkenness that is apparent therein, particularly at weekends. This is the cause of intimidation, violence and fear and must be recognised as a real problem. It is a pity the various measures being proposed are not considered a little more thoughtfully by the Minister. It may be that some are workable and some less workable but it is important that they be treated seriously. It is not easy to address the problem of drunkenness because there are people who are ill who appear to be drunk, drunk people who are also ill, and people who are only drunk. It is very difficult to diagnose such people unless they go through the normal procedures that obtain in accident and emergency units. When they can be identified, separation makes sense. It is important that efforts be made in this regard.

One proposal on charges does not stand up to scrutiny. At present, €3.7 million is owed per annum because people are not paying charges, mainly for accident and emergency services but also for other services. Doubling the charge will not make a considerable difference. However, the principles are important and, if acted upon, may alleviate a desperate situation.

It is interesting that the Minister acts as if she has just stumbled upon the accident and emergency crisis and as if she has not been Tánaiste for the past seven or eight years. During this time, chronic circumstances have got worse rather than better. There has been a steady deterioration. While the Government put more money into the health service, the accident and emergency crisis got worse. Over the years during which our population grew by 25%, we lost 25% of our overall bed capacity. This has not been fully addressed but needs to be. I felt the shade of the former Minister, Deputy Martin, reappearing while the Minister, Deputy Harney, was speaking. She talked about reviews, reports and action plans. This does not fill one with confidence.

I took the opportunity before this debate to look back over my records and noted a study was carried out on accident and emergency services in 2000 by Geraldine Regan, a senior nurse manager. She made many sensible proposals which, unfortunately, were not taken on board in the way they should have been. The proposals concerned bed management and staffing. In 2000 the problem was still manageable and waiting times were not nearly as severe as they are now. However, the Government did not heed Ms Regan's recommendations enough to make a difference.

The problem became more serious and in 2002 the Labour Party tabled a Private Members' motion thereon. The Government amendment to that motion was remarkably similar to the amendment it has tabled tonight. It is characterised by the same kind of self-congratulation. However, the only changes in accident and emergency services in the past two years have been for the worse.

In 2002 the former Minister for Health and Children announced 709 new beds, which were to be delivered within 12 months. They were not delivered within 12 months and were part of the 3,000 beds to be delivered by 2011. I would be very interested to hear if the Government is still honouring that commitment. Subsequent to the former Minister's announcement, we discovered that not all of the beds referred to were actual beds — some were trolleys and chairs.

The former Minister set up the accident and emergency forum, about which we have all forgotten. A nurse to whom I spoke when my colleagues and I were out supporting the nurses on the picket line in recent weeks described the forum as "worse than useless". This indicates where such fancy notions lead.

In early January 2003, elective procedures were being cancelled. A shock-horror story in a newspaper referred to a patient who had been waiting on a trolley for 17 hours. Nowadays there are patients who would probably be grateful if they had to wait for only 17 hours. In 2003, at which time the current Minister for Health and Children was Tánaiste, the Government commissioned the Capita report to inquire into bed management, bed capacity, community facilities, community nursing beds etc. The review was produced with great fanfare and of course we were told everything would improve and that we did not have to worry.

In early January 2004, 200 people were waiting for beds on accident and emergency trolleys. This figure is now lower than the norm considering the high numbers of people who had to wait on trolleys this winter. In February 2004, a headline stated there were 42 patients on trolleys in Tallaght Hospital. In February 2005, at which time Deputy Harney had become Minister for Health and Children, there were 63 patients on trolleys in the hospital. One unfortunate man stated in an interview on the radio that he had been in his bed in a hospital ward, gone out to the toilet and discovered on his return that his bed had been taken by somebody else. He ended up back in the accident and emergency unit. There has been a steady deterioration in conditions in accident and emergency units under the Government. Let us not pretend otherwise.

It is fairer to call the ten-point plan a nine-point plan because the MRI scanner is only to replace the one which should never have been taken away in the first place. I do not know why the replacement is taking so long. Why has it not been replaced?

We were promised that the various initiatives being taken by the Minister under the plan would deliver 1,000 step-down beds for home care and nursing home care. The figures speak for themselves. At most, we have 90 beds as a result of the nursing home initiative and 51 home care packages. Two weeks ago, 65% of all the beds in Beaumont Hospital were being used by people who were located inappropriately therein.

It is important that we get real about this issue instead of pretending there have been improvements. There have been none. It seems there may be none in the future on the basis of a statement by the very experienced accident and emergency consultant Dr. Aidan Gleeson:

I personally see very little light at the end of the tunnel. We are in for a very rough ride and ultimately, patients will suffer. I can work a 10-hour day in casualty, and it is stressful, but I can go home to my family at the end of the day. An 85-year old lady waiting on a trolley in A&E cannot do that. These patients are given no dignity or privacy, emergency departments are congested and can be violent and aggressive places at times.

I believe things will get worse as I am not convinced that the real problems relating to A&E are being tackled.

That is from the horse's mouth and nobody can disregard what a very experienced person working at a very senior level at the coalface has to say.

One of Dr. Gleeson's concerns is that there is insufficient funding to implement the ten-point plan. He is correct. I do not know how one could deliver the kinds of changes required on such a low budget. I did not know the HSE itself is being underfunded. This disturbs me greatly. There is a shortfall of almost €200 million and Kevin Kelly has admitted this to an Oireachtas committee. This is very serious.

Ms Harney

As I told the Deputy last week, an extra €950 million is not a shortfall. It is an increase.

Ms McManus

I am telling the Minister what Kevin Kelly stated on the record at an Oireachtas committee.

Ms Harney

Where is the shortfall?

Ms McManus

We need to take it seriously. Fantasies have been delivered. We have had three or four years of fantasies, stories being spun——

Ms Harney

And billions of euro as well.

Ms McManus

——and reports being prepared. It would be helpful if the Minister listened to Kevin Kelly. I do not expect the Minister to listen to me but this issue is important.

Ms Harney

This House voted the Estimates through. The sum was €950 million more.

Ms McManus

Midsummer is approaching but we have not yet seen the capital programme. There is a stalemate in the process. It does not appear to me, or to most members of the public, that there is a serious drive to deal with the problems in the accident and emergency departments and the capacity issues inherent in our hospital system. The problems in accident and emergency departments cannot be dealt with in isolation.

I wish we could all work together to improve the situation but that will not happen. I resent the suggestion that nurses and doctors do not work together. They do. I see them in the accident and emergency departments, as I see the other health professionals, and ambulance officers bringing in the patients. They all work together. The problems they face and the blockages in the system overwhelm them when it comes to making a difference and ensuring people can pass speedily through the system.

Mr. Howlin

I welcome the opportunity to address what is an important issue for the whole country. I welcomed the Tánaiste's move to the Department of Health and Children thinking maybe she would use her position as Tánaiste to bring about significant change in a measurable time frame. I welcome the opportunity afforded by this motion to review the progress of the Department under her stewardship.

The contents of the Fine Gael motion detail several measures set out to address some of the difficulties facing accident and emergency units. Alcohol abuse and bringing drunks into hospitals is a real and difficult issue. It is a feature of some weekends in accident and emergency units and some of the measures proposed by my constituency colleague in the Fine Gael Party are worthy of careful consideration.

No set of measures, however, can address a situation in which the basic infrastructure is inadequate. I have repeatedly raised the situation at Wexford General Hospital with the Tánaiste, since she became Minister for Health and Children, as I did with her predecessor in that office.

The situation in the accident and emergency unit there is critical. This morning as I left Wexford there were 20 people on trolleys and routine procedures for 15 people were cancelled today. That is a normal day in the hospital. In recent weeks there have been 20, 25 and up to a maximum of 38 people on trolleys. I invite the Tánaiste to visit the hospital and see those people. There is not enough room for them in the corridors. They are dispersed around the ground floor, in nooks and crannies. It would be bizarre in a Third World country.

The new state-of-the-art medical admissions unit, intended as a model of its kind, is defunct because it is occupied by people lying on trolleys. That is a disgraceful situation. Last Monday I saw a new sign on the corridor leading to the accident and emergency unit, bearing the words "Quiet — patients sleeping". I spoke to a woman who the previous night had tried to avert her eyes when the man on the adjacent trolley was relieving himself. There are no screens to protect people's decency or meet the standards we expect. I know some elderly people who chose not to go to hospital because they feared the indignity of being on a trolley. That is a disgraceful, scandalous situation.

There have been times when the accident and emergency unit was so overcrowded that it was formally closed and ambulances were re-routed to Waterford. On one occasion the hospital in Waterford was under such pressure that they were re-routed further afield.

This situation has not arisen because of the issues the Tánaiste addressed in her ten point plan. That plan will not solve the problem caused by a population increase that exceeds the bed capacity in the hospital. Adding extra beds to wards and removing the so-called bed blockers, will not address that core issue. Additional beds are required. Years ago, 40 additional beds were identified as necessary. It was agreed that 19 of those would be fast-tracked three years ago to deal with the urgent need.

Those 19 beds have become a source of annoyance, frustration and ridicule in Wexford. The previous Minister for Health and Children formally sanctioned them in April of last year, prior to the local elections. That announcement is now seen in Wexford as a cruel deception, a clear and blatant lie. Beds were promised, more than a year has passed and they have not been delivered. It was a cruel deception and a lie.

An Leas-Cheann Comhairle

The Deputy should not use the word "lie".

Mr. Howlin

In that case it was a cruel deception and a blatant untruth.

The Tánaiste calls on us all to work together. The opening sentence of the Minister of State, Deputy Tim O'Malley that "It should be clear by now that the Tánaiste has put accident and emergency services at the top of her and the Government's agenda" will be ridiculed in Wexford. If the Minister of State had any notion of how strongly the people of Wexford feel about their betrayal 13 months ago, he would know why his statement will provoke unmitigated anger.

The hospital needs the immediate release of the 19 beds, and hopefully the 40 beds originally planned, because the fast track has been so slow it is nonsense. The outpatients department has plans to move to a purpose built unit and the accident and emergency unit is to expand into the space formerly occupied by the outpatients department. The money for the outpatients department should be released so that the accident and emergency department can expand, and a proper outpatients facility be provided. That is needed now. I have invited the Tánaiste to visit the hospital.

The Taoiseach will be in Wexford this Friday. On behalf of the hospital's medical board, Mr. Ken Mealy invited the Taoiseach to visit the hospital. I hope the Taoiseach accepts the invitation. It is interesting that the only speakers from the Government benches tonight were Progressive Democrats. No member of Fianna Fáil wants to share the odium of this issue.

Mr. T. O’Malley

They will be here tomorrow night.

Mr. Howlin

The Fianna Fáil members are happy to lay all the blame at the Tánaiste's door. When the Tánaiste was appointed to the Department of Health and Children I said she was a decent, hardworking, capable Minister. That will be tested yet again but the patience of the people of Wexford has been strained to breaking point. When Deputy Tim O'Malley read out his litany of hospitals he did not mention Wexford General Hospital. I ask that the needs of the people of Wexford be addressed and that the facilities the elderly, the infirm and the ill of Wexford require be delivered forthwith.

Debate adjourned.