Dáil Éireann debate -
Wednesday, 11 May 2005

Vol. 602 No. 2

Private Members’ Business.

Accident and Emergency Services: Motion (Resumed).

The following motion was moved by Deputy Twomey on Tuesday, 10 May 2005:

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.

Debate resumed on 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 10 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.

—(Tánaiste and Minister for Health and Children).

Dr. Devins

I wish to share time with Deputies Fiona O'Malley, Keaveney, Cooper-Flynn, Sexton and Moloney.

I am delighted to have the opportunity to speak on this motion. There is no doubt that the work in accident and emergency units has come under intense media scrutiny in the recent past. There are a number of contributing factors for this scrutiny, but chief among them has been the unacceptable levels of delay encountered by patients either waiting for treatment or admission. Some weeks ago, the Minister for Health and Children announced a ten-point plan to deal with these delays. There has been real progress on these proposals to deal with the problems of accident and emergency services. It is worth noting that different problems exist in different accident and emergency units, hence the reason for a multi-factorial approach to dealing with these problems.

One of the proposals deals with the role of acute medical assessment and admission units. There is very good evidence that these units, when properly run and resourced can have a dramatic role in improving the service offered by accident and emergency units. These units provide rapid assessment, diagnosis and treatment of patients referred for urgent medical assessment or admission. Sligo General Hospital, has an excellent proposal for such a unit currently with the HSE. It is imaginative, radical and carefully-costed. I understand the national hospitals office of the HSE is currently evaluating the effectiveness and efficiency of acute medical unit proposals. This is right and proper, but I urge the Minister to ensure that this evaluation is completed as soon as possible. I have no doubt that when the proposals from Sligo General Hospital are evaluated, they will be found to be effective and efficient. When they are implemented, a reduction in waiting times at the accident and emergency unit in Sligo General Hospital will definitely occur.

In the remaining time available to me, I will touch on another element of the motion before us tonight, namely the risk of injury to staff and patients from people who are suffering from alcohol or drug misuse. Staff who work in accident and emergency units work in a demanding environment. They deal with people who may have life-threatening medical conditions. From a patient's perspective, attendance at an accident and emergency unit indicates that he or she is suffering from either an accident or an emergency. Naturally, the patient's anxiety levels are raised. Both of these factors contribute to a highly charged emotional situation. Thus, it is not an overstatement to say that the tension levels in accident and emergency units are very high.

In such an environment, it is very unfair to staff or patients to be obliged to deal with a person who is aggressive because of alcohol or drug misuse. As a junior hospital doctor many years ago, I worked in a very busy accident and emergency unit in the centre of Dublin. I am acutely aware of how difficult an environment an accident and emergency unit is in which to work. The protection of staff and patients is paramount. I strongly support the use of deterrents to prevent or limit aggressive behaviour by drink or drug-fuelled attendees in accident and emergency units.

However, all who have worked or who work in accident and emergency departments agree that careful medical evaluation must be carried out before any action is taken against anyone who is aggressive. The person suffering from an underlying medical problem is not simply treated as if he or she was drunk. It is against the ethos of all who work in the health care industry to summarily dismiss someone who is drunk as simply that, without first carefully checking the person over for other problems. This is not an easy task, but it is done routinely in our accident and emergency units, especially at weekends. If the staff is satisfied that no medical or surgical problem exists, then the natural procedures for dealing with anyone who is drunk or disorderly should come into play, that is, it becomes a matter for the Garda Síochána.

There may well be scope for severe penalties for such disruptive behaviour in a hospital setting because of the vulnerability of other patients. Perhaps the Minister for Justice, Equality and Law Reform should examine that aspect. The motion and the amendment before us tonight are worthy of consideration and I commend the amendment to the House.

Ms F. O’Malley

I agree with what Deputy Devins has just stated about the proposals before us in the Fine Gael motion. He has demonstrated the problem very well because a patient might not necessarily be simply a drunk patient and there could be other factors. This is the danger. The motion before us is so ill-considered as to be utterly careless. Fine Gael is a serious party with an important contribution to make in Irish politics, but presenting such a motion undermines its credibility. I am sorry to be obliged to state this, because Private Member's business and the motions debated should be about a constructive dialogue on pressing political issues of the day. I will outline why it is careless. The first proposal concerns the introduction of a so-called "wet room" for those found to be drunk——

Dr. Twomey

Has the Deputy ever been in one?

Ms F. O’Malley

No, I have not.

Dr. Devins

What kind of question is that?

Ms F. O’Malley

The Deputy was trying to knock me from my stride. Presumably, such people are to be given a bed to sleep on to sleep off their inebriation. This is absurd. We have a problem with space in the first instance and in any event, as Deputy Devins and I have mentioned, patients need to be medically assessed. Therefore they will not be separated initially from the sober members among the attendees. Then one must determine whether someone is drunk which will take much effort and might require the involvement of the Garda. If one takes the idea to its limit, is the Deputy looking for breathalysers in the units? It is simply not a runner.

Dr. Twomey

We should ask Deputy Devins to expand on that point as he has the experience.

Ms F. O’Malley

It requires the provision of beds for sleeping drunks and extra gardaí as I have already mentioned. The practicality of the Fine Gael motion makes it ludicrous, which is a pity. Under these proposals, hard-working staff would spend far more time dealing with drunks and attending to their needs than doing what they are supposed to be doing, which is treating the accident and emergency patients.

The opposition's second proposal is to have extra gardaí in accident and emergency units at weekends. We have a proposal. It could not be called a policy because it appears to have been plucked from the air. Tonight in the Seanad, on another Private Member's motion, Fine Gael looked for extra gardaí to tackle anti-social behaviour. Between 1994 and 1996 Fine Gael presided over a reduction in the number of gardaí. Now that we have some more, we must think carefully as to how they are deployed and to have them going in and out of accident and emergency units chasing drunks does not appear to be the answer. Accident and emergency units would be more like a carnival than anything else.

Dr. Twomey

How many gardaí are there?

Ms F. O’Malley

That is a matter for another evening. The third proposal is for a new offence of threatening behaviour in and around accident and emergency units. How does one legislate for the term "in and around an accident and emergency unit"? Why is a new offence required? The behaviour outlined is already an offence. Again, Fine Gael expects the gardaí to patrol in and around every accident and emergency unit in the expectation of imposing an on-the-spot fine. The fourth proposal made by the party "calls on the Government to remove hangers-on who are under the influence". How does one define a hanger-on? If a person who may or may not have had a drink accompanies an injured person who may be a relative or an elderly person to an accident and emergency unit, is he or she also a hanger-on? This is simply a crazy notion. Finally, the motion contains the proposal to charge drunks double fees for non-treatment. The person must be medically assessed. Drunkenness must be defined and proven. Consent for an evaluation must be gained and a Garda may have to be present. Once it is decided that a person does not require treatment, Fine Gael want him or her to be charged twice for that. Fine Gael has not spared the public the company of drunks as they will not be separated until they have been assessed. Fine Gael has not freed up staff in accident and emergency departments as drunken individuals must still be assessed. If Fine Gael thinks this measure will deter somebody who is drunk from ending up in an accident and emergency department, it is more deluded that I imagined.

Not much thought went into this motion, which is a shame. Tonight's debate was an opportunity for Fine Gael to showcase its solutions to the problems facing accident and emergency departments but what it has produced only compounds the problem and takes valuable staff time from dealing with the issues.

Cecilia Keaveney

This is a very serious issue. I was convenor of the health committee in the previous Dáil and it was one of the major issues that came before us. I am disappointed by the motion because it misses the core issue. It talks about how drunk people who end up in accident and emergency departments should be treated and charged but it ignores why they are there in the first place. There is no suggestion or inclusion of any measure to tackle binge drinking. When we talk about matters like waste management, we always talk about reducing the problem as the first step. If the problem lies in people arriving seriously inebriated in accident and emergency units either because they have drunk so much that their stomachs must be pumped out or because of injuries caused by their excessive drinking, we should try to tackle the culture of drinking. I am not a killjoy and I enjoy a drink as much as most people in the House. However, we need to examine Ireland's image abroad, which is of a country where people drink until they fall down and then potentially cause problems in accident and emergency units. While the motion deals with accident and emergency departments, it would have been helpful to have had a discussion regarding how we can tackle the core problem associated with alcohol.

Excessive drinking leads to people going to hospital and alcohol can mask medical problems with potentially serious results, a problem which was alluded to by the two previous speakers.

The Government amendment talks about recognising the pressure on some of our accident and emergency departments, acknowledges that alcohol abuse is a significant contributory factor and refers to the Tánaiste and Minister for Health and Children increasing her determination to bring about improvements in accident and emergency services. I congratulate the staff in Letterkenny General Hospital which deals with this issue every weekend. The hospital needs additional space and its application for a number of additional units is before the Department of Health and Children. It is important that lack of space is addressed and that people have sufficient space to deal with patients. If a person becomes rowdy or aggressive, the problem for staff and other patients is compounded by lack of space. An example I was told about by an accident and emergency nurse involved a girl of 14 who was brought into hospital and had to have her stomach pumped out. When staff spoke to her later, she said she had spent almost €100 on drink but could not remember how many drinks she had drunk. When asked how many rounds she had bought, she said she had only bought drink for herself. This leads to the bigger question of why people from that age drink so much.

We must promote responsible drinking and examine the role of everyone in the community in tackling this issue. Hospitals need the necessary facilities, such as more space and more beds in Letterkenny General Hospital, to deal with people. The Tánaiste and Minister for Health and Children intends to further the ten-point plan by ensuring the necessary accident and emergency services are provided there. It is too bad that, for example, the coffee dock in Letterkenny General Hospital is sometimes closed due to lack space for A&E and surgical cases.

I look forward to the implementation of the capital plan with regard to accident and emergency services. I would have preferred if tonight's debate could have addressed the core issue of alcohol abuse but perhaps it could be debated in future Private Members' or Government time. We shy away from it and it is time we faced up to it and see if we can work together to find solutions.

Ms Cooper-Flynn

The motion is very well intentioned. However, it is slightly narrow in its focus, while recognising that drunkenness in accident and emergency departments is a very serious problem. I have consulted with accident and emergency units in my area, and it is true that many young people arrive in accident and emergency units who are drunk and simply need to sleep it off. They are not able to look after themselves and there is nobody to look after them. Many drunken individuals who arrive in accident and emergency departments have a serious injury, perhaps as a result of a fight, and need treatment. Some people, often older people, who are admitted to accident and emergency departments are habitual drinkers and need to be admitted to hospital to detox and receive treatment. While many drunk people are admitted to accident and emergency units, they are not all disorderly and violent. Unfortunately, even if a very small percentage of them are, they cause mayhem for staff. From that perspective, I understand Deputy Twomey's perspective.

I wish to focus on a more general issue in accident and emergency services, particularly the ten-point plan and how it relates to a general hospital in my constituency. My concern with regard to many of the proposals put forward tonight and in the ten-point plan is that they are very focused on cities. Even when the Health Service Executive gives us a progress report on the ten-point plan, it tends to focus on the eastern region and new facilities for Dublin hospitals. I have visited the accident and emergency department in Mayo General Hospital on at least five occasions since Christmas and there are up to 18 people on trolleys on a regular basis, particularly at weekends. When the Health Service Executive came before the Oireachtas Joint Committee on Health and Children, it told me that there have been an average of nine patients on trolleys since Christmas. That may be the case but on any given week, there are up to 18 people on trolleys on one or two nights at the hospital. There are people who have to spend up to two nights on a trolley, getting no sleep and sometimes in the company of very drunk individuals, which is of huge concern. Having spoken to the staff and consultants about what they see as the solution, I do not see much mention of it within the ten-point plan. The main solution to the crisis in accident and emergency departments is more beds. We have a growing population and improved medical practices and technology but the number of inpatient beds has not kept pace with this. Deputy Mícheál Martin when he was Minister for Health and Children did a very good job in substantially increasing the number of accident and emergency consultants. However, there was no corresponding increase in the number of inpatient beds. While there are additional consultants, they can only work with the facilities that are available to them.

Another very important issue that must be addressed as soon as possible is changing the consultants' contract. When a consultant only works 33 hours per week and his or her hours are sometime between 9 a.m. and 5 p.m., there is no senior clinician in many accident and emergency units in the early hours of the morning when many of these problems occur. One of the recommendations of the Health and Safety Authority's report was that a senior clinician should be in charge of accident and emergency services. Accident and emergency consultants have plenty of experience in dealing with crises, in assessing a person and discharging him or her if appropriate. However, junior doctors attending to patients commonly err on the side of caution and admit rather than discharge people for fear of making the wrong decision. If a person of sufficient medical seniority were in the accident and emergency departments, they would be more effective in managing the activities and making better use of available resources. Dealing with this critical issue must be a priority.

I ask the Minister of State to bring to the attention of the Tánaiste an issue relating to the ten-point plan, that is, nursing home places for high dependency patients and step-down beds for intermediate care. I asked what facilities were being put in place in the west, in particular in Mayo, and was told this is a nationwide programme. However, not one County Mayo nursing home has tendered for beds because they were told when they contacted the HSE that they must have a minimum of ten beds available. In a 30-bed or 40-bed unit there will not be ten beds available at any given time to contract out to the HSE. Nursing homes were also given a short period of time in which to put their tenders in place. If no one has tendered, how can this be an effective mechanism to deal with the accident and emergency crisis?

Acting Chairman (Mr. Sherlock)

I must ask the Deputy to conclude.

Ms Cooper-Flynn

The plan is predominantly Dublin-based. This is a serious issue, particularly in respect of home packages and where they apply throughout the country.

Ms Sexton

I take this brief opportunity to thank the Tánaiste for her clear and concise contribution on this motion yesterday evening. If it were needed, the House was given further reassurance on the significant endeavours and numerous plans that are being put into place to meet what I consider to be the challenge of the decade. I take this opportunity to place on record something that every Member possesses, namely, our esteem and respect for the work of nurses, doctors and staff in all accident and emergency departments, especially those who work under severe pressures in particular units. The Tánaiste has placed on the record her commitment to follow the recommendations of the Health and Safety Authority to move patients from accident and emergency unit trolleys. No one here would disagree there is an increasing problem of intoxicated persons turning up at accident and emergency departments.

We on this side of the House concur with elements of the Private Members' motion but difficulties are posed by the calls on the Government to act in certain ways to deal with the problems. The motion concentrates on those presenting with alcohol-fuelled aggression. It fails to take into account that 30% of male admissions, 10% of female admissions and almost 25% of all accident and emergency attendances meet the diagnostic criteria for alcohol misuse or dependency, which poses its own problems. Medically, it is widely accepted that this misuse of alcohol can be closely tied to deeper psychological issues and the measures required to adequately and safely address the issues are being developed to ensure the proper and long-term strategies are devised and delivered.

There is the danger that we may think of drunks in accident and emergency units as a single uniform group, but that is not the case. I welcome the Tánaiste's announcement of initiatives to identify appropriate care settings at community level and the development of accident and emergency triage arrangements to enable more appropriate assessments and treatments of people with psychosocial issues. The House is unanimous in that any and every possible threat or abuse a health care worker might face must be removed. I hope a working partnership of management and trade unions will be in place to enable the implementation of the HSA's guidelines in the near future.

We have a duty to ensure all possible and practical steps are taken as quickly as possible. To this end, the Minister for Justice, Equality and Law Reform, Deputy McDowell, is determined to see that all efforts are made to tackle disorderly behaviour, in particular, assaults on emergency workers such as those in accident and emergency units. The Criminal Justice Bill 2004 provides for a fixed charge procedure regarding certain public order offences, which is welcome. That is in addition to legislation dealing with disorderly behaviour. I hope the penalties for disorderly conduct and intoxication in a public place receive the support of all Deputies. I also welcome the Minister's decision to examine the current position of assaults specifically against emergency workers. There is an acute possibility of providing for a specific offence in this respect by way of an amendment to the Criminal Justice Bill and I welcome that.

Asking the House to approve a motion calling for the Government to round up "hangers on" reveals a disregard for medical, legal and civil liberties and focuses on just one factor that creates difficulties for accident and emergency patients, which, when solved, will not be a panacea for the enormous difficulties that exist. The combined efforts of the many sectoral workers in the interests of patients will be required, such as out-of-hours GP services, 24-7 diagnostic testing availability and the co-operation and goodwill of everyone working in the provision of health care to deliver the type of health service of which everyone inside and outside the House will be proud.

Mr. Moloney

I welcome the opportunity to speak on the Private Members' motion. While I do not agree with the expressed wish in the motion I understand the sense of it and where the Opposition is coming from. Unlike most Private Members' motions, this is not a political device but an attempt to deal with an issue that is causing much concern throughout the health services. That so many people are attending accident and emergency units by way of drink-related abuse creates a problem for us all.

I do not wish to refer to many studies, but the health promotion unit in its study makes the point that 30% of male admissions and 10% of female admissions were drink-related. We must deal with this problem. I do not concur with the idea of wet rules, although I understand the thinking behind it. By coincidence, I spent two hours last Saturday evening in the accident and emergency unit in Portlaoise. We all understand the strains and stresses placed on staff. I take Deputy Cooper-Flynn's point that the ten-point plan is geared towards city hospitals. That concerns me and the matter should be examined further.

I will focus on one issue. In the past fortnight I was invited, as chairman of the Joint Committee on Health and Children, to a conference held by Alcohol Action Ireland dealing with alcohol abuse. Many presentations were made by people in the front line, particularly accident and emergency consultants. Those people have a specific submission to make concerning alcohol abuse and the consumption and sale of alcohol. I come from a public house background and I made the point at the conference that in dealing with alcohol abuse it is important to involve the drinks companies and the trade. Subsequent to the conference, I made contacts with representatives of the drinks trade. It is important to state that to attack the drinks trade purely for the sake of blaming it for all the ills of society is not the answer. The drinks trade has come to the understanding that for its future well-being, its members must become involved in finding the solution. When we examine the figures outlined by the group at that conference, there is a distinct problem in Ireland compared to other European countries not just with binge drinking but also under age drinking. That problem is evident in accident and emergency departments.

We should call on the drinks trade to put part of its profit, which is not meant in a negative sense, into promoting or conducting a study vis-à-vis the universities and colleges to determine the reasons Ireland is to the fore in terms of the effects of binge drinking and alcohol abuse. We must also recognise that, rather than condemning the practice for the sake of it, all the partners should be involved. As a member of the Vintners Federation of Ireland for many years, it is not in the interests of the vast majority of publicans to carry the so-called tag that the abuses and ills of society are directly related to the drinks industry. They must become involved in finding a solution.

I refer to two points made by the Tánaiste which are worth taking into account. It would be a mistake to expect short-term actions on alcohol abuse to solve the wider problems. Tackling alcohol abuse would not, for example, improve rostering to ensure patients are seen, diagnosed, treated and discharged quickly. That should be taken into account. I recognise where the motion is coming from and understand the concerns, but I agree with the Tánaiste that consultants must change their working hours, given that patients often have to stay overnight in accident and emergency units because no consultant is on duty between 6 p.m. and 8 a.m.

While I support the thinking behind the motion and understand why we must tackle this issue immediately, I will not vote for it. From reading the percentages of those presenting in accident and emergency units, if we can resolve the problem in the long term, it will have a significant beneficial effect on the difficulties in our accident and emergency systems.

I support the Tánaiste in all she has done since coming to office. The ten-point plan must be a road map for us to deliver at least on commitments to resolve the accident and emergency crisis. I ask the Minister of State to ensure that the ten-point plan is not only a solution to the difficulties experienced in the major centres. A pilot study should be carried out on how what is proposed will impinge to the benefit of rural hospitals.

I support the amendment to the motion in recognition that some action must be taken to resolve the crisis. This House should invite those who have a stake in the industry to become part of the solution in terms of the difficulty caused by the abuse of alcohol.

Mr. Morgan

I wish to share time with Deputies Finian McGrath, Catherine Murphy, James Breen, McHugh and Gormley.

Acting Chairman (Mr. Sherlock)

That is agreed. The time allocated is limited and therefore I will keep an eye on the clock.

Mr. Morgan

The acting chairman should keep an eye on the speakers with whom I am sharing because they will be worth hearing.

Mr. McHugh

The acting chairman can use the guillotine mechanism.

Mr. Morgan

I commend the Irish Nurses Organisation for its ongoing campaign, Enough is Enough. We need more people at the forefront of our health services to follow its example. It is heartening to see hundreds of people join nurses on their lunchtime pickets at hospitals throughout this country. The INO had a successful meeting at Our Lady of Lourdes Hospital in Drogheda the week before last, which I was honoured to join and support its members in their case.

The ongoing crisis in our accident and emergency units reached a critical stage on 20 April when the Health and Safety Authority criticised the level of congestion in accident and emergency departments saying that it increased the risk of injuries, infection and violence. The criticism followed a programme of inspection of 11 accident and emergency departments that commenced in March. The report stated that there were many issues in accident and emergency units that require immediate attention. It highlighted trolleys, chairs and medical equipment stored in fire-protected corridors and at doorways. Eight of the hospitals were reported to fire officers because exit doors and corridors had been obstructed. If this occurred in a hotel, I have no doubt the premises would be closed, but then that is part of the agenda of the Government in respect of hospitals in any event. The report emphasised how overcrowding leads to an increased risk of injury, infection and violence from frustrated patients.

The report, which was given to the Health Service Executive, also criticised the lack of senior clinicians in accident and emergency departments on a 24-seven basis. In the meantime we had the ongoing Enough is Enough campaign by the INO. What is the current position in our accident and emergency departments? The INO's trolley watch for yesterday, 10 May, reports that there were a total of 274 people on trolleys, with 150 in the eastern region and 124 in the rest of the Twenty-six Counties. That is a fine record.

We need to examine the accident and emergency issue from a long-term perspective. The Fianna Fáil-PD Government has been in power continuously since 1997. It was elected in 1997 and re-elected in 2002 on the promise that it would sort out the mess in accident and emergency units and clear the hospital waiting lists. One would think the Minister, Deputy Harney, had no responsibility for this mess over those eight years. She carries on as if she did her leaving certificate last June, was elected to the Dáil in July and took over the Department of Health and Children in September, still wet behind the ears. We are expected to give the Minister the benefit of a honeymoon period. That honeymoon period did not end last month but in 1999. In 2002, this coalition was re-elected on the promise that the hospital waiting lists would be cleared by 2004. However, we know the reality. We do not even have figures for the large number of people on waiting lists to get on to hospital waiting lists.

An e-mail I received from a friend yesterday stated:

The next time the government claim that they have cut the waiting list they should be told that is not true, what they do is not to put people in the list anymore. We got a referral for Temple Street Children's hospital at the beginning of April, I rang in May to the hospital to know why didn't I receive an appointment and I was told that they were still dealing with referrals made in February. Basically, I was told that I was on the list to get on to the waiting list.

I will not include the comment that correspondent made about the Minister for Health and Children.

The main focus of this motion is the chronic situation in accident and emergency departments, especially at weekends. Staff and patients are often in danger given the risks associated with overcrowding. People coming into these departments drunk, worsens this position. Many contributors have dealt with the issue of alcohol abuse, but that is not the fundamental point, which is the under-resourcing of these accident and emergency facilities.

Mr. F. McGrath

I thank the Chair for the opportunity to speak on this Private Members' motion on the health service and the work of nurses, doctors and staff of accident and emergency units who work under severe pressure each day.

I support the motion but before I go into detail it is important to state that the Government should stop pussy-footing around on the health issue and provide more beds. While this motion deals with anti-social behaviour of some people visiting our hospitals, the primary issue in any accident and emergency department is the need for beds. We need approximately 500 beds immediately and then we can increase the number of beds over a reasonable period. We have had enough when it comes to talk and reports, we want beds in hospitals.

I demand and put forward a proposal for the immediate implementation of the an action plan, including the ten-point plan for accident and emergency services, to bring about some improvement in the short term, and the development of a hospital development plan with a different time frame and funding commitments for the introduction of additional acute and non-acute beds promised in the Government's health strategy. I also demand better management of existing resources, including the lifting of the employment ceiling on nursing and other front-line staff, the opening of all closed beds with appropriate staffing and proper administration of admissions and discharge policies. These are three sensible proposals to end the nightmare for patients and staff at our accident and emergency departments.

The Government should hang its head in shame for the way it has dealt with the crisis in our hospitals. It is a disgrace and a clear breach of the civil liberties of patients and their families. The manner in which it has dealt with the crisis is also an abuse of our citizens and taxpayers, it having been in power for eight years and having spent €30 million on reports.

I also support the proposal for "wet rooms" where those found simply to be drunk, following a medical assessment, but not ill or injured, would be separated from other patients, especially our elderly or seriously ill patients. These are important issues for all patients and staff.

I am sick and tired of listening to constituents and complaints from patients and their families over the past eight years, yet nothing is being done in this area. I call on the Minister to come into the real world and to listen to the constructive proposals in this debate. This motion is about health care and our people but above all it is about providing a top quality health service for all our citizens, regardless of income, colour or creed.

Ms C. Murphy

I welcome the opportunity to speak on this motion. I know many nurses who no longer practice nursing and on pressing them for the reason they dropped out of the profession, they told me they no longer got pleasure from nursing. The constant pressure they were under and the overcrowded conditions also contributed to their decision to leave the profession. We are losing experienced skilled professionals at a time when we are going overseas to recruit staff. That does not make sense.

One need only visit an accident and emergency department at the weekend to see the problems that exist. From my few experiences of visiting accident and emergency departments, I detected that a menacing atmosphere prevailed. That is the only way I could describe the atmosphere. Overcrowding in the accident and emergency departments leads to a lack of security. If one were to watch the main entrance to a hospital, one would notice four or five people entering the hospital at a time looking for the accident and emergency department. It is unfair on nurses and doctors and it is impossible to ask them to monitor the people coming into the accident and emergency department. They do not know who is visiting a patient and that adds to the problem. There is no doubt that people being drunk in accident and emergency department is causing a problem.

A few weeks ago I attended the Naas General Hospital protest — that hospital together with Tallaght Hospital and Blanchardstown Hospital serve the people of north Kildare — which has 200 beds, 36 patients were on trolleys. That was the day that Punchestown festival got under way a great contrast could be made between that festival and the hospital protest. I agree with what an earlier speaker said about the proposal to provide "wet rooms" in that there would not be space to provide such a room in the hospital to which I referred. There is not even space for trolleys because it is so overcrowded. This problem needs to be addressed. Portacabins were provided while the hospital was under construction. I am sure they were the same type of portacabins that were offered on "Liveline" but for health and safety reasons were not accepted. We drop our standards in a crisis. It is important to focus on the health and safety issue in regard to hospitals.

There is also a problem isolating superbugs as a result of a lack of space, which is a health and safety issue. The major problem is the lack of space which needs to be addressed in a comprehensive manner.

Mr. J. Breen

It is very stressful for anyone having to attend an accident and emergency department in any hospital. This stress is compounded by concern about themselves, long delays, overcrowding and lack of adequate resources to deal effectively with the number of patients requesting treatment for a wide variety of illnesses. It is particularly stressful if one finds oneself in the midst of people who are drunk, high on drugs or, more commonly, have taken a mixture of both. It is unfair to ask people with genuine medical needs to tolerate such abuse by some people who are only there because of binge drinking, drug abuse and self-inflicted injuries as a result of their stupidity. We ask people to wait while these people are treated, even though they are usually abusive and sometimes violent towards staff and the public.

It is a sad reflection on society that we allow such situations to happen in our hospitals. It is worse on Friday and Saturday nights. If extra gardaí were present in accident and emergency units on such nights with the power to invoke on-the-spot fines of €200 for threatening, abusive or insulting behaviour, it would soon result in a decrease in such instances. Hitting these people where it hurts, namely, in their pockets, might be one way of getting through to them that their behaviour is intolerable and against the law. Many people are so out of it on the night in question that they do not even appear to know or care what is going on. If they wake up in a cell the following morning and find they are out of pocket by €200, they will think twice before again getting into the same situation.

Many people are afraid to attend accident and emergency units for fear of being abused and intimidated by these people. It is time we stood up for our rights and showed these people that this type of intimidation will not be tolerated. We have a responsibility to protect people from such abuse. If people are found to be drunk but not ill or injured, a hospital is not the place for them. If they cause a disturbance or infringe other people's rights, they should be removed immediately and confined somewhere until they sober up. The hangers-on who accompany such drunks should not be allowed inside the building if they are intoxicated or being abusive.

We owe it to the public to enforce the law and ensure such behaviour is duly ended and the offenders punished appropriately. We must allow the staff who work in these accident and emergency units to do their job in a safe environment. The Government amendment asks us to note the recommendations of the Health and Safety Authority. I ask the Government not just to note the recommendations but to act on them immediately. We cannot tolerate a situation in which hard-working staff in accident and emergency departments must endure threatening, abusive or insulting behaviour during the course of their work. The situation is bad enough without this type of pressure. I call on the various Departments involved to ensure that appropriate legislation is enacted to protect such workers and the public.

It should not take the Tánaiste as long to implement the ten-point plan as it did to deal with my complaint about the MRSA superbug which she undertook to deal with in the Dáil last October. It is now seven months on and I have heard nothing from her.

Mr. McHugh

I am pleased to have an opportunity to speak on this Private Members' motion. My comments may not find full favour with Deputy Twomey, but what I have to say is what I believe. My comments relate to the structure of the motion rather than its sentiments.

It is a very simple motion which calls for a particular way to deal with people presenting at accident and emergency departments who are under the influence of alcohol, which is a laudable sentiment. Surely this is a matter for local hospital management. It is a hospital micro-management issue which should be dealt with by management at accident and emergency level. The motion calls on the Government to implement health and safety procedures for staff and patients within the hospital environment.

This is an issue for hospital management at the coalface. Health and safety procedures must be the responsibility of local management. It is very simple. Health and safety procedures cannot be universal; they must be site specific. If not, they are only being developed as a cosmetic exercise. Site specific health and safety procedures are a matter for local management. The motion refers to removing hangers-on from accident and emergency units. Again this is an issue for management at local level.

The motion should call on the Government to provide the additional resources to ensure accommodation is provided in accident and emergency departments and provide the ancillary accommodation needed so that management can implement the measures called for. In that regard, I make a plea to the Tánaiste to ensure the application from the Health Service Executive western region for the provision of an assessment unit at Galway Regional Hospital is approved forthwith so that management there can set about improving the situation at the accident and emergency department.

I also appeal to the Tánaiste and the Minister of State, Deputy Brian Lenihan, to ensure that approval is given to the Tuam hospital project so that a community hospital can be built to replace the hospital that closed four years ago. The Tuam community hospital would act as a step-down facility. It would relieve the pressure on University College Hospital Galway, which is an acute hospital and a centre of excellence, and allow people to recuperate in an environment closer to home in a community hospital. That is the genesis of the Hanly report. I ask the Tánaiste to put it into effect on a pilot basis. She should use Tuam, a hub town, as the location to put the theory into practice.

Mr. Gormley

I said this afternoon that the strategy for primary care would help to alleviate much of the problem at accident and emergency units. The Tánaiste replied that there was under-investment in primary care strategy, a strategy which I welcome and which could deal with 90% of illnesses. Why was the last meeting of the steering group on primary care cancelled? I believe it was because the membership realise the investment will not happen. We know that prevention is the best way to deal with illness. One in two people are overweight, one in eight are obese and 90% of people with type two diabetes are obese, yet the response of the Government is to endorse the health and nutrition foundation. This foundation is sponsored by people like Coca Cola and McDonalds. It reads like a "who's who" of obesity-friendly companies. Surely this should tell the Tánaiste something about the lack of joined-up thinking and consistency in the Government. It makes no sense to me, yet it appears that the Tánaiste will accede to the request of IBEC and endorse this particular foundation.

The problem in our accident and emergency units is a capacity one. We have 25% growth in our population and 25% fewer beds. It is obvious that there is a major capacity problem and the Government has failed to deliver on the 3,000 beds it promised. Instead the Tánaiste seeks to scapegoat nurses. In her speech to the Irish Nurses Organisation she spoke about flexibility. If one reads between the lines, what she is saying is very clear. She is saying that either they do what the Government and the Health Service Executive says or else there will be no pay increase. I support the claims of the nurses. These are the people at the front line, who work their guts out in terrible conditions, surrounded, as we have heard, by drunks and people on drugs. Their place of work is like a war zone, as I said to the Minister for Health and Children on one occasion. In spite of this, she is trying to force nurses to accept a pay deal. This is very regrettable. The Green Party supports the nurses unequivocally. They do Trojan work. I hope there will be a resolution to the dispute but if there is none by 9 p.m., we will certainly continue to support the nurses' cause.

We have a cultural problem in regard to alcohol in that we do not regard it as a drug. Drinking is our very worst drug problem and is worse than the abuse of heroin, crack cocaine and cannabis. Why, therefore, have we not implemented the range of recommendations of the task force on alcohol abuse? These have been put to one side. We do not implement them because the drinks companies are enormously powerful and wield considerable influence. Drinks companies should not sponsor sports events. There is a proliferation of pubs and we are doing nothing to tackle the drink problem at source. Drunks should not end up in accident and emergency units. This does not happen in other cultures. Consider the Italian experience in this regard. Why do we not tackle the drink problem at source?

Mr. Neville

I wish to share time with Deputies Kehoe, Ring and McGinley.

Acting Chairman

Is that agreed? Agreed.

Mr. Neville

I commend Deputy Twomey for tabling this very important motion on developments in accident and emergency services. These have been discussed at length, mostly in respect of delays and the consequent difficulties, such as patients having to lie on trolleys in corridors.

We must ensure the protection of patients and staff who suffer from abuse in accident and emergency units, especially in the evenings at weekends. This problem has been mentioned but its extent has not been highlighted. The arrangements for protecting staff have been proven to be inadequate. The staff, who expect protection, are serving the extremely vulnerable. A very delicate procedure applies in the case of ill people being admitted to hospital. They are under considerable stress owing to their circumstances.

A survey indicates that 80% of staff in accident and emergency units stated they had been verbally abused at some stage. This is extremely worrying and should be dealt with as a matter of urgency. The suggestions in the motion before the House should be considered seriously and introduced by the Government.

While there is an avenue to express concerns for the safety of hospital staff, there is no official avenue for expressing concern over the safety of patients. I know what it is like for somebody who is seriously ill and awaiting assistance to have disorderly and often drunk people in their vicinity. One feels for the safety of patients in such circumstances.

The motion proposes that special wet rooms be introduced for people who are deemed drunk following a medical assessment. Some will argue such people should not be tolerated or admitted to hospital at all, but I appreciate the Minister could not agree to this. He must be concerned for the safety and health of all people as they seek admittance to hospital, regardless of their condition or the abuse to which they subject themselves or others. The argument that drunks should not be admitted obviously cannot hold.

We must take into account the suggestion that extra gardaí should be available in accident and emergency wards, especially during the high-risk periods. The issuing of on-the-spot fines for public order offences committed in and around accident and emergency units may act as a deterrent. People who abuse themselves and others often offend repeatedly and present themselves at accident and emergency units on several occasions over a period. They should be made aware that they will be dealt with differently and that their behaviour has consequences.

As I stated, a survey showed that 80% of staff in accident and emergency units were verbally abused. Some 56%, more than half, stated they were subject to threatening verbal abuse. Some 80% of nurses stated they were sexually harassed. This is intolerable and a programme should be introduced to deal with it. My colleague Deputy Twomey outlined such a programme.

The aforementioned problem highlights the difficulty faced by the State, perhaps because of its affluence, as a result of the abuse of alcohol, especially by young people at places of entertainment during weekends. It must be stated, however, that the majority of young people are extremely well-behaved, extremely responsible and would never dream of engaging in disorderly behaviour. Unfortunately, there is a minority with which we must deal.

The report of the task force on alcohol consumption indicated that the increase in consumption is directly related to the incidence of accidents, unprotected sex and chronic illness. The problems the report stresses affect people right across the community. It is stated that alcohol was a factor in one in four visits to accident and emergency departments and 97% of public order offences.

The report cites a study of seven European countries that indicates that Ireland has the highest level of binge drinking, with 58% of drinking occasions ending up in binge drinking among men, and 30% among women. Alcohol-related mortality has increased in line with the increases in alcohol consumption, particularly alcohol-specific chronic conditions such as dependency, abuse and psychosis, and acute conditions such as alcohol poisoning. Nearly €6 billion of personal income is spent on alcohol in Ireland each year. Alcohol is the third most detrimental risk factor for European ill health and premature death, after only tobacco and high blood pressure.

Alcohol abuse, therefore, is a very serious issue. While we highlight it, we do not seem to be able to tackle it properly. I do not know if there is sufficient commitment. I examined the reports and campaigns of the Department over the past three or four years and noted that they do not seem to have any effect. Is the Department evaluating the success of its campaigns? I have raised the link between alcohol and suicide on numerous occasions.

Today I tried to raise the need for the Dormant Accounts Fund Disbursements Board to fund suicide prevention programmes and tried to draw attention to a report on this subject, but unfortunately I was not allowed to do so. The Chair was unfair in this regard and the latitude I expected was denied to me.

Mr. Kehoe

I thank my colleague Deputy Twomey for tabling this important motion. This issue affects everyone in this House and in the broader community. In the past year I saw a "Prime Time" programme about people who, having consumed large quantities of alcohol, wound up in accident and emergency departments on weekend nights. This is a serious problem. Deputy Twomey has made some good points in this motion, which I urge the Government to support. These proposals would go a long way towards solving the crisis in accident and emergency departments, especially on weekend nights.

Deputy Neville said one in four people present at accident and emergency departments with alcohol in their system. In recent years attendances in accident and emergency departments have increased. The attendance in the accident and emergency department of Wexford General Hospital in 2000 was 21,398 and in 2004 it was 28,467, an increase of 7,069 or 33%. Doubtless many of those were involved in drink-related incidents.

A drink culture of alcohol abuse has developed among young people. Most of those in accident and emergency departments at night, especially at the weekend, are aged between 16 years and 24 years. One regularly sees ambulances on the streets of Dublin and outside nightclubs at weekends collecting these young people from the streets and bringing them to accident and emergency departments where they clog up the hospital system. The safety of medical staff working under severe pressure in accident and emergency units must be considered. That is why it is good idea to place gardaí in those units on weekend nights.

The only way to teach these people a lesson is to hit them in their pockets. If they must pay to attend an accident and emergency unit when they are drunk, they will quickly recognise they cannot regularly behave in this way. It would be interesting to know if the same offenders appear each weekend or on several occasions.

I call on the Government to support the motion and recognise its importance.

Mr. Ring

I am delighted to speak on this motion and I compliment Deputy Twomey on tabling it. By accepting this motion, the Government would show that it intends to deal with this problem. The Government has a vested interest in alcohol because of the tax income it earns from it. When one calculates the amount earned in taxation and the amount spent in hospitals, common sense suggests something should be done to resolve the problem. If we made the same effort to deal with the drink problem as we made to implement the ban on smoking in the workplace, we would have a better society. Abuse of alcohol is too widely accepted by the general population and by the Government. When someone has cancer, people say he or she must be treated but the response to someone on the street who is drunk and abusive is to pity the poor fellow. No other disease evokes such sympathy but it should not receive it.

People should be made to take responsibility for themselves. For example, I was in a hospital late one night for an emergency when a person who was intoxicated was brought in following an accident in a pub. Twenty-one members of his family arrived and created chaos in the hospital. I must be politically correct so I will not name the section of society from which these people came or the media will attack me. Anyone would know of whom I speak. Eventually, the gardaí were called to remove the people from the hospital because the medical staff could not do their job and the people who were genuinely sick were frightened by this behaviour. It is wrong that medical professionals who must deal with the sick, injured and traumatised should also be faced with people who are drunk.

The extension of opening hours in licensed premises was a scandal because the Government conceded to the vested interests. As a result, thousands of people come onto the streets at the same time in the middle of the night in every town and village. This not only applies to Dublin but is true of Mayo and the west as well. It is not safe to be on the streets at night because people are drinking and misbehaving.

The time has come to take on the drink culture, like it or not. I compliment the "Prime Time" programme on showing us what happens at night. Sometimes politicians are out late and see the thuggish behaviour of people coming out of nightclubs onto the streets. This problem must be cleaned up. When a politician goes into a pub, within three minutes he or she is cornered for the night by a drunk. No matter what one does, it is impossible to get rid of him. The first thing the politician wants to do is leave. I could tell a story on this topic but it might not be suitable for this House.

Something must be done about the drink culture. Hospital staff must be protected. It is bad enough that people who are genuinely sick must be there without having to put up with this kind of nonsense. The Garda Síochána probably will not be able to police these departments because they find it difficult enough to police towns and villages.

Mr. McGinley

This is a timely and opportune debate. Two events precipitated it. One was the visit by the leader of our party, Deputy Kenny, and our health spokesperson, Deputy Twomey, to several Dublin hospitals. They witnessed the chaos that reigns there, particularly at the weekend, caused by people under the influence of alcohol being brought in after closing time in the pubs. The second factor was the recent report by the Health and Safety Authority supporting what Deputies Kenny and Twomey saw on their hospital visits. Abuse of alcohol generates chaos and pandemonium in accident and emergency units. However, such chaos is evident in many accident and emergency departments and is not always caused by abuse of alcohol, rather by inadequate facilities in these departments.

This is true of the hospital with which I am most familiar, Letterkenny General Hospital, which serves a population of 140,000 in Donegal. This year, and for most of last year, the accident and emergency section in that hospital was effectively taken over, such were the number of people on trolleys. Operations and day procedures were cancelled. The hospital system was thrown into pandemonium. Deputy Twomey visited Letterkenny General Hospital, met the consultants and saw how inadequate facilities are there. The hospital applied several years ago for a new accident and emergency department. What is there at the moment is completely inadequate. A new accident and emergency department would relieve some of the pressure and prevent the cancellation of important operations and procedures in the hospital. There is also a shortage of beds. There are less than 300 beds in Letterkenny to serve the population of Donegal, which is 140,000. We need 60 or 70 additional beds. The application is with the Department and is awaiting sanction. I appeal to the Minister of State, and ask him to convey to the Minister, that we need a response as soon as possible. In Donegal we are entitled to as good a health service as any other part of the country. The two priorities are a new accident and emergency department and 60 or 70 extra beds.

Minister of State at the Department of Health and Children (Mr. B. Lenihan)

I thank the main Opposition party, Fine Gael, for tabling this motion, which is good. The Minister has tabled an amendment, as is traditional, which goes some way towards recognising the concerns shared by all Members about conditions in accident and emergency units. In this city the Mater Misericordiae Hospital and the Connolly Hospital, Blanchardstown, are frequented by my constituents and I am aware of the conditions that obtain in each of these. In one, conditions are very difficult and in the other, conditions are excellent.

The Tánaiste has clearly demonstrated her commitment to improving the delivery of accident and emergency services. From the time of her appointment she has said that this is the top issue she has to tackle in the Department. It is a priority for her and for the Government. It will take time for the measures in the ten-point plan to be fully implemented. I wish to make clear that the ten-point plan is a beginning, not an end. The funding provided for it is additional to the substantial and growing resources for hospitals, long-term care and primary care. The Health Service Executive is working to deliver these measures and on additional actions by hospitals to ensure that the investment produces sustainable solutions. Work is under way to achieve a measurable effect in improving patients' experience of accident and emergency departments.

The Minister of State at the Department Of Health and Children, Deputy Tim O'Malley, provided details of the progress being made on the ten-point action plan. A total of 64 patients from hospitals in the eastern region and 23 patients in the Cork region have been discharged as a result of the intermediate beds being provided in private nursing homes. Additional home care packages have been provided, resulting in 51 patients being discharged from acute hospitals in the eastern region and discharge arrangements are being finalised for a further 45 patients. References have been made to experiences of individual patients in their encounters with the acute hospital system, but more than 100 individual patients so far have benefited from the specific actions being taken to free up acute beds. These patients have returned home or have been placed in a more appropriate care setting.

Capital investment in acute hospitals is resulting in modern accident and emergency departments being made available to treat patients. Only this week the Tánaiste officially opened the new accident and emergency department at Cork University Hospital. Not long ago, as Minister of State at the Department of Health and Children, I had the pleasure of officially opening the new hospital block and accident and emergency department at Connolly Hospital in Blanchardstown.

Yesterday evening there was an article in the Evening Herald containing a number of allegations about conditions at that accident and emergency unit. Management in the HSE northern area, wrote to the editor of the Evening Herald pointing out the inaccuracies in the article. One must be careful when making allegations about these matters. I know Members of the House have not abused their privilege in the course of this debate — far from it — but it is sad that an article appears in an important newspaper, which has a substantial circulation in the Dublin area, suggesting that conditions are not as they should be in a particular accident and emergency unit. This article was published yesterday and was associated with a photograph of a local Fine Gael representative in a parallel article.

Management had to write to the HSE pointing out that the article contained the wrong name of the hospital and the wrong date for the opening of the accident and emergency unit, and comments regarding overcrowding in the accident and emergency department were completely unfounded. That was frustrating and insulting to the emergency department personnel, whom I salute. Since the opening of this unit they have done a fabulous job in providing the best accident and emergency unit in the Dublin area. With the assistance of management, they are to a significant degree managing waiting times. The average waiting times in that hospital are among the lowest in the eastern region. Individual cases were mentioned in the article upon which we cannot comment, but one of the cases mentioned was not treated in the accident and emergency department on or around the date stated in the article.

On the dates referred to in the article, the average waiting time on 5 May, from registration to triage was ten minutes and from triage to a doctor, two hours and 14 minutes, while the average waiting time to admission was seven hours and 50 minutes. They are the facts. The average waiting times on the weekend of 7 and 8 May were, from registration to triage, 12 minutes and from triage to doctor, two hours and 50 minutes, while the average wait time to admission was eight hours and 40 minutes. It is accepted that cardiac patients may require a telemetry bed, which is a specialised procedure and can add to wait times. A chest pain observation unit will be commissioned in the emergency department in July 2005, which will ensure that patients presenting with chest pain will be treated in a dedicated facility and within a shorter timeframe.

Contrary to what was suggested in the article, there are no new wards lying unused in the hospital. It is important newspapers check their facts before printing articles about conditions in accident and emergency units. I do not take from any Member of the House who has made comments this evening, but the allegations in that article about a fine hospital where there is a new accident and emergency unit were wrong.

Mr. O’Dowd

I wish to share time with Deputy Twomey.

An Ceann Comhairle

That is agreed.

Mr. O’Dowd

There were photographs in all the newspapers of public representatives from Fine Gael and other political parties complaining about the problems in accident and emergency units. I attended one protest in Drogheda and spoke to the nurses and staff, who are under dreadful pressure. I am not aware of the case the Minister of State referred to, but there is a serious problem throughout the country in accident and emergency wards.

The most common complaint I get is from people who are retired, have given their lives to the State, reared their family and done their best, but end up, through no fault of their own, in accident and emergency departments. They feel bad having to lie on trolleys for perhaps a day or two and feel the Government is not providing the care to which they are entitled. The Minister for Health and Children has been in this office for less than a year, but she sat at the Cabinet table for the past five years and, while she has introduced new plans, the Government has done nothing about the problems.

I am concerned about the so-called Health Service Executive. It is somewhat like Alcoholics Anonymous, one does not know who the people involved are and cannot find out. It is very difficult to get information about what is going on in our hospitals. There are no performance indicators for the HSE, there are no discussions in the Dáil about it and it is not responsible in terms of parliamentary questions. We do not know who the people involved are, nor the changes they have made. We do not know what is going on until we see and hear from nurses. It is appalling. Previously there were health boards, with all their faults, but they are gone. Now there is the HSE and we cannot get information from it. We are told in replies to parliamentary questions that the HSE will respond in due course, but we do not know whether it will do so.

I suggest one reasonable change to the Minister. There is an extremely successful system in operation in the Department of Social and Family Affairs whereby when one submits a parliamentary question one receives a phone call within an hour and the answer is supplied within a day, if possible. A central location in the HSE is needed where all parliamentary questions are responded to immediately and a timescale given if the answer cannot be given within 24 or 48 hours. The neglect of parliamentary questions is appalling and unacceptable.

I do not know what hospital the Minister of State was referring to, but I was in a Dublin hospital recently where the care was world class. When one walked the corridors or entered the lifts, however, there were unpainted, dirty surfaces and a lack of well lit, well maintained corridors. If I am healthy and well I can walk through but if I am unwell I do not know where the bugs are and we cannot eradicate them because of serious problems in our hospitals. I would like to see an active policy of painting and cleaning down all surfaces in all hospitals. The neglect is appalling and unacceptable.

The doctor on call service is a wonderful scheme. It keeps people out of the accident and emergency units where it is working successfully. Many counties do not have a doctor on call service which leads to additional pressure on accident and emergency departments. I ask that the doctor on call service be rolled out to the rest of the country immediately. I welcome it as a method of keeping people out of accident and emergency departments.

Never was there so much money in the State and never were we so well off, yet the state in which the Government has left accident and emergency departments is appalling. It is unacceptable and a disgrace.

Dr. Twomey

I thank Government and Opposition Deputies who contributed to the debate and even though they did not restrict themselves to the motion, they gave interesting insights on the issue. The Government amendment makes little reference to the recommendations of the national task force on alcohol. That is possibly because it is embarrassed by the fact that it has done so little on the recommendations of the national task force on alcohol and the abuse of alcohol. The Government should circulate it to its members to see if we can achieve some progress on it.

It was insinuated during the course of this debate, and it is insulting to the professionalism of the doctors and nurses who work in our accident and emergency departments, that they would treat anybody as being just another drunk. I worked in accident and emergency departments. I recognise when a person is drunk and I do not need to breathalyse them. Neither do doctors and nurses in accident and emergency departments. I know when a person is aggressive or is abusing staff and I do not need any breathalyser to make that judgment. Some Members have said the doctors and nurses in the accident and emergency departments cannot tell the difference between a person who is irresponsible and a person who has a significant illness. Every doctor and nurse can tell whether a person has a head injury which may have internal bleeding and may have alcohol on board. We can tell if a diabetic has alcohol on board or if a person has epilepsy and a range of illnesses. To insinuate that because a person has alcohol on board he or she will be treated in a negative manner is a disgraceful remark to make in this House.

When discussing this issue, Deputy Fiona O'Malley did not appear to understand the proposal. She certainly does not appear to have been following the debate during the past two weeks. If so, she would have understood the most rudimentary aspects of what we are talking about. There are no beds in the "wet rooms". They are plastic mattresses on the floor to ensure people do not roll out of bed and hurt themselves.

Deputy Fiona O'Malley referred to dragging gardaí off the street and into accident and emergency departments. Patients who are sick in accident and emergency departments are as entitled to the same protection from the law enforcement agency as those walking the streets. The reason we cannot have gardaí in accident and emergency departments is that the Government made a promise to put 2,000 extra gardaí on the street and has not bothered to do so during the past three years. We should also examine how the Garda is rostered and, if there is a difficulty, it should be examined. The Minister referred to changes to the Criminal Justice Bill to enable a person to be prosecuted for assaulting emergency workers. Emergency workers are ambulance personnel, fire fighters, doctors and nurses. I suggest these changes be made.

Some Members have a difficulty in understanding what I mean by hangers-on. I am talking about an elderly person, a responsible friend or a relative. Any Deputy who does not understand what is a hanger-on should take a trip to an accident and emergency department on a weekend night when they have nothing better to do and they will soon know what is meant by the term. In and around the accident and emergency department is the hospital environment. This problem exists not only in the accident and emergency department waiting room or even in the treatment room but in the public areas of hospitals, in wards and in and around hospitals. For those Members who question what the term "in and around accident and emergency departments" means, we will get them a map and show it to them. Also, hospital visitors have their cars broken into when visiting sick relatives. A substantial number of incidents occur around hospitals and glib remarks from members of the Government show their lack of interest in this issue and their arrogance.

A report on aggression and violence in accident and emergency departments will be published in the Journal of Nursing Management. Perhaps we will send a copy to some of the Members in question. The authors of this report, Ryan and Maguire, point out that this is a growing problem internationally. The UK is pursuing a policy of zero tolerance towards this problem. Zero tolerance is a phrase we have not heard from the Government for some time. It has given up on it. Complacency and arrogance mean it does not have to care any more. It does not matter if there is indiscriminate violence on our streets, if teachers are being assaulted in classrooms or if doctors and nurses are exposed to intimidation while trying to do their work.

In her contribution, the Tánaiste and Minister for Health and Children said that tackling alcohol will not improve rostering to ensure patients are seen. For the Tánaiste's benefit, international research shows that fear for personal safety emerges as the key influencing factor when individuals decide on a nursing career. Therefore, violence contributes to the recruitment of people to train as nurses and their retention in a nursing career. Nurses leave the profession because they are exposed to violence and harassment in the workplace. More than 80% of staff in accident and emergency departments have suffered verbal aggression. At the same time, less than one third of staff are trained to deal with this type of violence and aggression that they face on a regular basis. Some 20% of nurses experience harassment of a sexual nature, much of which is related to alcohol, while trying to do their work and it appears the Government has little or no interest in it. Some 50% of nurses and care assistants were exposed to either physical or verbal violence in the course of this study. Much of it goes unreported because it is reaching a level of acceptance instead of management tackling the issue before there is a greater problem in retaining staff.

There is a major maternity hospital in the country which has pregnant women and new-born babies with significant illness, yet it is has no dedicated security staff after 10 p.m. That is one hospital I have been informed about during the course of this debate. If we probe more, since we cannot get this information from the Health Service Executive or the Government, we will discover there is much more of this type of behaviour.

This is what our Private Members' motion is about. It is not that we should broaden the debate. I would like to broaden the debate and would come in to the House every night for the next month and do so but I know what would happen. The Government will take no notice of what we are saying and is deaf to the concerns of the people it represents. That is what is happening here today. If the Minister for Justice, Equality and Law Reform were serious about this issue, he would bring this Bill forward sooner and make it stand-alone legislation to protect doctors, nurses and teachers who have been left out of the debate. It applies to everybody who makes a major contribution to society on our behalf. We do not respect them or look after them in the way we should.

There was a reference in the Tánaiste's ten-point plan to the effect that the director of the national hospitals office is finalising arrangements for the establishment of a national audit and inspection process to measure cleanliness in all acute hospitals. What was different 20 years ago when hospitals were clean that an audit is now required? Rather than an audit, what is required is someone to take responsibility. This is the problem with the health services and with the Government which has a fierce problem finding out who is responsible. There is a difficulty in finding out the Government responsibility in the matter of the €1 billion in nursing home charges. There is no need for an audit nor for more reports on the cleanliness of acute hospitals. Who is in charge of the hospitals? The Government should inform the House. This is the issue which the Government should deal with, not this nonsense about audits and more investigations and reports.

The Minister of State, Deputy Tim O'Malley, stated last night in the House: "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." What are the requirements? Perhaps I am stupid. Will the Government tell me the requirements? Why can this Government not take action on anything to do with the health services? Why can it not take action against the abuse of alcohol which is out of control in accident and emergency departments? What are these civil rights and medical and legal requirements which tie the hands of the Government? One side of the House tells me the Government is taking action and then we are given this nonsense. The problem is the Government refuses to do anything.

Amendment put.

The Dáil divided: Tá, 64; Níl, 47.

Tá

• Ahern, Michael.
• Ahern, Noel.
• Andrews, Barry.
• Ardagh, Seán.
• Blaney, Niall.
• Brady, Johnny.
• Brady, Martin.
• Brennan, Seamus.
• Browne, John.
• Callanan, Joe.
• Callely, Ivor.
• Carey, Pat.
• Carty, John.
• Cassidy, Donie.
• Collins, Michael.
• Coughlan, Mary.
• Cowen, Brian.
• Cregan, John.
• Cullen, Martin.
• Curran, John.
• Davern, Noel.
• de Valera, Síle.
• Dempsey, Noel.
• Dempsey, Tony.
• Dennehy, John.
• Devins, Jimmy.
• Fahey, Frank.
• Fitzpatrick, Dermot.
• Fleming, Seán.
• Gallagher, Pat The Cope.
• Grealish, Noel.
• Hanafin, Mary.
• Harney, Mary.
• Haughey, Seán.
• Hoctor, Máire.
• Jacob, Joe.
• Keaveney, Cecilia.
• Kelleher, Billy.
• Killeen, Tony.
• Kirk, Seamus.
• Kitt, Tom.
• Lenihan, Brian.
• McDowell, Michael.
• McEllistrim, Thomas.
• McGuinness, John.
• Martin, Micheál.
• Moloney, John.
• Moynihan, Michael.
• Mulcahy, Michael.
• Nolan, M.J.
• Ó Cuív, Éamon.
• Ó Fearghaíl, Seán.
• O’Donnell, Liz.
• O’Keeffe, Batt.
• O’Malley, Fiona.
• O’Malley, Tim.
• Power, Peter.
• Sexton, Mae.
• Smith, Brendan.
• Smith, Michael.
• Treacy, Noel.
• Wallace, Mary.
• Walsh, Joe.
• Wilkinson, Ollie.

Níl

• Allen, Bernard.
• Boyle, Dan.
• Broughan, Thomas P.
• Bruton, Richard.
• Burton, Joan.
• Connaughton, Paul.
• Connolly, Paudge.
• Costello, Joe.
• Cowley, Jerry.
• Crawford, Seymour.
• Deasy, John.
• Deenihan, Jimmy.
• Enright, Olwyn.
• Gilmore, Eamon.
• Gormley, John.
• Healy, Seamus.
• Howlin, Brendan.
• Kehoe, Paul.
• Lynch, Kathleen.
• McGinley, Dinny.
• McGrath, Finian.
• McGrath, Paul.
• McManus, Liz.
• Mitchell, Olivia.
• Morgan, Arthur.
• Moynihan-Cronin, Breeda.
• Murphy, Catherine.
• Murphy, Gerard.
• Naughten, Denis.
• Neville, Dan.
• Noonan, Michael.
• Ó Snodaigh, Aengus.
• O’Dowd, Fergus.
• O’Keeffe, Jim.
• O’Shea, Brian.
• Pattison, Seamus.
• Penrose, Willie.
• Quinn, Ruairí.
• Ring, Michael.
• Ryan, Eamon.
• Ryan, Seán.
• Sherlock, Joe.
• Shortall, Róisín.
• Stagg, Emmet.
• Stanton, David.
• Timmins, Billy.
• Upton, Mary.

Tellers: Tá, Deputies Kitt and Kelleher; Níl, Deputies Kehoe and Stagg.

Amendment declared carried.

Question put: "That the motion, as amended, be agreed to."

The Dáil divided: Tá, 63; Níl, 48.

Tá

• Ahern, Michael.
• Ahern, Noel.
• Andrews, Barry.
• Ardagh, Seán.
• Blaney, Niall.
• Brady, Johnny.
• Brady, Martin.
• Brennan, Seamus.
• Callanan, Joe.
• Callely, Ivor.
• Carey, Pat.
• Carty, John.
• Cassidy, Donie.
• Collins, Michael.
• Coughlan, Mary.
• Cowen, Brian.
• Cregan, John.
• Cullen, Martin.
• Curran, John.
• Davern, Noel.
• de Valera, Síle.
• Dempsey, Noel.
• Dempsey, Tony.
• Dennehy, John.
• Devins, Jimmy.
• Fahey, Frank.
• Fitzpatrick, Dermot.
• Fleming, Seán.
• Gallagher, Pat The Cope.
• Grealish, Noel.
• Hanafin, Mary.
• Harney, Mary.
• Haughey, Seán.
• Hoctor, Máire.
• Jacob, Joe.
• Keaveney, Cecilia.
• Kelleher, Billy.
• Killeen, Tony.
• Kirk, Seamus.
• Kitt, Tom.
• Lenihan, Brian.
• McDowell, Michael.
• McEllistrim, Thomas.
• McGuinness, John.
• Martin, Micheál.
• Moloney, John.
• Moynihan, Michael.
• Mulcahy, Michael.
• Nolan, M. J.
• Ó Cuív, Éamon.
• Ó Fearghaíl, Seán.
• O’Donnell, Liz.
• O’Keeffe, Batt.
• O’Malley, Fiona.
• O’Malley, Tim.
• Power, Peter.
• Sexton, Mae.
• Smith, Brendan.
• Smith, Michael.
• Treacy, Noel.
• Wallace, Mary.
• Walsh, Joe.
• Wilkinson, Ollie.

Níl

• Allen, Bernard.
• Boyle, Dan.
• Broughan, Thomas P.
• Burton, Joan.
• Connaughton, Paul.
• Connolly, Paudge.
• Costello, Joe.
• Cowley, Jerry.
• Crawford, Seymour.
• Deasy, John.
• Deenihan, Jimmy.
• Enright, Olwyn.
• Gilmore, Eamon.
• Gormley, John.
• Healy, Seamus.
• Hogan, Phil.
• Howlin, Brendan.
• Kehoe, Paul.
• Lynch, Kathleen.
• McGinley, Dinny.
• McGrath, Finian.
• McGrath, Paul.
• McManus, Liz.
• Mitchell, Olivia.
• Morgan, Arthur.
• Moynihan-Cronin, Breeda.
• Murphy, Catherine.
• Murphy, Gerard.
• Naughten, Denis.
• Neville, Dan.
• Noonan, Michael.
• Ó Snodaigh, Aengus.
• O’Dowd, Fergus.
• O’Keeffe, Jim.
• O’Shea, Brian.
• Pattison, Séamus.
• Penrose, Willie.
• Quinn, Ruairí.
• Ring, Michael.
• Ryan, Eamon.
• Ryan, Seán.
• Sherlock, Joe.
• Shortall, Róisín.
• Stagg, Emmet.
• Stanton, David.
• Timmins, Billy.
• Twomey, Liam.
• Upton, Mary.

Tellers: Tá, Deputies Kitt and Kelleher; Níl, Deputies Kehoe and Stagg.

Question declared carried.