Dáil Éireann debate -
Wednesday, 26 Apr 2006

Vol. 618 No. 2

Accident and Emergency Services: Motion (Resumed).

The following motion was moved by the Tánaiste and Minister for Health and Children on Wednesday, 26 April 2006:

That Dáil Éireann,

—commends the Government and the Tánaiste and Minister for Health and Children for their commitment to improving care for patients in our hospitals;

—recognises and supports the necessity for a substantial reform to accompany the unprecedented level of resources being invested in our health services and in hospitals in particular;

—acknowledges and supports the commitment of the Government to providing increased resources to accompany reform; and

—supports the substantial actions being taken to address the problems in Accident and Emergency (A & E) Departments, including:

—the comprehensive range of initiatives under the 10-Point Action Plan to deal with the many factors impacting on Accident and Emergency Services;

—the introduction of new measures to build on the Action Plan, including the setting of performance targets for individual hospitals;

—the establishment of a dedicated A & E Task Force to advise on how further improvements can be made to the efficiency and effectiveness of A & E Departments;

—the opening of new A & E Departments in Cork University Hospital, Connolly Memorial Hospital and St. Vincent's University Hospital;

—the provision of additional long-term care beds in private nursing homes and home care packages to facilitate the discharge of patients who have completed the acute phase of their care;

—the provision of admissions beds and appropriate facilities to ensure that patient privacy, dignity and comfort are preserved while awaiting admission to an acute bed; and

—the renewed emphasis on hygiene in our hospitals through the second national hygiene audit which is currently taking place.

Debate resumed on amendment No. 3:

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

"—asks the Taoiseach, Tánaiste and Minister for Health and Children and former Minister for Health and Children, Micheál Martin, to apologise to the people of Ireland for their failure to ensure appropriate emergency medical services in hospital accident and emergency departments, despite being in Government for nine years;

—condemns the Government for its failure to deliver the following services as promised in the National Health Strategy and Primary Care Strategy 2001:

—3,000 promised acute hospital beds;

—200,000 full medical cards to families on low incomes;

—the 5,600 community nursing unit, community care, community support, extended care beds (800 promised each year over a seven-year period from 2001);

—40-60 primary care teams by the end of 2005;

—condemns the Government's further failure to deal with the accident and emergency crisis despite numerous public relations attempts such as the Tánaiste and Minister for Health and Children's accident and emergency ten-point plan; and

—demands that:

—the Government's commitment to deliver a "world class health service" as announced by the Taoiseach in 2001 is fulfilled;

—the Tánaiste and Minister for Health and Children take appropriate measures to reduce the suffering of patients both young and the elderly who are regularly forced to endure unnecessary hardship when seeking medical attention due to the failures of the Fianna Fáil-Progressive Democrats Government; and

—the Tánaiste and Minister for Health and Children clearly outline the measures she intends to take to improve all aspects of acute hospital care that will allow patients to be treated in a dignified and respected manner."

—(Deputy Twomey).

Mr. Blaney

It is with great dismay that I speak again about the dire circumstances being faced in accident and emergency units. I am well aware this is a national problem but let me focus on the problems facing the accident and emergency unit in Letterkenny General Hospital. The professional staff at the hospital are trying to deal with very sick members of the public in what only can be described as very cramped facilities. The accident and emergency unit in the hospital is too small, equipment is inadequate and old, there are far too few beds to cater for those who need to be admitted to the hospital, and the staff and public are tired of the situation.

While I very much welcome the sanctioning of a new accident and emergency unit for Letterkenny General Hospital by the Tánaiste with work due to start next year, this unit will not become available for use until 2008. I dread to think of the number of people who will have to be cared for in the existing unit in the meantime. I believe that discussions are ongoing about providing additional beds for a new accident and emergency unit. I urge the Tánaiste and Minister for Health and Children to ensure that this takes place. If the beds are provided, it will be a major factor in providing the answer to Letterkenny General Hospital's current overcrowding problem. If that were to be the case, it would solve the problem of an inadequate accident and emergency unit while also providing additional beds which are so badly required.

Clearance has been given for an additional 30 beds in a special prefabricated development which is expected to come into operation before the end of the year. This development is indeed welcome but a prefabricated development is not a long-term solution.

The day services unit is being used to house people on trolleys daily, with 14 people on trolleys in Letterkenny General Hospital last night. This results in inpatient and day case procedures being cancelled daily owing to the unavailability of inpatient beds and the fact that the day service unit is being used as an accident and emergency overflow. With the economy booming, it is not acceptable that people are expected to tolerate the conditions at Letterkenny General Hospital.

Last year the Tánaiste and Minister for Health and Children announced the possible sharing of radiotherapy cancer services with Northern Ireland. While I welcome the Tánaiste's efforts to find a solution to this debacle, services will have to be provided in the north west, not in Belfast. However, I welcome the agreement in principle between the breast care teams in Letterkenny General Hospital and Altnagelvin Hospital in Derry on a model for co-operation and the provision of services for breast cancer patients in County Donegal. I urge the Minister to see this through, while ensuring it is not based on bed capacity and that it complements the service on offer in both hospitals in the best interest of patients in counties Donegal and Derry. An effective arrangement between the two hospitals, which would ensure the retention of the current services in Letterkenny General Hospital, is very much needed.

I refer to other problems people face in the north west. No neurologist has been appointed to the region for some time, despite a recommendation in 2003 by Comhairle na nOspidéal that two consultant neurologists should be appointed to the north west. Three years have passed and all we have been offered to date is a teleneurophysiology pilot project with Beaumont Hospital. While I welcome progress, it is not staggeringly positive. EEG recordings were due to commence earlier this month and I urge the Minister to roll out the pilot project and appoint at least one consultant neurologist to the north west. Patients suffer from many conditions ranging from multiple sclerosis to brain tumours and so on and they cannot face the trauma of travelling to Dublin or Galway to visit a neurologist on a regular basis.

BreastCheck is expected to be rolled out in the north west next year. This service once again has been rolled out in many other parts of the State ahead of the north west. While we have had to wait longer than most for the roll-out of the service, the development is welcome and I ask the Minister and her officials to correspond with the Donegal Action for Cancer Care group regarding the implementation of this service in the region.

Given Donegal's peripheral location, I fully support the concept of cross-Border services. It could be the way forward. I urge the Minister to take stock of all the issues I raised and to reflect upon the health services the people of Donegal must put up with. The county is often marketed under the slogan, "Up here it is different", and Donegal is certainly different when it comes to health care. I invite the Minister to visit Letterkenny General Hospital, despite the controversy surrounding it recently, because a visit would boost the overworked staff.

Mr. Neville

I welcome the opportunity to contribute to the debate. I wish to raise with the Minister of State, Deputy Tim O'Malley, the issue of Limerick Regional Hospital. Yesterday 12 people were on trolleys in the hospital, although it has one of the better accident and emergency departments. I raised the accident and emergency department issue with Professor Drumm when he appeared before the Oireachtas Joint Committee on Health and Children and he highlighted three hospitals, one of which was Limerick Regional Hospital, that were doing well in this area. Each day we read the Trolley Watch figures and usually between four and six patients are on trolleys in the hospital. On one occasion, the number reached 35 because there was a crisis but, overall, the hospital in Limerick is one of the better ones in this regard.

I cannot understand, therefore, why it was fined €1.2 million for being inefficient. I do not understand the criteria for evaluating hospitals, given that it is accepted that the efficiency of a hospital has a great deal to do with the operation of its accident and emergency department. In other words, the department is a barometer of a hospital's efficiency. How could Limerick hospital be fined €1.2 million when other less efficient hospitals obtained an increased allocation because of their efficiency? That does not make sense and I hope the Minister of State addresses why the hospital was fined in this fashion. The implication is the hospital is efficient but it is being fined €1.2 million to make sure that efficiency does not continue. However, if the hospital's budget is reduced, its efficiency will not be maintained.

The manner in which elderly people are treated in hospital is an issue. It is accepted the number of elderly people who will attend hospital will increase substantially because of our ageing population. The way they are treated leaves a lot to be desired. I dealt with a case in this regard last week. When an elderly person is in hospital, he or she is practically ignored while discussions take place with family members and decisions are made on their treatment, continuing care, transfer to a nursing home, the winter initiative and so on. The patient, who is the key person, is often not consulted. It is almost as if when one reaches a certain age, one does not have a view or one should not be consulted on one's treatment and so on. Families face difficulties because of a lack of information about the care and treatment of their elderly relatives and it is a sensitive issue. Discussions take place on whether a patient should be transferred to a private or public nursing home, but criteria should be laid down, as far as possible, in this area so that people can fully understand what is happening and decisions are explained to them.

Last week I was contacted by a family regarding an elderly relative in hospital who was told she was being transferred to a nursing home. When the family members visited the hospital, the elderly relative was dressed to go to the nursing home. She did not understand that she was being transferred to a nursing home for two weeks under the winter initiative and that was not explained to her relatives. They were worried about how to pay for her care in the nursing home because she was only on an old age pension and the relatives were not a son or daughter. The person most affected by the move was the patient, who was not consulted and did not know what was happening.

I refer to the waiting lists for initial psychiatric assessment for children. I received a letter from the HSE on 7 April, following the referral by the Minister of State of a parliamentary question I tabled a number of months ago, in which I was informed there is a considerable waiting list for assessments and the waiting times are also lengthy. If this is not an emergency, I do not know what is. It is accepted that early intervention for children with difficulties who are in need of psychiatric assessment is vital to their recovery. The waiting times can vary significantly. For example, 214 children are waiting in Kerry and the waiting period is between 22 and 41 months. It is surely not acceptable that a child in need of psychiatric assessment must wait up to 41 months. In Cork, there are 267 children waiting between 12 and 17 months. In south Tipperary, 40 children are waiting 18 months. Professor Drumm has noted the efficiency of Waterford, where only four children are on the list, waiting between six and eight weeks. There are 300 children waiting an average of ten months in Limerick, Clare and Tipperary.

Very little attention is paid to the issue of waiting lists for psychiatric illness, especially child psychiatric illness. Early intervention for children with psychiatric difficulties multiplies the chances of early recovery. It represents bad economics to allow children become chronically ill before they are assessed. If early intervention can be achieved in Waterford, why can it not be achieved in the mid-west, in Kerry, Cork and elsewhere? There is a ten-month waiting list in Dublin. There is a waiting list of 1,000 in the Lucena clinic, with a waiting time of approximately two years.

The report of the Irish College of Psychiatrists into child psychiatric services, published last autumn, showed that in excess of 200,000 children have a mental or behavioural problem at any one time. While in excess of 100,000 of these have a mild disorder, 80,000 have a moderate to severe disorder and 20,000 have a disabling disorder. Dealing with this serious situation effectively requires 236 inpatient psychiatric beds, but there are currently only 20 beds in Galway and Dublin. Responding effectively to the psychiatric needs of these children requires 150 consultant child and adolescent psychiatric posts, but there are currently only 62 psychiatrists in this field of the profession.

The lack of psychotherapists, family therapists, clinical psychologists, occupational therapists and other key staff seriously inhibits the internationally acknowledged best practice for the provision of child psychiatric services through multi-disciplinary teams. When a child gets into emotional or psychiatric difficulties, early intervention is crucial to deal with the situation urgently. It may have a profound effect on the future life opportunities of that child.

Mr. O’Connor

I welcome the opportunity to make a brief contribution to this important debate. I welcome the Minister of State to the House and I remind him that it is a little while since he has been in Tallaght.

I was going to make a general speech on this issue, but I noticed other colleagues, including the main Opposition spokesperson on health, made very parochial contributions so I will speak about Tallaght for a little while. I represent the third largest population centre in the country. Dublin South-West embraces Tallaght, Firhouse, Templeogue, Greenhills and Brittas. The catchment area for Tallaght hospital stretches through Kildare and Wicklow, all the way to Carnew. The Ceann Comhairle, who was Minister for Health in 1987, developed the project and made the decision to appoint me to the board. At the time, I was the first person with a Tallaght address to be appointed to that board.

Tallaght hospital is very important for the local community and I have been proud to be associated with the hospital through membership of the planning board, which was only wound up last year. I pay tribute to the members of that planning board, including Des Rogan, the project manager and the former Senator Richard Conroy, who chaired the board. I was also proud to be a member of the new AMANCH board when it was set up, following the move of the Adelaide, Meath and National Children's Hospital to Tallaght in 1998.

Last weekend, the Tánaiste pointed out that we should be very careful not to speak badly of the services as that will help nobody. We all get political pamphlets in our letter boxes making political points about the service, which is fair enough, but I am upset that these people run down the services and those involved in the provision of services. There should be a different way of making political points. I am a politician and I understand the thrust of politics, but we should not throw the baby out with the bath water. I am a Government backbencher and I am proud to be a supporter of this coalition, but I am not afraid to admit that there are problems with the health service. Tallaght hospital, with the other Dublin hospitals, often gets bad press and we should continue to press their needs.

Tallaght hospital has one of the busiest accident and emergency departments in the country. In 2005, there were almost 75,000 accident and emergency attendances, 29,000 attendances in the children's accident and emergency department and 45,000 in the adult department. The hospital has 350 acute adult beds to manage this workload. This equates to one bed for every 600 persons in the catchment area. In contrast, Beaumont Hospital has one bed for every 350 persons. The past few years have seen a significant increase in the number of patients admitted from the accident and emergency department.

New services have been established in Tallaght hospital, such as the very busy oncology service. However, no additional beds have been provided to cater for the needs of the new service or the increasing needs of emergency admissions from the accident and emergency department. Tallaght hospital has taken a very proactive approach in an attempt to reduce the numbers of patients who must wait on trolleys. The HSE's figures confirm that the number of patients waiting on trolleys has been reduced significantly, as has the waiting time. The figures also confirm significant improvements in the long-term care waiting list in the hospital. Much of this has been achieved by the establishment of a multi-disciplinary discharge team at the hospital. This initiative has not yet been funded by the HSE.

A 41-bed temporary transition unit is being constructed at Tallaght hospital, which will be operational by July. This will be used to accommodate acute admissions from the accident and emergency department. When it is opened, it is expected that patients will not have to wait on trolleys for more than six hours. A number of key issues for Tallaght hospital have also been identified that must be put in place if an optimal acute service is to be provided for patients in the area. These include a new CT scanner to improve speed and quality of diagnostic services, an extension to the ICU unit which currently cannot meet the demands of critical care beds, the establishment of a permanent acute hospital admission unit for which funding has long been sought, an increase in consultant numbers, particularly in the acute medical specialties, and diagnostic support services. The management and staff at Tallaght Hospital are committed to providing for the acute care needs of people in the community and the wider catchment area. Many of the difficulties experienced over recent years have begun to ease and the hospital has a plan and a strategic approach for the future which will minimise many accident and emergency problems by the second half of this year. It is hoped that elective surgical and orthopaedics practices, which have been severely curtailed in recent months, will be restored to full activity. The hospital is confident that it can obtain the necessary support and resources from the HSE and the Department to progress these plans. I ask the Minister of State to inform the Tánaiste of my strong support for these activities because it is important that she understands the special needs of Tallaght Hospital. My colleagues will discuss other areas and hospitals but I am not afraid to express the concerns I have with regard to Tallaght Hospital.

Recently, there has been a great deal of speculation about plans for a new paediatric hospital. In terms of the criteria and infrastructure, the case for Tallaght is very strong. Tallaght Hospital can be accessed from all parts of the country, is connected with Limerick by a good road and accessible from Dublin's train stations by Luas. I hope those who are charged with the responsibility for making important decisions on the future hospital care needs of our children will take account of Tallaght's potential.

The contributions of different disciplines and the role of GPs has been subject to extensive discussion in recent times. I support local GP services and often visit my local GP. It is important that we realise difficulties can arise at each end. In a community such as Tallaght, with its busy and active hospital, there is a role for GP services. In my local GP clinic, the Mary Mercer Health Centre in Jobstown, a successful service is run by Professor Tom O'Dowd which could be a great model for the rest of the country. We should try to relieve the pressure on hospitals by providing good GP and other medical services in modern and properly equipped facilities. The Mary Mercer Health Centre was partly funded by the Mercer's Hospital Foundation. Anyone who walks around St. Stephen's Green will remember the old Mercer's Hospital and it is great that the foundation is making a contribution to communities in Tallaght and elsewhere.

I want to be upbeat about the future but must also acknowledge the problems. I often visit neighbours in Tallaght Hospital, who recognise that they are being provided with a tremendous service. I have no sympathy for those who go to accident and emergency departments when they are not ill but have cut their fingers or have taken too much drink. However, when people genuinely need care, we all have to stand up to say that something has to be done about a system which, to some extent, has let people down. I hope the Minister of State will take my message about the needs of Tallaght to the Tánaiste.

Mr. Ring

By agreement, I would like to share time with Deputy Crawford.

An Ceann Comhairle

Is that agreed? Agreed.

Mr. Ring

Nobody living here can fail to realise that there is a serious crisis in the health service. It is sad that families have to contact Deputies on a daily basis to find hospital beds so that loved ones can be moved from trolleys. In my constituency, Mayo, there have been ongoing problems of people waiting on trolleys. It is a disgrace that when the people who pay their taxes need a hospital bed, they have to spend days on trolleys waiting. We never had as much money as we do now. As I said ten years ago as a Fine Gael deputy spokesman, if the managements of hospitals are unable to do the job, we should sack them all and start again. We are worse off today than we were ten years ago because services have deteriorated.

I am glad the Minister of State, Deputy O'Malley, is here because he has responsibility for the elderly. I have been contacted by many people who are vulnerable because their loved ones have been told to leave hospital. People over 70 years of age are put into State beds but, before they are there 24 hours, they are pressured to move to private nursing homes. These patients, with no resources, are being bullied by the health system. I told the family of one such patient that the law of the land provides that a person over 70 years of age in need of a hospital bed and in possession of a medical card is entitled to that bed. The patient in question was told to move to the private sector and was described last week as fit to leave hospital. However, the patient died last Tuesday and is now buried. Why was the State trying to force that person out of a bed? We cannot have a situation in which we want people to leave hospital beds when they need to be there.

For more than ten years, the people of Ballinrobe have been waiting for a nursing home but the State will not provide the necessary money. We cannot say we need to free up beds in hospitals if we do not provide step down beds for patients. How many people have contacted the Members of this House with regard to loved ones who need two or three weeks of physiotherapy? Families know that if they bring their loved ones home, they will have to wait a further two years for treatment but all they want is to look after their loved ones and to bring them home.

I blame the Government for the fact that my county did not use the winter initiative scheme, despite drawing money from the Department for that purpose. If a scheme is put in place, the Tánaiste should instruct Mayo General Hospital to make use of it. She should be strong enough to say that the time has come to provide more step down facilities.

I also blame the Government for the problems that have arisen with regard to home help services. We are told to keep our loved ones at home and that support will be provided. I know of a young man with four children whose wife died of cancer. He had seven hours of home help per day but the service was reduced by four hours last week. The helper now works from 9.30 a.m. to 12.30 p.m. and the four little children coming home from school will neither have a mother or a father, who is trying to keep his job, from 12.30 p.m. until 9.30 the following morning. That is the kind of health service we have here.

Many people will enjoy themselves in Punchestown today. Money is made available for that industry and for the builders but not for the people who need it the most.

Mr. Andrews

The Seán Barrett Bloodstock Insurance stakes.

Mr. Ring

I ask the Deputy to shut up and allow me to speak. He will have time soon.

Mr. Andrews

Deputy Ring is well aware of who is at Punchestown.

Mr. Ring

The Deputy represents the bloodstock industry because that is all he or his colleagues care about.

Mr. Andrews

Seán Barrett was a candidate for Deputy Ring's party.

An Ceann Comhairle

The Chair is reluctant to intervene when Deputy Ring is in full flow but his colleague Deputy Crawford has five minutes remaining.

Mr. Ring

I thank the Ceann Comhairle. I am sorry I cannot help Deputy Andrews, who would not have much understanding for the poor of this country because he is a rich man's man.

Mr. Andrews

Deputy Ring knows everything. Seán Barrett Bloodstock Insurance——

Mr. Ring

Where Deputy Andrews comes from they would not have much understanding because Deputy Andrews and his family would go to the private hospitals and wards.

Mr. Crawford

I hope the Ceann Comhairle will give me some of the time lost by Deputy Andrews.

Mr. Andrews

By Deputy Ring.

Mr. Crawford

In the last 12 months I had some experience of seeing the health service from a bed and I pay tribute to the Mater Private Hospital, where I was for a short time, and in particular Beaumont Hospital. We hear all sorts of bunkum about how these issues will be solved. The consultants, nurses and other staff are under pressure. Above all they need step-down beds to which people who need longer treatment than expected can be moved. They do not need a new hospital. Since I was in Beaumont it estimated it needs approximately an extra 200 step-down beds to ensure the acute beds can be used. Imagine if a loved one was waiting three months in serious pain for neurosurgery while somebody, through no fault of his or her own, was holding up one of those beds for a number of weeks or months. We must deal with that as a matter of urgency.

I return to the situation in my constituency of Cavan-Monaghan. Many areas of Monaghan General Hospital are under-utilised. The new, state-of-the-art theatre was being used for national treatment purchase type schemes in Northern Ireland when the hatchet was brought down on it by some outside body and it was closed. I urge the Minister to ensure that facility is used. I listened with pain to the Tánaiste talking about the scarcity of numbers in the Cavan-Monaghan region. If the people were allowed to be treated in the Cavan-Monaghan region instead of being sent away under the national treatment purchase scheme there would be plenty of work for the theatre and hospital.

The late Mr. Benny McCullough, who lived a few yards from Monaghan hospital gates, died on the way to Cavan. Since his widow died, their handicapped daughter whom they both loved and looked after, must be looked after by the State for the rest of her life. The Tánaiste talks about safe service. How safe was that service? It seems to be safe if one dies outside the hospital but not if one dies inside it. Many lives have been saved by Monaghan hospital because people were brought there by car. I urge the Minister to ensure the Tánaiste takes a little time to visit Monaghan General Hospital, talks to the people there and sees the situation. She has plenty of time to visit other institutions including pubs, which the Government seems to be good at.

Cavan General Hospital was never extended to take the overflow from Monaghan. Some 20 to 30 patients are on trolleys there every week. I have a letter from a Monaghan nurse who gave her life service to the State health service and who had to spend three desperate days on a trolley in Cavan waiting for a bed in Beaumont. I hope when the Minister receives this letter he will read it in full and see what he is imposing on the people of Cavan and Monaghan through neglect. It is a failure of management to provide extra beds. There are beds available in the psychiatric section of the hospital, where there is less than half usage of the beds, and with realistic thinking these could be used. Other beds are used for full-time elder care. Some of these could be used as step-down beds if the occupants were moved out to permanent homes. There are many ways of dealing with this that need little cost, just some common sense.

Deputy Ring mentioned subvention. Why should somebody have to wait eight weeks to have a subvention form dealt with? If any other business operated in this way it would not survive two days. Because subvention forms are being held up, patients are being held in wards. Another issue is the failure of home help. The Ceann Comhairle is aware of a case in our county in which a person moved from Donegal, where he received 12 hours of home help, to Carrickmacross, County Monaghan where he receives two hours. How does the Minister explain this difference? How does the Minister explain that medical cards are not available in areas such as Cavan-Monaghan, compared to areas such as Cork? The figures show that there is a discrepancy in allocation. Why should a community welfare officer not be able to hand out a medical card? Why must it go through six different layers? I urge the Minister to examine the administration, how the health system is being worked and deliver what the people require and could have.

Mr. Andrews

I am pleased to be able to speak on this important issue. In my area a number of important changes have taken place recently, particularly in St. Vincent's, into which St. Michael's has been subsumed. This has given extra specialties to St. Michael's and it has become a first-class hospital. Its accident and emergency department operates between 8 a.m. and 8 p.m. and it has been successful. There are waiting lists, but that is inevitable. It has developed specialties and on visits I have noticed a pride among the staff in the work they do and the specialties they have undertaken. It is an example for the centralisation of certain specialist deliveries, which should be continued to be rolled out nationwide.

I claim no great expertise in this area, and my one observation is a shortage of senior clinical decision makers in hospitals. No matter how good the primary care service, if the person with a headache visits a GP, and the GP cannot definitively say the person is okay, he or she will try to set up an appointment with a consultant. Because the consultants are unavailable and the patient must wait 14 or 16 months for an appointment, a visit to an accident and emergency department is his or her only recourse. The junior hospital doctor in the accident and emergency department is unwilling to take a clinical decision because there is somebody above him or her and services, such as a scan, are unavailable. The patient must therefore wait until either a consultant or a scan is available. If the patient goes to the accident and emergency department on a Friday or a Saturday he or she could wait two or three days for a decision. The patient may or may not have a serious illness.

More senior clinical decision makers are needed in the system and without this we will face a continuing logjam. As the Tánaiste pointed out to the Committee on Health and Children, accident and emergency is a symptom of other problems in the health service. There was an illuminating letter in today's The Irish Times which contained in one long and farcical sentence all the problems identified in a debate of three or four hours here.

All of those problems exist, but the most grave and serious symptom is of course the trolley problem. It is clear that problem is more significant during the winter months. At the time, the Irish Nurses Organisation opposed the HSE proposal in regard to moving accident and emergency patients into hospital wards to relieve congestion.

My next point concerns the industrial relations problems being experienced as the attempt is made to roll out this massive health reform strategy. Deputy Crawford referred to the individual problems in regard to the HSE. If 12 hours home care is available in Donegal and only two hours is available in Monaghan, that is an inevitable consequence of the fact that there were 11 health boards in the Eastern Regional Health Authority. When the system is centralised, the anomalies will be revealed. It will take some time for that to be——

Mr. Sherlock

It was Fianna Fáil which controlled the health boards. The Deputy should not have any doubt about that.

An Ceann Comhairle

The Deputy will have the opportunity to make a contribution shortly.

Mr. Andrews

Whether anybody controlled the health boards, the medical staff decided who got home care health packages, as the Deputy well knows. I know it is the knee-jerk reaction of Opposition Deputies to try to draw politicians into blame.

Mr. Sherlock

It is a fact.

Mr. Andrews

That is inevitable and is part and parcel of the work we do. Clinical decisions are made by hospital staff, not by councillors on health boards, as the Deputy knows. I make the point that the HSE in its present organisation will inevitably take time to reform. During that period of reform, during which it is difficult to have patience, it will take time to iron out anomalies. We may suffer a political fall-out as a result but that is not as important as whether patients are properly treated.

On the question of industrial relations, the IMO is always blamed by the politicians for all the problems that exist in the health service, which is to take a simplistic view. Let us focus on the facts. The IMO advises its members not to co-operate with the setting up of primary care teams — one of the points being made concerns the development of out-of-hours services. While the Government has invested €60 million, Opposition Deputies and Senators tell it to provide primary care services and ask why it has not been done as it was part of the health care strategy of 2001. I am not suggesting the IMO is to blame. This is a democracy and it is entitled to oppose such policies, but the IMO is a factor in this problem, and a symptom of the problem is the situation in accident and emergency units.

The number of doctor-only medical cards was increased last October by 20%, and 30% in other cases, but the IMO objected to that increase at the Labour Relations Commission. It also objected to discussion on the consultant contract, which is the sine qua non for real reform within the health service. It even refused to take part in talks and, while I stand open to correction, my impression is that it refused to allow Professor Drumm to address its conference. The IMO objected to the introduction of cervical screening at primary care level.

Mr. Costello

Everybody is responsible but the Minister.

Mr. Andrews

It may not have objected specifically to that but there were objections to the way in which it was delivered. I do not want to give the simplistic impression that the IMO is simply in it for its own interests. However, as we are having this debate, it is important to recognise that there is a major industrial relations problem which is not all the fault of the Government. That is how I will leave the matter.

With regard to improvements, the Tánaiste is more than capable of defending her record and that of the Government back to 1997. She made the point that we spend more on health than France and Great Britain, which is a fact. I have heard Members state in the Chamber that we have employed an extra 35,000 to 40,000 staff but that none of these is doing anything useful because they are all in their offices playing sudoku and business games. Ten out of 11 of those staff are direct line service providers, which is why 93% of patients who come through our hospitals are satisfied with the service they receive.

We cannot constantly run down our health service and feed into a spiral of despair. I notice that Fine Gael's latest disastrous billboard campaign, which follows the tradition of the Celtic snail campaign, delivers a body-blow to all those who are proud of the services they provide in the health service. It demoralises and diminishes the work being done by doctors, nurses and health care professionals throughout the system to claim that people are scared to go into hospital. They are not scared. People are concerned about accident and emergency units and waiting on trolleys, but nobody is scared. These facts should be acknowledged by Fine Gael, although, from a narrow political perspective, I am pleased to see Fine Gael shoot itself in the foot once again.

Ireland's spending on health shows the fastest growth of any OECD country. However, spending is not everything. We must acknowledge that many of the best developments in our health service will be free. We need to provide better information for patients entering accident and emergency. For example, Deputy James Breen has personal experience of the dangers associated with people not washing their hands. Improved practice in this area will be free of charge to the health service. Patients should be treated with respect and as important clients of the service. Basic courtesy and manners cost nothing but would make a significant improvement to the health service.

The home care packages are important. The waste of money and the handing back of €135 million by the HSE is unbelievable. I am fortunate that my family and I do not have many health problems but a personal anecdote may underline the wastage that occurs. Last year I visited a health centre which had just bought a new bed for one of its rooms. I commented on the bed as it looked fantastic and was told that it had been bought because if the money had not been spent, the health centre would not get the same budgetary allocation the following year. The old bed was lying somewhere despite being in perfect condition. This kind of problem is rampant throughout the HSE and it has much to do with budgeting. However, we must remember that the HSE balanced its budget in its first year. That is a good news story that should also be acknowledged if we are to be honest about this debate.

I am delighted to have the opportunity to discuss this issue. Huge progress has been made. On a political level, I fully support the Tánaiste in what she is doing in an extremely difficult job. Major, revolutionary changes are under way and we must be patient to some extent.

Mr. F. McGrath

She has not delivered.

Mr. Costello

I wish to share my time with Deputy Sherlock.

An Ceann Comhairle

Is that agreed? Agreed.

Mr. Costello

Deputy Andrews is clearly in cloud cuckooland in regard to the health service.

Dr. Devins

He is actually in Dún Laoghaire.

Mr. Costello

Perhaps Dún Laoghaire is cloud cuckooland.

Mr. Andrews

Tell that to Deputy Gilmore.

Mr. Costello

It appears that Tallaght is cloud cuckooland also because Deputy Andrews shares territory with the Tánaiste.

Three years ago the situation in the accident and emergency unit of the Mater hospital had reached such a pass that the Labour Party decided to mount a protest outside the hospital from 1 p.m. to 2 p.m. on occasional Saturdays. It was only then that the full appalling state of affairs became known to us from regularly visiting the accident and emergency unit and speaking to patients and relatives who were visiting the hospital. Consequently, we decided to mount the protest on a weekly basis and have done so for almost three years.

At the time, 20 to 35 people were lying on trolleys at any one time. The accident and emergency department was short four nurses and needed more medical staff. There were 60 nurse vacancies in the hospital, over 70 beds were occupied by patients who could be catered for in a recovery unit, if there was a recovery unit, 100 new beds were desperately needed and the waiting list for serious operations and treatment was a massive 4,000. That was the position in the Mater hospital in 2003. That situation was replicated in all major hospitals throughout the country at the time. Hospital consultants said there were 3,000 fewer beds than in 1990. Three years on, the situation is worse. There are clearly now chairs as well as trolleys in overcrowded accident and emergency departments. A new hyrdo-tilt chair has been installed in the Mater Hospital within the last few weeks, and the hospital authorities clearly do not expect major changes in the foreseeable future.

The Tánaiste became Minister for Health and Children in September 2004 and immediately launched a ten-point plan to eliminate the accident and emergency crisis once and for all. Major improvements were promised within a few months. She said the Government's credibility would depend on its delivery. Now, 18 months later, she has declared a national emergency. She clearly does not have a clue what to do, and the ten-point plan is in tatters.

The Labour Party published a policy document entitled Healthcare — A New Direction Towards Primary Care. It spells out a long-term strategic approach to delivering community-based health care that has the funds and resources to treat the many patients clogging up accident and emergency departments and that can acquire the confidence of the patient. In the short term, however, there is a need for urgent action to address the national emergency.

First, we must separate accident and emergency reception areas to divide ill people who are elderly and frail from the noisy and boisterous who have overdosed on illegal drugs or are drunk and disorderly. Second, existing wards and hospitals closed for years should be opened and staffed immediately. Third, a formal link should be established between each local authority and the bed management section of the local hospital. Remedial work required on the home of someone in hospital recovering from a serious illness such as a stroke or heart attack should be able to bypass the usual bureaucracy and queue and be carried out without delay, dovetailing with the patient's readiness to return to his or her home and community.

Fourth, there is a need to enforce strict hygiene standards for all staff and overhaul the system of contract cleaners, who clean the hospitals at certain times of the day rather than according to need, thus cutting the appalling level of MRSA to which vulnerable patients are prone. It damages their health no end and extends their stays in hospital. Fifth, there is a great need to sort out the industrial relations procedures to which Deputy Andrews referred. Those result in virtually no GP service after hours or at weekends on the north side of Dublin. Finally, there is a need for a recovery unit or step-down bed facility on the grounds of every hospital or adjacent thereto.

None of those measures is rocket science. They are simple, logical procedures that do not cost an arm and a leg, if the Minister will pardon the pun. They can be introduced quickly and prevent untold suffering on the part of old and ill citizens at their most fearful and vulnerable.

Mr. Sherlock

I call for the development of services at Mallow General Hospital rather than transferring patients to Cork University Hospital, as has been suggested. Some 125 GPs referred to Mallow General Hospital, which is the only emergency facility and acute hospital service north of the River Lee. It is an asset to Cork University Hospital and can help ease some of the problems there by catering for the local population's secondary hospital needs. Mallow General Hospital currently services 90,000 to 100,000 people, and the entire area is developing rapidly, having been designated a hub town and growth area under the national development plan.

Despite that, there is a belief locally that badly needed acute, 24-hour accident and emergency services may be transferred to the larger Cork University Hospital in an effort to centralise. While that may make some sense from a bureaucratic perspective, it makes absolutely none in reality. Downgrading or removing 24-hour accident and emergency services at Mallow would leave some patients two hours' journey from acute care, something totally unacceptable by international standards.

However, a gradual erosion of services at Mallow General Hospital has been under way for several years. In the mid 1980s, it was a major 101-bed hospital servicing the needs of the local community. Its status was confirmed by Mr. Justice Gannon in the High Court in 1989, when he designated it a general hospital. Now, however, despite a growing population and the development of new industries in the area, the hospital has only 81 beds.

There is an urgent need to develop a day facility, a position adopted by the health board in 2002 but, to date, not provided. That must come alongside a new day theatre and more day beds, including 150 new rehabilitation beds. It appears the Government's answer to the problems of the health service is to encourage people to pursue private health care as much as possible. That may be an option for a small number who can afford it, but not for the overwhelming majority, including those who rely on Mallow General Hospital.

Part of that strategy involved the consolidation of services in large city hospitals rather than the development of facilities at local units. However, I want to impress upon the Minister that it makes little financial sense to transfer patients by ambulance from Mallow to Cork and treat them at University Hospital, considering the estimated daily cost per patient in Cork in 2005 was €848 but only €574 in Mallow, a great difference.

The Tánaiste and Minister for Health and Children must be aware of the potential for development on the hospital grounds. Certain buildings are currently vacant and could be refurbished and made available, thus retaining and improving all the services that the hospital currently provides. There must be improvements in nurse, clerical and general grade staffing levels.

I invite the Tánaiste to visit Mallow General Hospital and see the vital work being done and the potential for even more development, after which I will ask her to consider appointing a new management board rather than allow officials at Cork University Hospital to manage Mallow, keeping finances in their own institution. That is what we have been dealing with in recent years, and I would like to see the Tánaiste do something about it. There should be a local management board and a manager appointed to look after moneys allocated to Mallow, ending dependence on Cork University Hospital.

Dr. Devins

I am delighted to have the opportunity to speak on this timely and important motion.

Sometimes commentators claim that much of what is debated and discussed in Dáil Éireann lacks relevance to the citizens of the State. However, this motion flies in the face of such beliefs. It is extremely relevant, not just to those who attend accident and emergency departments but to every citizen. The enormous media coverage that has taken place recently proves the importance of accident and emergency services in all our lives. It also proves that all is not well with those services.

Mr. F. McGrath

Hear, hear.

Dr. Devins

I state quite categorically that there are serious problems with accident and emergency services in certain hospitals. Approximately 35 of them provide such services in the country, and I understand that research undertaken by the HSE shows that approximately 15 such units have specific issues.

It is important to stress that the level of service provided by each accident and emergency unit depends on the specific service commitment of the individual hospital. As a result, the number of patients presenting themselves at accident and emergency departments depends on the hospital's location, the service that it offers, and other factors such as the level of GP cover available in the hospital catchment area. A hospital serving a large population base will generally have more attendees at its accident and emergency department.

As a non-consultant hospital doctor many years ago, I engaged in a training programme for general practice. As part of that programme, I spent six months as a casualty officer in one of the main Dublin hospitals, part of the city's on-call ambulance rota. That six months' training was very rewarding on a personal level and very informative on a professional level. It gave me great insight into the enormous pressure cooker an accident and emergency unit is and how stressful it is for all the staff who work in it. It is only right and proper that I pay tribute to all the staff, whether nurses, doctors, paramedics or support staff, who work day and night in all the accident and emergency units. I know many of the staff in the accident and emergency unit in Sligo General Hospital and there is no doubt in my mind that there are very few jobs anywhere which are as stressful as the jobs they undertake. It is a rewarding job but it is also exceptionally stressful. In all the debate about accident and emergency, it is frequently forgotten that these vital units would not function without these dedicated people.

Accident and emergency units are simply that — units which deal with accidents and emergencies. One of the issues which contributes to some of the overcrowding in accident and emergency units is inappropriate attendances at such units. Patients may chose to go to accident and emergency units inappropriately for a variety of reasons but frequent educational programmes throughout the media can better inform the public what cases are best dealt with in accident and emergency units and what can be best dealt with elsewhere. In that regard, we in the Republic can take a lesson from the NHS and our friends across the water in the United Kingdom who frequently show well prepared, informative advertisements on television informing the public on what accident and emergency units are specifically equipped to dealt with.

Much comment has been made of the trolley count and the difference between the figures produced by the Health Service Executive and the Irish Nurses Organisation. This is a side argument. It is obvious the number of people in accident and emergency units can vary depending on the time of day and the day of the week. There are certain times of the year when admission rates to hospital rise and this can put more pressure on accident and emergency units.

In the limited time available to me, it is not possible to discuss in detail the many causes contributing to the problems experienced in some accident and emergency units. Let us not beat about the bush. There are severe problems in some accident and emergency units. I am delighted the HSE set up a dedicated accident and emergency team last month to deal with the problems in these hospitals. The HSE has made dealing with the accident and emergency situation its number one priority this year. I welcome the commitment by the Tánaiste and the HSE that no person should have to stay overnight on a trolley. We want the best service for all who attend accident and emergency units and it is intolerable that anybody should be required to stay overnight or longer on a trolley.

I say this in full cognisance of the enormous range and complexity of medical and surgical problems which can present at accident and emergency units. Emergencies by their very nature must be dealt with immediately, whether a potential stroke, heart attack or whatever. Many of them will need immediate treatment followed by further and continuing assessment with admission the end result in many cases. At the same time, all accidents must be dealt with, whether severe ones from road traffic accidents or minor accidents. Recognising the complexity of these problems and the need for immediate treatment in many of them, the commitment by the HSE to end the practice of overnight stays on trolleys is most welcome.

While the cause of overcrowding in accident and emergency units is multifactorial, there is little doubt that the unavailability in certain areas of suitable beds for discharge patients has resulted in some of the problems. I welcome the fact the HSE is sourcing an additional 250 beds to accommodate some of these discharge patients. It has been frequently reported to me that patients are kept in acute hospitals after their due discharge dates because of the unavailability of a suitable bed elsewhere, whether for short or long-term care.

In my area of Sligo-north Leitrim, there are geriatric hospitals such as St. John's, long-stay facilities such as Nazareth House and many excellent nursing homes available to accommodate people who are ready for discharge from Sligo General Hospital but not ready to go straight home. I urge the Tánaiste to ensure full use is made of all these excellent facilities whenever they are required. Using such facilities will ensure that the acute beds in Sligo General Hospital are occupied by people who need the full range of investigative and therapeutic services a hospital such as Sligo can give them.

In that regard, I have asked before, and I do so again today, that approval be given for the establishment of an acute medical assessment unit in Sligo General Hospital. Such units have worked exceptionally well in other hospitals and have resulted in accident and emergency units in such hospitals not experiencing the overcrowding that exists elsewhere. There is no doubt that such units are a vital component in the smooth running of accident and emergency units. Sligo General Hospital submitted detailed planning of such a unit to the HSE some time ago. I have spoken to the Tánaiste and Professor Drumm of the HSE about the urgent need for such a unit. I again ask that immediate approval be given for the establishment of such a unit in Sligo.

The patients who attend accident and emergency in Sligo need and fully deserve an acute medical assessment unit immediately. Its establishment will result in a much better service for patients. The patients of the north west want this unit and I again ask the Tánaiste to use her influence with the HSE to ensure this unit is established as soon as possible.

I refer briefly to Trolley Watch, as published by the INO. On 5 April last a record number of patients were recorded as being on trolleys in accident and emergency units — in excess of 360. Since then the figures nationally have shown a very welcome decrease to a low of 186 last Friday. While there was a slight rise yesterday, I note the figures for Sligo General Hospital have been among the lowest nationally and I say well done to all concerned. However, we need that acute medical assessment unit to keep up the high standards in the hospital. I fully support the Tánaiste in her work to date to deal with this very difficult problem. I support the motion.

Mr. Sargent

Tá mé ag roinnt mo chuid ama leis na Teachtaí Crowe, Gregory agus Finian McGrath.

Cuirim fáilte roimh an díospóireacht mar is deis thábhachtach dúinn é an scéal práinneach seo a iniúchadh agus a phlé. Accident and emergency facilities are rarely out of the news and, unfortunately, it is all too often because they are so inadequate. We talk about the need for resources but, first and foremost, there is a need for more beds in our hospitals to deal with the demands created by accident and emergency units. The legacy of this Government and of previous ones comprising the same parties is multiple bed closures over the years. Despite all the talk, spin and the latest press releases and so on from the Government, the reality is that Ireland is below the European average in terms of acute beds. We have three acute beds per 1,000 of population whereas Germany has six acute beds per 1,000 — twice as many. We must face up to that reality.

The Tánaiste said that last year, more than 1.2 million people attended accident and emergency — an average of 3,300 per day. If we want people to go to their doctors, we must have more doctors. Ireland has 20 doctors per 10,000 of population while Germany has 36 doctors per 10,000. We all want more primary care.

This is a question of resources and it will not be dealt with by a few short debates or press statements. The former Minister, Deputy Martin, told us not to blame him in that people were getting sick more. That is probably true but the Government must take responsibility for failing to prioritise preventative health care. The last time I looked, it comprised 1% of overall health spending. If that is still the case, it is a disgrace. Alcohol advertisements are still allowed and we do not have an alcohol control office. Accident and emergency is about an end-of-pipe approach to health and the Department must take on board the need for a more holistic approach.

The bottom line is that an unhealthy lifestyle is a consequence of poverty. The Government has widened the gap between the rich and poor. From 1997 onwards, the top 20% got 40% of the budget giveaways, while the bottom 20% got 5%. The top 20% received six times the share of wealth afforded to the bottom 20%, whereas in Denmark the top 20% received three times the share of the wealth afforded to the bottom 20%. A divided society creates an unhealthy society. That is the bottom line.

Mr. Crowe

Many sods were turned over the years before the opening of Tallaght hospital, the hospital for the area I represent, and many politicians have visited the area in which it is located. It was supposed to be a flagship hospital, yet there are more people lying on trolleys in its accident and emergency department than there are in most other hospitals in the country. At one stage there were three times more patients on trolleys there than in other hospitals. Many patients in the hospital must spend up to eight days on trolleys. One man who had a heart complaint said, on the basis of what he went through in the hospital, that he would rather die than go back into its accident and emergency department.

The staff of the hospital should not be criticised because the Tánaiste is responsible. Will she explain to its staff and patients, and to residents of Tallaght and its hinterland, why there are nearly three times more patients on trolleys there than in any other hospital in the State. She can no longer get away with the excuse that she is new in the job. Circumstances have become significantly worse since she took office more than a year ago. She needs to act on plans to deal with the bottleneck in the accident and emergency unit which is now overwhelming other sections of the hospital. The necessary funds exist but the political will is lacking. The Tánaiste has made no positive impact on the crisis in Tallaght hospital and has failed in her role.

Less than a month after my highlighting a case in which a man was eight days on a trolley, similar cases arose. This is unacceptable. We hear nightmare stories weekly and I dread to think what stories will have to be heard to get the Government to act.

People should understand what is involved in waiting on a trolley in an accident and emergency department. I visited people in the accident and emergency department of Tallaght hospital and know of people who died in the hospital. What is happening dishonours the memory of the latter.

All public representatives have a responsibility to address this matter and it demeans us all that this problem exists in one of the richest countries in the world. Quick action is needed. In this regard, the Tánaiste should note that the answer does not involve prefabs outside Tallaght hospital. A proper unit is required and the site exists. Money and political will are the only elements that are lacking.

Mr. F. McGrath

I am thankful for the opportunity to speak on this important debate on the crisis in the accident and emergency departments of our hospitals. After nine years in power, the Government, in spite of its having had substantial resources and finances at its disposal, has done nothing about the nightmare of patients on trolleys in our hospitals. To me, it is a crime, scandal and disgrace. I find it a bit rich to hear Government parties talking about tax cuts for the wealthy while people are lying on trolleys, children with disabilities cannot avail of a speech therapy service, there is a lack of beds in our hospitals and a lack of proper home care packages for the elderly, there are students at second level without proper support services and there are many urgent needs to be met in society. I challenge the populist politics of Members of this House and must say straight out that health and education are much higher on my agenda than tax cuts. It is time for our politicians to hold their nerve, hold the line and demand investment in and reform of the health service. Let us put health ahead of greed and tax cuts.

The Ministers and other politicians should note that we need more beds and they should put a stop to the nonsense and guff in the media to the effect that the problem can be solved by reforming the service alone. This is misleading and dishonest and is conning the public. The reality is that successive Governments have failed to provide the necessary infrastructural support required by vulnerable citizens. The health system is sick and we need investment and reform to make it better. I reject the new mantra that the elderly patients are somehow to blame and I urge all Deputies to stop using the term "bed blocking" in respect of them. They deserve the service they get and they also deserve respect and, above all, our support.

The Independent Deputies in this House will stand by good practice in the health service and by patients and the citizens who pay their taxes for a quality health service. We have had too much old talk about accident and emergency services and we have had too much old guff and too many reports. We now want action. The solution comprises beds, investment and reform. If we provide for these, we will solve the problem.

Mr. Gregory

The Tánaiste was probably correct about one matter, that is, that the accident and emergency crisis should be regarded as a national emergency. The problem is that the Progressive Democrats and Fianna Fáil have now been in office for more than nine years during which time the accident and emergency crisis has festered. It has caused dreadful pain and suffering and, worse, it has caused deaths, especially of elderly people. It is only now, with an upcoming general election, that the crisis is being recognised for what it is — a national emergency and scandal.

What is being done about the crisis and where are the emergency measures to deal with it? The Government seems to be bankrupt of ideas in responding to this national emergency. Perhaps the statement of the Tánaiste and Minister for Health and Children was just another public relations ploy to give the impression of concern while she lacks the political will to take effective action.

I would be interested to hear the Tánaiste's responses to the following practical questions. Why is there no consultant on the floor of accident and emergency units throughout the evening and night, thereby resulting in a backlog of patients who must wait until 6 a.m. for a consultant to make decisions. Why are x-rays, blood tests, scans, etc. not available on a 24-hour basis? Why are persons under the influence of drugs and alcohol not diverted from accident and emergency units to a more appropriate location at weekends? Why do 411 elderly patients in the Mater, Beaumont and Blanchardstown hospitals still await the provision of beds in nursing homes, for which the Government will not provide funds? Why are the necessary, additional nursing staff not recruited? Why is the system becoming top-heavy with managerial and administrative staff?

If the Government genuinely regarded the accident and emergency crisis as a national emergency, the aforementioned issues would be dealt with on an emergency basis. The Government is bankrupt of ideas on this issue and this leads to only one conclusion, that is, greed is uppermost in the minds and on the agenda of the Progressive Democrats members and their partners in government. Health is simply not accorded sufficient priority. This is the bottom line.

The Government has failed to deliver the deliver the world class health service the Taoiseach promised us in 2001. He made this commitment to the people and has reneged on it. The people will remember this at the next general election.

Ms Cooper-Flynn

I, too, welcome the opportunity to speak on the problems with accident and emergency services. When the Tánaiste outlined her ten-point plan last year, I stated it could not work throughout the country, particularly in the west. The majority of points in the plan were geared towards problems in hospitals in Dublin, yet the problem in accident and emergency units was and is countrywide. I am very conscious of this in County Mayo. Almost four weeks ago, there were 30 people on trolleys in Mayo General Hospital, which is the highest ever number recorded in that hospital.

I listened very carefully to the Tánaiste's contribution. In outlining what has been achieved to date under her plan, she referred to the minor injuries unit. This is inapplicable to Mayo General Hospital in that it did not benefit from it. The Tánaiste also referred to the MRI scanner for Beaumont Hospital. I am sure it is very welcome in that hospital but it does not help Mayo General Hospital. She referred to the acute medical assessment units but Mayo General Hospital has not benefited from these either.

The Minister mentioned contract beds, which is a real bone of contention for me. No contract beds, either medium or long-term, have been allocated to County Mayo and Mayo General Hospital. Three times in recent weeks people were sent from Mayo General Hospital to beds in nursing homes, without budget, as an emergency response to the problem in the accident and emergency unit. I mentioned this problem to Professor Drumm at the meeting of the Oireachtas Joint Committee on Health and Children and it needs to be addressed as a priority.

Last year the Tánaiste announced 500 home-care packages under the plan, of which five were allocated to Mayo General Hospital. The home-care package is an excellent scheme. How could this option be mentioned to an elderly person when only five are available in a county with 110,000 people, of whom 12% are over 65? In reality nobody is getting it and it is unfair to offer such an attractive option. In rural communities people are much more inclined to want to stay in their own home and community because very often nursing homes and hospitals necessitate travelling in excess of 50 miles across very bad roads. When I brought this issue to the attention of Professor Drumm I was delighted that he expressed horror and surprise at Mayo having got only five places. He reassured me that between 2,000 and 3,000 home-care packages will be announced and we will get a greater percentage of those in the west. I ask that the matter be dealt with as an absolute priority.

The out-of-hours GP service operates only in the east of County Mayo, which means that people on the west side need to go to accident and emergency units at all hours of the day and night. The one positive aspect of the plan is the direct GP access to diagnostic equipment, which is working quite well in Mayo General Hospital and has ensured that many more people do not need to go to accident and emergency units.

However, this is not just a Dublin problem. I do not always want to talk about Dublin versus the west. In reality we need a nationwide response. In this regard I congratulate Professor Drumm on a new initiative which could be successful in dealing with the accident and emergency problems. I refer to a new pilot scheme to apply to 15 accident and emergency units throughout the country, of which, I am pleased to say, Mayo General Hospital is one. For a change the HSE is now asking the local hospitals to give the solutions to the problem in their areas. It recognises for the first time that every area has different problems. It might be beds and capacity in one area and something completely different in another. Our hospital is seeking 20 contract beds, which is not an unrealistic request. We are seeking an increase in the home-care packages.

One of the step-down facilities catering for elderly people in County Mayo is the Sacred Heart Hospital in Castlebar. In the past five years the capacity of that hospital has been reduced from 300 to 160. Phase 2 of Mayo General Hospital, which cost €40 million — I signed the contract documents when I was chairperson of the Western Health Board — increased the capacity of the hospital by 100 beds. During the same time, a step-down facility has reduced its capacity by 140 beds, which is crazy. Part of the local scheme to address the problem in Mayo will be to increase the capacity of the Sacred Heart Hospital. Another aspect will be to carry out tests locally that are currently being carried out in Galway. People are staying in beds for three or four nights when they only need to stay for one night. At the Oireachtas Joint Committee on Health and Children, Professor Drumm accepted that this was a critical component in dealing with the accident and emergency problem.

I wish to refer to the performance appraisal indicators. Last year my local hospital received a penalty of €1.2 million based on the performance indicators adjudicated by the HSE, which deemed the hospital to be inefficient. I made the point that the hospital was not inefficient. It had a problem relating to the new orthopaedic unit which had been set up but was not operational. The indicators examined, the inpatient numbers in the hospital, gave an inaccurate reading for Mayo General Hospital and as a result we suffered this penalty of €1.2 million. How can a hospital be expected to improve its efficiency when that level of penalty is levied against it? When the new performance appraisal indicators are determined by the HSE, it should consider all hospital activity, not just inpatient activity. It must also consider outpatient activity, particularly for the smaller hospitals. Otherwise these performance indicators will favour the bigger hospitals and the smaller hospitals will suffer as a result. This was certainly the case last year with hospitals such as those in Letterkenny, Sligo and Mayo, which all suffered on the basis of the performance appraisal that took place. That will not be acceptable in future.

Between January and June last year, Mayo General Hospital had an average of between ten and 15 people on trolleys, reaching a high of 30 three and a half weeks ago and on occasions a low of absolutely nobody. Between June and December the average was between four and eight people on trolleys, which indicates a seasonal aspect to the problem. The accident and emergency unit in Mayo General Hospital has seen a year-on-year increase of 5% in the past three years. The number of people attending accident and emergency units in the county has increased substantially. While I was surprised this is not the case throughout the country, I believe that while the numbers of people attending accident and emergency units has declined, the number of admissions to hospitals has increased. We need to carefully consider this trend, which is obviously a direct result of the age profile of our population. In ten years' time 16% of our people will be more than 65 and the problem will continue to increase. While we may see a further reduction in the numbers in hospitals, particularly if we improve the out-of-hours GP services, the number of admissions will be greater.

I am seriously concerned about the mechanism for admitting a person through an accident and emergency unit. The Oireachtas Joint Committee on Health and Children was informed that up to five different people could attend to a patient presenting at an accident and emergency unit. The person deciding whether to admit a patient may ultimately be a junior doctor. In my county recently an elderly man, who had been admitted to hospital through the accident and emergency unit, was discharged from hospital at 2 a.m. and sent home in a taxi, which arrived at a rural part of the county at 4 a.m. He was readmitted the following day in an ambulance. What kind of decision is that? Surely a mechanism should exist to prevent an elderly person from being discharged after a certain time in the evening. This sad case in particular was outrageous.

I listened to Deputy Gregory talking about accident and emergency consultants at 6 a.m. Where are they? There are no accident and emergency consultants on duty at 6 a.m. In my county the service operates from 9 a.m. to 5 p.m. Today I asked my local hospital manager whether having an additional accident and emergency consultant would improve the situation. There is no point in recruiting an additional accident and emergency consultant if he will only work between 9 a.m. and 5 p.m. We need 24-hour cover and not to have junior doctors making the decision to admit patients. It is ludicrous to have a chain of events whereby a person is admitted, seen by a nurse, a junior doctor and a consultant, who should make the decision, and finally a few hours later seen by another junior doctor who second-guesses what the consultant should have decided a number of hours previously. A junior doctor under that type of pressure will err on the side of caution and will admit rather than discharge. Many of the problems in our accident and emergency units arise as a direct result of that process.

I am particularly concerned about this matter. For the first time I believe there will be a regional focus to the problem. However, only time will tell. The pilot scheme has not yet started and I urge the Government to put the resources into the regions as well as into the city of Dublin.

Mr. Kehoe

I am delighted to have the opportunity to speak on the motion. Everybody has experience of the problems in accident and emergency departments, particularly the staff in those departments. Those staff are under tremendous pressure, are stressed out and overworked, and in most accident and emergency departments the staff have to work in very small spaces. In my county, Wexford, I meet the staff in accident and emergency departments on a regular basis. The union representative said the staff at Wexford General Hospital are totally stressed out by the amount of people who are coming to the accident and emergency department there. They are stressed because they have to rush here and there from one end of the day to the other. There are constant queues of people outside the door of the accident and emergency departments of Wexford General Hospital and most other hospitals in this country.

I have spoken to patients who had to wait at accident and emergency departments for five, six or seven hours. I recently spoke to a lady whose son was injured in a hurling game. He went into the accident and emergency department at 4.30 p.m. on a Saturday evening and did not leave until 12.30 a.m. the next morning. That is totally unacceptable. Having waited from 4.30 p.m. to 12.30 a.m., he was told to go to Waterford Regional Hospital the next day. That is totally unworkable and totally unsatisfactory. No business would be run in such a manner. Accident and emergency departments should be run like businesses — they should be able to deal with people as quickly and efficiently as possible.

Deputy Cooper-Flynn spoke about the case of an elderly person from a rural part of her constituency who was discharged from a hospital at 2.30 a.m. I am familiar with a similar case in County Wexford not too long ago, when an elderly lady in her 80s who is blind and lives alone was dropped home in a taxi in the early hours of the morning. The taxi driver did not even get out of the car to open the woman's door. The woman got into bed when she got inside her house, but she fell out during the night and was readmitted to Wexford General Hospital the following day. She spent three or four weeks in Wexford General Hospital following that fall. It could be argued the woman was holding up the supply of a bed during that time. She should have been treated in the first place, rather than being sent home to a rural part of County Wexford alone. It is totally unacceptable that a person with a sight impairment was treated in such a manner.

The accident and emergency department in Wexford General Hospital is very small. It has just six or eight beds, which is totally unsatisfactory. The patients are almost on top of each other. The small department fills up on a regular basis because it has to deal with many people each year. One of the major problems in County Wexford is that its population almost doubles in the summer months, from May to August or September, when many tourists come to the county. Children who are on holiday are brought straight to the local accident and emergency department when they get injured while playing. This is a major concern for the hospital manager in County Wexford over the summer months. It is great that we have accident and emergency consultants, but they are of no use if they only work between 9 a.m. and 5 p.m. Most of the work of accident and emergency departments is generated after 5 p.m., especially at weekends. Many people are admitted to such departments at weekends when injuries occur while people are playing sports like hurling and football. That can cause chronic problems for nurses and doctors. There are plans to build a new accident and emergency department at Wexford General Hospital. A Deputy referred earlier to a Minister visiting a constituency to turn the sod on a new development. It is great to see someone coming to turn the sod, but there is not much use in turning the sod unless further action is taken. In this case, the accident and emergency department needs to be built.

I feel strongly about the fact that the CT scan machine in County Wexford is manned just five days a week, between 9 a.m. and 5 p.m. The machine cost the Department very little because it funded just a small percentage of the cost. The larger percentage of the funding — up to 80% of it — was acquired by the people of County Wexford by means of fundraising. The people were led to understand the machine would be in operation seven days a week, 24 hours a day, but that has not happened. The Department has not lived up to the commitment it gave the people of Wexford six or seven years ago. It is totally unacceptable that the machine is not in operation other than between 9 a.m. and 5 p.m. between Monday and Friday. The people of Wexford accepted in good faith the Department's commitment to ensure the machine would be in operation at all times.

I would like to have a clearer understanding of an issue relating to trolleys. Perhaps the Minister or the Minister of State can confirm, when concluding this debate, whether patients on trolleys have to pay the full bills for hospital beds. One of my constituents who spent five nights in Wexford General Hospital, four nights on trolleys and one night in a bed, is due to go to court soon. I assure the House the man will go to jail before he pays the amount he has been charged. He did not enjoy the level of service or comfort he would have received if he had been in a bed. He has been charged the same amount he would have been charged if he had spent five nights in a bed. I ask the Minister of State, Deputy Tim O'Malley, to clear up this matter. Do people have to pay to spend nights on trolleys? The number of people on trolleys at Wexford General Hospital is one of the highest of any of the hospitals outside our cities. Some 19 people were on trolleys at the hospital yesterday, 25 April, and I suppose it is more or less the same today. The number of people on trolleys at the hospital is usually one of the highest of any of the rural hospitals. I ask the Minister to address this matter as soon as possible because people are constantly being left on trolleys.

Elective surgery is being cancelled on a regular basis as a consequence of the lack of beds at Wexford General Hospital. Many people have been telephoned at 7 a.m. on the day of their operations to be told they should not attend for surgery because there are no beds for them. It is totally unacceptable. Such people are being returned to waiting lists for two or three months. It is unfair on a person who has prepared for surgery, especially an elderly person, to get a telephone call from the hospital manager on the morning of the operation to say no bed is available and they will have to wait. I have raised this matter with consultants on a number of occasions, to be told the hospital is full and no beds or trolleys are available for people who are due for elective surgery.

I ask the Tánaiste and the Minister of State to address the major issues in County Wexford and to ensure Wexford General Hospital receives the same slice of the cake as the other hospitals throughout the country. I have asked the Tánaiste on numerous occasions to visit the hospital, to witness the chronic overcrowding there and to learn about exactly what is happening there. It is sad she has not yet found an opportunity to visit the hospital. I emphasise to her the importance of visiting Wexford General Hospital, where she can see what is happening at first hand.

Mr. Moloney

I am glad to have an opportunity to speak on this motion for a few minutes. I do not intend to suggest that all is well in accident and emergency departments. It is not the case that Government Deputies are expected to do so. I accept the points made by Deputy Cooper-Flynn. It is obvious that not all accident and emergency departments face the same demands. It is clear, therefore, that the same responses or solutions are not required. As a member of the Joint Committee on Health and Children in recent months, I refute any allegation that the health service is being neglected by the Tánaiste or the Government. I recognise that the Tánaiste made a commitment, shortly after she became Minister for Health and Children, to attend a meeting of the joint committee every three months to deal with the issues which crop up on a daily basis, unfortunately, and to respond directly to them. The last meeting of the committee that the Tánaiste and Professor Drumm attended was scheduled for an hour and a half, began at 9.30 a.m. and ended at some time close to 2 p.m. Obviously the longevity of a meeting is no indicator of the outcome. That suggests, however, that there has been no hidden agenda or attempt to run away from the facts. They were quite clearly outlined to members of the committee.

Some accident and emergency units throughout the country work well and successfully. From memory I believe Kilkenny, Waterford and Limerick were in this category. On the other hand, some accident and emergency units have a very poor record. The most startling statistic to emerge that morning was the fact that often in some accident and emergency units a patient may be seen by up to five medical practitioners, and quite obviously this is something that must be attended to. Obviously, that is only part of the problem. Nevertheless, it shows there is no consistency throughout the service and, more importantly, people may be left waiting unnecessarily.

Those who have the privilege of serving on the Joint Committee on Health and Children have the time to listen to the Tánaiste give specific details on the issue. A few minutes ago it was asserted that the greed of the Government meant it was ignoring the health service. Rather than waste the few minutes I have talking about the health spend, it is important for us to realise that health funding has gone from €3.6 billion to €12.6 billion.

Debate adjourned.