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Dáil Éireann debate -
Tuesday, 21 Oct 2014

Vol. 855 No. 1

Topical Issue Debate

Ebola Virus Outbreak

The rapid rise in Ebola-related deaths is sounding alarm bells right around the globe. International leaders have been slow to ramp up the necessary humanitarian support in order to combat the crisis emanating from west Africa. In this instance the authorities appear to be failing to act to combat the spread of the virus. If the international community had acted in a co-ordinated and concise manner at the beginning of this outbreak, I believe we would not be witnessing the current situation.

Deaths have occurred in Spain and in Germany, bringing the threat of an outbreak even closer to home. The warning from the head of the UN mission for Ebola emergency response, Anthony Banbury, that the disease is, "winning the race", is extremely worrying and highlights the need for a comprehensive humanitarian response plan from the European Union and from the rest of the international community. Europe has always acted in a much speedier manner than other parts of the international community but it needs to do more. Furthermore, the fact that the Irish Medical Organisation has expressed concern about Ireland's contingency plans in the event of an Ebola case, is something which should concern us.

Last week, the assistant director general of the World Health Organisation, Dr. Bruce Aylward, stated that the fatality rate of Ebola has reached 70%. He stated that this is a high mortality disease and that the UN health agency is still focused on trying to isolate sick people and provide treatment as early as possible. It is important to note that previously the WHO had said that the death rate was around 50%. Dr. Aylward stated that if the response to the Ebola crisis is not stepped up within 60 days, a lot more people will die and a very great effort will be required to deal with the spiralling number of cases. He added that in the past four weeks there have been approximately 1,000 new cases per week, although this figure includes suspected, confirmed and probable cases.

Given the background which I have outlined I sought this Topical Issue matter and I am pleased that the Minister of State, Deputy Sean Sherlock is taking it. I compliment him on his visit to west Africa. Our former colleague, Barry Andrews, is chief executive of GOAL and he stated that the Minister of State's visit was very important and very useful. He and his colleagues in the different non-governmental organisations appreciate that support.

This matter was discussed during Question Time almost two weeks ago. It is important that the Minister of State has this further opportunity to outline the response. I ask what protocols have been put in place to ensure that Irish NGO workers travelling to Africa have the proper equipment and training to tackle the crisis. I ask the Minister of State to outline what will be the arrangements for them on their return to this country. Our aid workers travelling to Africa to help combat this disease should be commended on their bravery and their selflessness and should be supported with the best possible equipment and training. I listened to presentations from GOAL and from Doctors Without Borders at the joint committee a number of weeks ago. They provided the committee with details of the huge suffering and hardship that so many communities are experiencing, in particular in three countries in west Africa.

I commend the Minister of State on his visit to the region and I hope that the statement from the Foreign Ministers Council meeting yesterday will result in Europe having a better co-ordinated plan and greater co-operation between member states. It was disappointing to hear that the level of funding provided by EU member states and by the European Union as a whole, is not adequate. The British Foreign Secretary has suggested that the €500 million committed by the member states and the European Commission needs to be doubled. I ask the Minister of State to say whether Ireland intends to propose at the Heads of Government meeting later this week that the European Union and the rest of the international community should provide without further delay the necessary resources to tackle this very serious outbreak.

I thank Deputy Smith for raising this issue and I thank him for his kind words.

It is appropriate to have this discussion on Ebola today, given the rapid deterioration in the situation in west Africa over the past month and with cases appearing elsewhere in the world. This debate is particularly timely, given that the Ebola crisis was discussed at the EU Foreign Affairs Council meeting yesterday and will be discussed at the European Council later this week.

The latest World Health Organisation figures are alarming - well over 9,000 people infected by Ebola, and over 4,500 deaths in west Africa. Despite all the efforts of the international community, the likelihood is that the situation will deteriorate further before it improves. I met Mr. Banbury when I was in Freetown in Sierra Leone. He indicated to us that the crisis would get worse before it gets better. Ireland has been very actively engaged at all levels in addressing the crisis on the ground and internationally.

As the Deputy is aware, I travelled to Sierra Leone at the start of the month and witnessed at first hand the devastating impact of Ebola there. I came away from my visit with three strong impressions. There was a key gap in leadership and co-ordination, which I am glad to say is now being filled by the UN emergency Ebola mission, UNMEER, headed by Mr. Nabarro and co-ordinated by Mr. Banbury. There remains important funding needs and this has been recognised in yesterday's motion at the Foreign Affairs Council. There is a need to scale up capacity for isolation and treatment. There is an urgent need for more international health care professionals to staff the isolation and treatment centres.

Ireland is one of a very small number of EU member states with an embassy in Freetown. I was struck during my visit by the very strong advocacy and co-ordination role being played by the Irish ambassador-designate, Ms Walsh, and her small and dedicated team. Ireland is working closely with international partners and others, including the US and the UK and the Government of Sierra Leone, in the fight against Ebola. The question of co-ordination is a key issue if the Ebola virus is to be tackled effectively in the west Africa region and if its spread to other countries is to be prevented. This was discussed at the Foreign Affairs Council in Luxembourg yesterday which was attended by the Minister, Deputy Charles Flanagan. The Council's decisions yesterday represented an important further step in EU efforts to tackle the crisis by reaffirming the need to work together in a co-ordinated way and to pool our strengths.

I wish to assure the Deputy that as a result of visiting Sierra Leone it is my view that Ireland must use its influence at the United Nations and through the European Council to support the need for a pan-European or strong EU response to this crisis. The bilateral response is a powerful one but it is not sufficient to tackle the nature of this crisis. There is a clear need for health workers and other key personnel to be represented on the ground. The Council meeting yesterday recognised the need to support international health responders. It agreed that the EU will provide appropriate care for them, including the possibility of medical evacuation if necessary.

We must now work urgently to ensure it is implemented in full.

I thank the Minister of State for his response. In his latter comments, the Minister of State said the EU will provide support for medical evacuation. I presume this will be done for citizens of all member states of the European Union, because I do not think we would have the capacity or aircraft necessary to carry out a medical evacuation.

There have already been more than 4,500 deaths in west Africa from this particular virus. Yesterday in Strasbourg, the Commissioner for International Co-operation, Humanitarian Aid and Crisis Response spoke about the possibility of 10,000 new cases of Ebola per week by mid-December. This is really frightening, when we consider that at present the World Health Organization's figure is 1,000. Surely this statement by a member of the European Commission demonstrates the need for the European Union to double the funding level and commitment made available to date.

A particular issue which may be more relevant to the Minister for Health, who is with us this afternoon, is a statement by the Irish Association for Emergency Medicine that it is not reassured by Department of Health and HSE claims of full preparedness should the virus reach our shores. This issue needs to be addressed, and I hope the Minister, Deputy Varadkar, will be able to deal with it in a public statement.

I compliment the people who have gone out to work in extremely difficult circumstances. I also compliment the officials from the Department working in the region, all of the Irish NGOs and our colleagues from every country who are working against the tide to try to bring some semblance of normality to communities which have lost everything. I heard a representative from an NGO of another country state that perhaps the true level of deaths is not being recorded due to the nature of the virus and the fact many people are losing their lives in very remote communities. Does the Minister of State share this worry?

I can only speak for Sierra Leone. I concur absolutely with the Deputy on his remarks on the efforts of the NGOs. The work done by GOAL, Concern, Plan and other agencies is extremely effective. The Irish Government's response is that we need to be flexible in our approach and Irish Aid, which is very close to the NGO community, is being allowed to pivot towards the Ebola response. The big concern I have as Minister of State with responsibility for official development assistance is we must be mindful of the fact that we need to ensure we do not spark a humanitarian crisis in all of this. The nutrition programmes being delivered need to continue apace.

Instinctively, I think the Deputy is right about the underreporting. It is only a matter of weeks since I was there, and it was at that juncture the UN had come to Sierra Leone in particular. Now that Mr. Banbury has been appointed as co-ordinator, our ambassador is working very closely on liaising with the Sierra Leone Government to ensure we assist in building the infrastructure to treat people medically on the ground, and this response is happening. It is a fair assumption that where there was no international involvement until relatively recently, and instead reliance on the Sierra Leone departments of health, social welfare or education to deliver programmes with the NGOs, there was a certain lack of capacity and the NGOs were punching above their weight. Now we have international co-ordination and various governments have responded proactively.

I agree absolutely the European response needs to be rapid. The resolution yesterday, arising from the Luxembourg meeting, is significant because it recognises for the first time the need to ensure we protect health workers who go out there. A live issue we were dealing with when I was there was the need to ensure local Sierra Leonean health workers were paid, because they had not been paid for quite a period of time. It is difficult to expect an Irish or Spanish health worker to go there if the Sierra Leonean health workers are not being paid and are staying away. There was a strike at one stage. These are the issues we are dealing with. We are very effective and making solid progress on these issues. I agree the international response needs to be more proactive, but for our part as members of the European Union we have had an influence in bringing this to bear, in terms of our interventions through the Minister, Deputy Flanagan, at the Foreign Affairs Council yesterday. We are keeping a daily watch on this because we want to ensure where possible cases are dealt with medically within the region. This is the most effective way of dealing with cases.

Nursing Home Inspections

I welcome the presence of the Minister for Health. I wish to speak about a report on the HIQA website on the inspection of homes for the elderly. I praise HIQA for the tremendous commitment and dedication of its staff who always work, as they must, within the law. In the year about which I am speaking, more than 500 individual investigations into various homes were conducted with regard to inspection reports. A serious legal anomaly has arisen, as more than 350 written or verbal complaints were received by HIQA relating to more than 213 homes, but none of them could be investigated directly by HIQA because the law does not allow it to do so. The list of issues raised in these complaints includes elder abuse, financial abuse, verbal, physical and sexual abuse of residents, dementia patients with fractured ribs, patients being unwashed, a 90 year old patient freezing cold, broken furniture and, specifically, reference is made to a number of deaths from septicaemia and at least seven other deaths. At present, HIQA cannot investigate these.

I will give a sample of some of the individual complaints. A resident died due to staff not being trained properly and poor quality of care. A doctor called did not visit the actual patient. Another doctor stated the patient had a slight chest infection, but on arrival at hospital the person had severe pneumonia and dehydration and died. Forms were updated in the office by three members of staff after the admission to hospital.

A male patient was calling for help with two bare legs over his bed rails. After ten minutes a staff member closed the door on him and did not help. The poor man died with unexplained marks on his hand.

In another home a resident suffering from Alzheimer's was not looked after properly. No verbal communication took place with her and she was not called by her name. Occasionally she was covered in excrement, on the toilet with a pillow behind her, weak and unable to sit up. She ate meals with excrement on her hands. Although she was vomiting and ill, no ambulance was called. A family member brought her to hospital where she subsequently died.

There are other issues involving unresolved elder abuse and a staff nurse resigned as a result. There has been intimidation of residents. Residents have been left on commodes for four hours or more. There are also cases of residents being scared and in fear. Complaints have not been listened to. Residents have been on commodes at 4.30 a.m. Dementia patients have been given breakfast on commodes.

Professor Des O'Neill, who inquired into the appalling abuse at Leas Cross, found deficient care at many levels.

There was an inadequate number of trained staff and he found that the charge of institutional abuse was proved against Leas Cross. He made two important recommendations - he made 11 in all. The minimum number of staff should be defined nationally and the nursing needs need to be assessed by a nursing needs assessment tool, with which I am sure the Minister is very familiar. On the question of nurses, nurses with qualification in gerontology were absolutely essential to ensure residents of homes were properly and well looked after.

In summary, the charge is that we have failed to change the law enough to allow HIQA to do the excellent job it wants to do. I understand from HIQA that a simple amendment to the Health Act 2007 would allow it to go in and challenge each of these individual complaints. That is the very least we can do to protect our elderly residents in these nursing homes for which they pay an absolute fortune.

I am taking this debate on behalf of the Minister of State, Deputy Kathleen Lynch, who has responsibility for nursing homes. I thank Deputy O'Dowd for raising this matter in the House.

The Health Information and Quality Authority, HIQA, is the independent authority established under the Health Act 2007 to drive continuous improvement and to monitor safety and quality in Ireland's health and personal social care services. Since 2009 all nursing homes - public, voluntary and private have been registered and inspected by HIQA. The Government also extended HIQA's function to residential services for those with disabilities and child-protection services. In addition, we are committed to introducing a regulatory system for home-care services, making them subject to registration and inspection by HIQA, on which work has already commenced.

As regulator, HIQA's remit is to inspect facilities and services rather than investigate individual complaints. Nursing home operators must ensure all reasonable measures are taken to protect residents from all forms of abuse. They must have policies and procedures in place for the prevention and detection of, and the response to abuse. Furthermore, operators must notify HIQA of any allegation of abuse or serious adverse incidents that occur in a nursing home.

All nursing homes are required to have an accessible and effective complaints procedure of their own, including an appeals process. They must investigate all complaints promptly and following investigation, put in place any measures required for improvement. They must keep a record of complaints made, and this record must be available for inspection enabling HIQA when it carries out an inspection to determine whether the nursing home's complaints system is sufficiently robust.

In addition to this, HIQA takes into account and uses all information received, to inform and plan its regulatory activity. Information on individual cases can provide useful pointers in this regard. HIQA's programme of scheduled and unannounced inspections helps to ensure standards are maintained and where issues of non-compliance arise, that these are addressed and rectified. The Department of Health, in consultation with HIQA and service providers, is working to improve and update the requirements that apply to nursing home care.

Lest there be any concerns about this I want to clarify that with public HSE nursing homes, people can make a complaint through the HSE complaint system. If they are not happy with the HSE complaint system, they can go to the Office of the Ombudsman for an independent complaint. Private nursing homes are supposed to have in place their own complaints procedure and to have an appeals mechanism. For both public and private nursing homes a complaint about elder abuse can be made directly to the HSE. The HSE's elder abuse services have 30 senior case-workers who work on exactly that.

HIQA's role is different. Currently, HIQA's role is not to deal with individual complaints but to be a regulator and inspectorate. Any change to that role would not be a simple amendment; it would be a major change in the role of that organisation and would require it to be resourced very differently from now in addition to a change in legislation.

I thank the Minister for his reply but I do not accept what he is saying is accurate. HIQA has sought powers from the Oireachtas and from the Department of Health and has addressed the Oireachtas Joint Committee on Health and Children on getting increased powers of inspection, particularly regarding the complaints it receives.

I acknowledge that the Minister's answer is what he has been given. However, the facts are that none of these complaints has been investigated. It is not good enough for anybody to say - I am not personalising this to the Minister - that if a person is not happy he or she can go to the Information Commissioner. Someone who believes his or her relative - who might be dying - has been abused or is being treated appallingly expects HIQA to act. My point is that HIQA wants to act. It wants to do it and is ready to do it. It assures me there is no question of a staff complement. There is no issue about qualified staff to go in. However, it has to deal with the issues it finds there. It is the licensing authority for a nursing home. If following a written complaint, including by e-mail, or an oral complaint its inspectors cannot go into that home and see what happened to Johnny Murphy, how Mary Murphy died, what is happening with dementia care or what are the qualifications of staff, we will have a repeat of what happened in Leas Cross.

I appeal to the Minister to listen to what I am saying and to talk to representatives of HIQA. He should read what they said on the record at the Oireachtas committee about the power it needs to protect the elderly. That is a sacred duty for all of us. There can be no avoiding that. There can be no saying, "It's not me; go to somebody else." As I have said there have been more than 352 complaints, many of them about serious issues where people have died. I ask the Minister to reconsider this when he returns to his Department. I intend to continue to pursue this matter. If it means I have to introduce legislation, I will do that to ensure that all these complaints are dealt with immediately and urgently to protect the elderly from abuse. That is our sacred duty.

I clarify once again. If it is a public nursing home, complaints can be made to the HSE, using its complaints procedure or subsequently to the Ombudsman if people are not happy with that. For private nursing homes, complaints have to be made through the private nursing home's own complaints procedure or through the appeals procedure if people are not happy with that. If it is elder abuse, regardless of where it is, complaints can be made to the HSE. It is not the role of HIQA currently to investigate individual complaints.

I must ask whether these complaints have been made through the appropriate channels. Have these complaints been made to the HSE and have these complaints been made to the private nursing homes themselves? I would be concerned if they have not been investigated. However, the fact that they have not been investigated by HIQA, which does not investigate individual complaints, is a very different point from saying they have not been investigated at all. Perhaps the Deputy might clarify that. Is he claiming that they have not been investigated at all or just that they have not been investigated by HIQA, which does not have the authority to investigate individual complaints in the first place?

In my meetings with representatives of HIQA, they have not requested this power. I will check with the Minister of State, Deputy Kathleen Lynch, if they have done so in their meetings with her. If they request it and they can assure me it does not require additional resources and it is willing to take on that existing role from the HSE, from the Ombudsman and from the private nursing homes and the existing appeals procedures, then I am happy to give that full consideration.

Lest anyone thinks otherwise, I want to clarify that the fact that HIQA does not investigate independent individual complaints does not mean they are not investigated. HSE nursing home complaints should go to the HSE and if people are not happy with that, they go to the Ombudsman. When it comes to private nursing homes, every private nursing home has to have its own complaints procedure and appeals procedure in place.

Hospital Services

On the afternoon of 14 October management at Letterkenny General Hospital issued a statement to the general public in which it asked people to avoid the hospital's emergency department owing to what it described as high activity levels. It also advised those seeking medical attention to visit their GPs instead of presenting at the emergency department.

In addition - reminding us just how understaffed and under-resourced that hospital is - the statement went on to explain that all those who were due for a planned admission as an inpatient at the hospital were being asked to phone the hospital beforehand so that staff could confirm the availability of a bed in advance of their arrival. If ever one needed further evidence that Letterkenny General Hospital is struggling to cope with the demands placed on it, this latest crisis should provide all the necessary proof.

Deputy Pádraig Mac Lochlainn and I have repeatedly raised the issue at the heart of the hospital's crisis. It is not surprising when one takes into account that management was forced to release a statement regarding the provisions afforded to the hospital compared with other major hospitals in the State.

Every year the hospital has on average 21,000 inpatient discharges, that is, patients who pass through its doors seeking treatment. To put that in context, LGH is the seventh largest hospital in the State, yet, despite this, it has still not been given regional hospital status nor has the facility been given the additional resources it desperately needs to appropriately serve the people of the north west. Based on the inpatient discharge numbers, LGH not only has the lowest budget allocation in comparison to other hospitals with a similar case mix, it also has the lowest allocation of medical staff. As a consequence, the hospital is forced every year - sometimes a number of times a year due to the failure to provide it with the necessary staff - to appoint an unnecessarily high volume of agency staff to deal with demand, something which is extremely costly for an institution with an overstretched budget. When HSE officials appeared before the Committee of Public Accounts, there was a discussion on the five vacant consultant posts in LGH. The hospital pays €110,000 through the HSE for those posts on a locum basis every 13 weeks. The cost of recruiting a full-time consultant would be approximately €110,000, yet the hospital is forced to pay €444,000 for the same post. We understand that five of these positions are filled in this way and not just one. In addition, agency staff fill other positions in the hospital.

It is clear from the national employment monitoring unit, which publishes health statistics, that the hospital is being disadvantaged in the context of the number of medical dental staff, nursing staff and agency staff per 1,000 inpatient discharges and in the allocation of funding. Given the resources available, how can the Minister ensure that next week, next month and next year patients who need to access the accident and emergency department are not asked to tune into Highland Radio, Radio na Gaeltachta or Ocean FM to be told by management not to attend and to visit their general practitioner and to be told that if they have a scheduled appointment, for which they may have had to wait for a long time, they may not have a bed for them? This is not suitable for patients in Donegal. This is the most important element of public infrastructure in the county and we are proud of it. It is close to our hearts, given it is where many of us have spent our first hours and will spend our final hours. We want to ensure the hospital is resourced in order that it can meet the needs of our communities.

I thank the Deputy for raising the issue. Letterkenny General Hospital has an average of 98 presentations to its accident and emergency department on a daily basis. I have been advised by the HSE that over a period of several days last week the hospital encountered a spike in demand, where there were more than 120 presentations on each of the three days involved. Coupled with this was the acuity or degree of complexity in sickness of the patients. Sicker patients typically require more complex care and for longer periods. A series of measures was undertaken to manage this surge in volume, including a message to the public to avoid the accident and emergency department if possible and for people to contact their GP to see if their emergency merited them attending the department. This is a usual response for hospitals to pursue in the event of unusually high demand and this is not unique to LGH. All acute general hospitals are faced with these challenges when it comes to a spike in demand.

LGH has taken a range of measures to deal with increased demand and is working closely with the special delivery unit, SDU, on an almost daily basis to manage and identify strategies to expedite patients' journeys through the hospital. An additional 19 beds were opened in the hospital in July this year while the SDU funded a further 11 beds in primary and community care to expedite discharges from the hospital by creating additional capacity for patients who require step-down care before they return home. The navigational hub bed management unit was set up to improve the efficacy of management of inpatient beds in the hospital.

Further measures include prioritising patients who require diagnostics, other interventions for patients who can be discharged on same day and working closely with colleagues in primary and community care to minimise the impact of delayed discharges in the hospital. Letterkenny General Hospital has one of the lowest levels of delayed discharges in the country. Last week, there were no delayed discharges compared with more than 300 in the Dublin hospitals. Today at 8 a.m. only one patient was waiting on a trolley and by 2 p.m., there was none.

A consultant physician has been appointed to lead on the acute medical assessment unit, AMAU. All medical referrals to the accident and emergency department are directed to the AMAU where a senior decision maker can assess and treat patients, thus avoiding admission. There also has been a reorganisation of work practices of the consultant and non-consultant hospital doctor staff in order that those who are on-call to the accident and emergency department have no other commitments elsewhere in the hospital. For instance, the surgeon on-call does not do any scheduled care in theatre that day. This has led to a much more timely response in seeing emergency presentations.

The hospital's patient flow policy was also recently reviewed and updated. The outcome was the adoption of a range of measures to expedite patient flow throughout the hospital such as improved discharge planning with the aim of discharging patients by 11 a.m., meaning the bed is freed up for another patient earlier in the day. The measures include nurse-led discharge and the identification of estimated date of discharge for each patient. The patient flow escalation policy has been also updated.

The target waiting time from presentation at the accident and emergency department to discharge or admission is six hours. LGH meets this target 87% of the time. The hospital experienced an unexpected spike in demand over the usual demand, therefore, additional special measures were taken to respond. All patients who presented to the accident and emergency department last week were assessed and treated as required.

As well as the exceptional measures outlined, the modern facilities created through the rebuilding necessitated by the flooding events in 2013 will ensure patients have improved access to safe, sustainable services for the long term. This is a direct reflection of the commitment and hard work of staff and management of Letterkenny General Hospital, the rebuild steering group and Saolta University Health Care Group.

I thank the Minister for his response. I am not sure he appreciates that the hospital is in crisis. This is not just my view; it is a view I have heard from senior levels within the hospital. The crisis presents itself at different times in different areas with the issue in the accident and emergency department last week an example of that. The hospital is kept going and meeting demand only because of the diligent efforts of its nursing staff, doctors, consultants and non-medical staff. This is where the problem arises. Many people are going beyond the call of duty.

I have statistics for 2012 and we need the updated statistics. However, LGH had 6.8 staff per 1,000 inpatient discharges that year compared with Kerry General Hospital, 7.2; South Infirmary Victoria University Hospital, 7.4; Mayo General Hospital, 7.8; St. Luke's General Hospital, Kilkenny, 7.8; Midland Regional Hospital, Tullamore, 9.9; and Sligo Regional Hospital, ten. I do not compare the hospital to the Mater Hospital and so on. LGH had 24.7 nursing staff per 1,000 inpatient discharges; Kerry General Hospital, more than 30; South Infirmary Victoria University Hospital, 31.9; Mayo General Hospital, 25; St. Luke's General Hospital, Kilkenny, 29; and so on. The number of agency staff in LGH was 0.7 per 1,000 inpatient discharges; Kerry General Hospital, zero; South Infirmary Victoria University Hospital, zero; Mayo General Hospital, zero; St. Luke's General Hospital, Kilkenny, 0.6; and so on. LGH, therefore, has the highest number of agency staff and lowest number of medical and nursing staff.

If LGH were compared to Mayo General Hospital, it would need 22 additional medical staff to meet demand while it would need 105 additional nursing staff when compared to St. Luke's General Hospital, Kilkenny. Consultants would not take up a position in the hospital if it was offered today. There is only one consultant, who cannot take holidays because he knows patients will not be treated.

The hospital is being run down because it does not have sufficient resources and staff. I do not expect the Minister to respond to the statistics I have outlined.

What I would like is if, as previously requested of the former Minister, Deputy Reilly, Deputy Varadkar as the new Minister for Health would look at the comparative data of Letterkenny General Hospital versus other hospitals with similar case mix and explain why in terms of all of these indicators Letterkenny General Hospital again comes at the bottom of the league in terms of resources.

The Minister referred in his reply to efficiency.

Letterkenny General Hospital has proven year on year that it is one of, if not the, most efficient hospitals. It has done everything it can but there are still major structural challenges within that hospital that cannot be met without the required resources.

I thank Deputy Doherty for his comments. I have no doubt the Deputy is sincere in his concerns for Letterkenny General Hospital. We all need to be careful, however, when dealing with health issues, not to do down good hospitals or services in the belief that somehow that will generate more resources because, first, it does not and, second, it undermines public confidence in the health service, unnecessarily and unfairly in my view.

During my time working as a doctor I worked at eight different hospitals, all of which had spikes in activity from time to time. There are two ways of dealing with this. One can either have huge latent capacity staff waiting around in case a hospital gets busy, which is very wasteful, or one can have mechanisms in place to deal with spikes in demand, including, for example, going off-call. It would not, for example, be unusual in the city of Dublin for one of the accident and emergency departments to go off-call for a short time during busy periods. The work is then moved to other hospitals. Also, during a busy day at an emergency department when many people have to be admitted, it is not unusual for elective surgery to be cancelled. That is always the case. The only way around that is to have a huge number of unused staff and so on, which is very inefficient.

When it comes to agency staff, Letterkenny General Hospital spent €4.9 million in this area. As the public sector embargo is being relaxed, it will have much more flexibility next year to hire people on temporary contracts or as full-time employees instead of hiring them through agencies. Significant savings can be made through the hiring of people on temporary contracts rather than through agencies, which is very expensive.

I am not familiar with the statistics and data mentioned today by the Deputy. They were not given to me in advance. I am happy to receive them and have them examined. It is not my role as Minister for Health to decide the staffing levels or budgets of the 47 acute hospitals in the State. That is a decision for the HSE and the national director of hospitals and, in time, the south hospital group when fully up and running. I am happy to commit to having the statistics referred to by the Deputy examined to see if they stack up. I must clarify, however, that I do not make decisions in regard to hospital staff or budgets.

Hospital Services

I thank the Ceann Comhairle for selecting this topic for discussion and the Minister, Deputy Varadkar, for being in the Chamber today to respond to it. The emergency department at Galway University Hospital is the busiest or second busiest in the country. On 17 September last, a number of nurses and health care staff who work in the emergency department at that hospital held a one hour lunchtime protest to highlight their difficulties in caring for patients, in particular elderly people, the extreme pressure on staff and the large number of people on trolleys and so on. Following this, I had engagements with management at Galway University Hospital and with the nurses during which a few issues came to the fore.

The statement issued by the hospital in terms of its acknowledgement of the difficulties being experienced by patients was honest. It also stated that despite the ongoing efforts of staff and management, not all emergency department patients are afforded privacy and dignity. The statement that not all patients in one of our busiest emergency departments are afforded privacy and dignity is powerful. Mr. Bill Meagher, then group CEO, said he would not want that service for himself or any of his loved ones and he did not want it for any of his patients or staff. That hospital management was able to acknowledge this was good and constructive. It allows us to move on and try to solve the issues. The management and staff agreed that staffing levels needed to be increased. As far as I am aware, that is now happening, which is very positive. However, there are still issues with the physical infrastructure that is the emergency department at Galway University Hospital. Bed management is also an issue. I welcome that construction of a new 70-bed ward will commence next year.

In response to a parliamentary question to the HSE about the emergency department at Galway University Hospital, I received the forthright and stark response that the original emergency department was constructed in the 1950s and the interim development of the late 1990s is still in place. I was also informed that annual emergency department attendance had increased from 57,000 in 2006 to 65,000 in 2014 and that the existing emergency department does not allow effective patient streaming, is not compliant with infection prevention and control standards and does not enable compliance with the emergency medicine programme or targets for unscheduled care patients experience. It is very honest of the hospital to put that on the record. In effect what the hospital is saying is that regardless of what is done in terms of the special delivery unit, increased bed management and re-routing services out of the emergency department, the physical infrastructure is not fit for purpose. I understand an application has been made to the capital steering group for two possible outcomes: a two-floor emergency department or a six-floor emergency department. I would appreciate if the Minister could tell the House when a decision in that regard will be made. The existing emergency department does not meet the basic requirements of an emergency department. Can provision of a new emergency department at Galway University Hospital, which meets the standards for patients, staff and the wider community in Galway and the west be a priority for the capital programme?

I thank Deputy Nolan for raising this issue today. Galway University Hospital has approximately 700 beds and is a tertiary referral centre for the western region, as part of the south hospital group. Its emergency department has approximately 66,000 attendances annually. Like many other major emergency departments in the country, it has experienced an increase in activity over recent months. The HSE is working closely with the special delivery unit to better manage patient flow through the hospital, and this collaboration has reduced the overall number of patients awaiting admission from the emergency department by 2,038 when compared with 2011.

The HSE advises me that Galway University Hospital is approving and recruiting experienced general and paediatric nurses for its departments. A recent interview process resulted in the creation of a panel of 21 experienced staff, 11 of whom are approved to commence in the coming weeks in the emergency department. Last week a fourth advanced nurse practitioner was appointed for the emergency department, with a specific function in the management of minor injury treatment.

To reflect the central importance of patient experience, GUH has appointed a patient advice and liaison officer with the role in the emergency department of addressing the needs of patients and attempting to improve patients' experience as they wait for access to services. Staff members also receive mindfulness training to assist in their approach and management of their ongoing workload. All these initiatives are of benefit to the public, patients and the staff.

The hospital has carried out a feasibility study to examine the benefits of an internal reconfiguration project of the existing emergency department versus a new build solution. This was completed in line with the development control plan for the site and accepted by the HSE capital steering group on 19 October 2013, subject to a cost-benefit analysis being undertaken. This cost-benefit analysis is under consideration. Future plans for the ED will incorporate capacity to meet the requirements of the emergency medicine programme and include capacity to meet the requirement of any future reconfiguration of services across the group. The HSE has been engaging on a consistent basis with the main unions, principally the INMO and SIPTU, regarding the activity levels within the department and the capacity issues therein. As part of this, a number of initiatives are being implemented to improve the pathways of care, including the navigational hub and the early discharge programme. A specific pathway for frail elderly is also being considered.

It is becoming evident from the data that the rising number of patients over 75 who are attending and requiring admission is rising but as the Deputy rightly points out, any of these measures around patient flow, greater use of community beds and so on will only be stop-gap measures. It is a very old emergency department and the medium to long-term solution will have to be a rebuild so that it is fit for the purpose we would all intend.

I thank the Minister for his response. It should be put on the record that an enormous amount of work has been done by hospital management, together with hospital staff, to make the best of that facility. One of the ideas put forward in the interim as a stop-gap measure, as the Minister put it, is to have an independent external person - a fresh pair of eyes - come into the emergency department to see what we can do in the meantime in terms of moving services out, looking at the way we do triage, looking at the way we allocate nurses, advance nurse practitioners and so forth, with a view to using that space in the best way possible. As the Minister said, where it is at the moment is simply not good enough.

The cost benefit analysis was submitted on 19 October 2013. That is a year ago, which is a very long time in which to consider and debate a cost benefit analysis. First, can the Minister give me a commitment that he will contact the Health Service Executive and get an answer on the option it intends to go for? Does it intend to go for a new two storey or six storey building?

Second, given that what we are talking about is not a luxury but a clinical need and that we are not meeting key requirements for emergency departments in terms of medicinal programmes, patient streaming, infection control and so forth, can we be assured that the infrastructure we so badly need is put as a priority for the HSE and that the 66,000 people who attend Galway University Hospital emergency department every year will not go into a substandard facility but one that is fit for purpose? Will the HSE make that a priority?

Third, would it be possible for the Minister to come to the emergency department and meet with the staff nurses? Ministers frequently attend conferences in Galway and it might be easy for him to come and meet the staff for 20 minutes or half an hour. It might put in his head the absolute requirement for a new building and to influence the capital project and make sure we get this as a priority capital project for the HSE.

Every Adjournment debate another invitation is forthcoming. As the Deputy is aware, hospitals are only one small part of the health service. There is much more to the health service than acute hospitals, and there are almost 50 of them so if I were to bunk off one day a week and do site visits it would take me a year just to get around them. That is something I intend to do but it will take quite some time to get around to visiting 47 acute hospitals, never mind all the other health care and primary care institutions.

It is the intention of the HSE in the coming months or certainly over next year to bring in outside consultants - people who are experts on how hospitals are run in other parts of the world - have them go into particular hospitals and work out the way those hospitals can be better run and better managed. It is obvious when we examine the trolley numbers - the fact that they peak on Wednesdays, fall back down on Fridays and peak again late on Saturdays and Sundays, that if we could smooth out activity in our hospitals we could make much better use of existing resources. There is a good deal that can be learned from overseas in that respect, and we hope to identify a few hospitals next year that are up for it, so to speak. That means changes in working practices and in the way things were always done to make better use of our facilities. Some hospitals will be chosen to take part in those type of projects.

When it comes to the new build, if there is a two-floor new build to replace the existing emergency department and put in an acute medical assessment unit, AMEU, and an ASU, which is what would be needed, we are talking about €30 million, and a six-storey building would cost about €60 million. It is a very substantial amount of money within a capital budget which only runs to 2016, but I will chase it up with the HSE to determine what is happening with the interim reconfiguring project.