Billy Kelleher
Question:1. Deputy Billy Kelleher asked the Minister for Health when the waiting lists and waiting times for inpatient and day case scheduled admissions will improve; and if he will make a statement on the matter. [2647/15]
Priority Questions
Hospital Waiting Lists
When does the Minister envisage an improvement in waiting lists and waiting times for inpatient and day case scheduled admissions? The most recent figures are for October 2014, but the Minister may have more recent ones. At the time 59,463 were on inpatient day case lists, of whom 54,250 were adults and 5,205 were children. Those on the lists, who require some service from the health service, have been waiting an inordinate length of time. Things are moving in the wrong direction. Even though there has been an increase in funding for acute hospitals, when does the Minister envisage a decrease in waiting times?
Improving waiting lists for inpatient and day case treatment is a key priority for me and the Government. My Department is working with the HSE to put in place a plan to eliminate very long waiters by the end of the year. This will involve productivity improvement and rigorous waiting list management. Further increasing day case surgery rates for specific procedures will be important in improving elective access within available capacity. Priority will be given to adherence to the guidelines on the scheduling of patients for surgery, including chronological scheduling, which will be vigorously monitored by the HSE throughout the year.
The management of competing demands for emergency and scheduled care requires changes in how and where patients are treated. The movement of care and treatment from inpatient to day case and from day case to outpatients is most important, as is ensuring the appropriate ratio of new to return appointments, which reduces unnecessary return appointments. Limiting elective surgery in preparation for, or as a response to, increased emergency department attendances is intended to help to manage the need for immediate emergency or trauma care.
Where it is necessary to prioritise cancer and other complex cases, the HSE assures me that this is being done. This inevitably will affect waiting lists. The challenge is to minimise the need for cancellation at short notice and to manage the impact of such cancellations effectively, within the hospital and in collaboration with other hospitals. As I have stated publicly in the context of the significant emergency pressures being experienced by hospitals, realistically I do not envisage significant improvement in elective waiting times in the early part of the year. However, based on the high priority attached to this area in the HSE service plan and the first overall increase in the HSE budget in seven years, it is expected that improvement will occur later in the year.
The previous Minister for Health, now Minister for Children and Youth Affairs, Deputy James Reilly, said, "For people and patients, a key barometer of the success of our reform programme must be the performance of emergency departments and waiting lists." I cannot blame the Minister for Health for the previous Minister's failings, but I cannot absolve him because of the fact that he is a member of the Government which put a fierce emphasis on the pretence that it would address all of these issues. We are facing into the fifth year of the Fine Gael and Labour Party Government and things have got progressively worse. Even though the Minister changed the criteria for counting those on waiting lists and the time people were waiting, things are still getting progressively worse. The idea that the solution to overcrowding in emergency departments is the cancellation of elective surgery beggars belief. This is creating a major difficulty for individuals in terms of being told their elective surgery has been cancelled and that they are back on waiting lists. If we could have clarity on what the Minister intends to do about this, we would appreciate it.
It is important to point out that all waiting lists are not the same. There are different waiting lists for different procedures, surgery, outpatient appointments, scans and other investigations. There are different waiting lists in different hospitals and for different consultants. Not all waiting lists are increasing; some are decreasing. For example, the waiting lists for physiotherapy and occupational therapy in the community are decreasing and there are very short wait times, if any, for palliative care. It is the case that the waiting lists for hospital-based investigations, procedures and appointments are rising. The figures for November which will be released tomorrow will show that they are rising and they will continue to rise for a number of months, not least because we have had to cancel so many elective surgeries this month. I agree that it is not a solution, but it is a necessary response to the overcrowding we are facing in emergency departments. We are doing three things. These involve transparency, greater efficiency around waiting lists such as adherence to chronological order, more new patients, fewer returns and other such things, and specific initiatives. Some 20,000 more day cases will be dealt with in 2015 as a result of the increase in the budget and there are specific initiatives in the case of scoliosis, endoscopy, ophthalmic services for children and orthodontics. We will see the impact of this but not until later in the year.
We welcome any commitment that there will be an improvement, but we would like to see an improvement in how we manage waiting lists. More importantly, we would like to see resources being put in place to streamline the assessment of patients and the lists on which they should be placed. What confounds people is the idea that we are consistently cancelling elective surgery in order to deal with crises in emergency departments. The idea that we put people on a waiting list while knowing that there is a chance that elective surgeries will be cancelled in January is something we need to examine. That policy exerts major stress and pressure on the many people preparing for operations throughout the Christmas period and in January who are then told that the response to the continuous emergency overcrowding in January is the cancellation of elective surgery. This has caused great distress for many, as the Minister knows from his other profession. People have major concerns when they are waiting for operations and procedures and that they are being cancelled as an emergency response is not good enough.
It is important to point out that roughly 80% of people are seen within the target time. We tend to focus on those for whom the target is not met. While non-urgent elective surgery is being cancelled, out-patient surgery is not and in most cases day surgery and investigations such as scopes, for example, are not being cancelled. It is not the case that everything is being cancelled or anything like that.
It is the case that emergency departments are much busier at this time of year every winter. What it might make sense to do would be to smooth out activities in hospitals so we do not plan as many elective procedures in January and instead plan to carry out more in the summer. At the moment, the surge happens in January and elective surgery is deferred but then wards are closed in the summer. It might make more sense from now on to plan to do fewer elective procedures in January and February and during the summer to keep the wards open and to do more elective procedures at that time. This would be a way of smoothing out the activity in hospitals. I am sure if it was that simple it would have been done long ago but it may be something that at the least may need to be attempted.
Hospital Services
Caoimhghín Ó Caoláin
Question:2. Deputy Caoimhghín Ó Caoláin asked the Minister for Health his plans for structural changes affecting hospitals and primary care and to address the shortage of residential nursing home places following the record high numbers of patients waiting for admission on trolleys; the numbers of non-urgent elective surgical procedures that have been cancelled and the way will they now be accommodated; his plans to ensure that nursing staff no longer feel forced to engage in work-to-rule and that this action does not affect patient care and the throughput of hospitals; and if he will make a statement on the matter. [2599/15]
My question seeks to establish the Minister's plans to address the ongoing crisis across our acute hospital network and the related issues of the under-provision in primary care and in residential nursing home places and other matters.
The Government regards trolley waiting times of more than nine hours as being unacceptable and it acknowledges the difficulties which the current surge in emergency department activity is causing for patients, their families and the staff who are doing their utmost to provide safe quality care in very challenging circumstances.
All hospitals have escalation plans to manage not only patient flow but also patient safety in a responsive, controlled and planned way that supports and ensures the delivery of optimum patient care. These plans include the opening of additional overflow areas, the re-opening of closed beds, the provision of additional diagnostic scans and additional ward rounds being undertaken by consultants in order to improve the appropriate flow of patients through hospitals.
The Government has provided additional funding of €3 million in 2014 and €25 million in 2015, to address delayed discharges. Actions being taken include the provision of additional home care packages, additional transition beds in nursing homes, 300 additional fair deal places and an extension of the community intervention teams. Where it is necessary to prioritise emergency and trauma surgery, cancer and complex non-urgent cases, the HSE assures me that this is being done. Inevitably, this will affect waiting lists and waiting times. The challenge is to minimise the need for cancellation at short notice and to manage the impact of such cancellations effectively within the hospital and in collaboration with other hospitals. As I have mentioned it may be necessary to increase elective activity over the summer period.
Last month I convened the emergency department task force in order to develop long-term solutions to overcrowding by providing additional focus and momentum in dealing with the challenges presented by the current trolley waiting times. My Department and the HSE are currently working together on a plan which will ensure that trolley waiting times are contained throughout the year, that operational arrangements in acute hospitals and across acute and community care are designed and implemented consistently so as to contribute to sustainable improvement in the future and to the provision of a strong basis on which to evaluate and manage performance.
While some of the steps outlined by the Minister in his response are indeed required, nevertheless he has not indicated in his reply the importance of providing adequate staffing. I did not note it in the reply he has read into the record of the House. It is very important to recognise that the crisis that has presented in recent weeks across our acute hospital network, is continuing. I have noted that the INMO trolley watch yesterday indicated 431 people on trolleys. There is a continuing suspension of elective day case surgery at a number of sites, including at the Louth County Hospital in Dundalk, where the staffing resources at that hospital are being redeployed to Our Lady of Lourdes Hospital in Drogheda, in order to prioritise urgent patient care and surgery there. This decision is to be reviewed on a weekly basis. That problem is continuing and I have provided one example.
I refer to the situation of the impending work to rule which no one wants to see happen. The nurses do not want to take these decisions. It is critical that appropriate steps are taken to recognise the complexity of the situation and the need for all elements to be progressed.
In conclusion, we discussed the matter in the Joint Committee on Health and Children last Thursday when the Minister and the director general of the HSE came before us. We did not on that occasion have the information that was revealed yesterday by the Minister's colleague regarding an expected further difficulty because of the exodus of some 1,000 nurses between now and June. I ask the Minister to outline to the House exactly what action he is taking to address the chronic shortage of nurses, both in terms of acute hospitals and the needs of the psychiatric hospitals.
Adequate staffing levels are a given; I do not think it should have to be stated. The Deputy may be interested in some of the facts. We have more consultants than ever before and if we can achieve agreement with the IMO on the new consultant scales we will be able to regularise and advertise for quite a number of posts in the next couple of weeks, although, inevitably, such posts will take a few months to fill. We have significantly more midwives than previously, with an increase in numbers, from 900 or so, a few years ago, to close to 1,500 now. This increase is along with a falling birth rate in recent years. In the past year the number of nurses employed by the HSE increased by 500. It is true that the number has reduced by 4,500 from a number of years ago but I refer the Deputy to the extra hour worked by nurses, the graduate nursing programme and the extra 500 nurses employed last year. We are starting to go in the right direction again. Approximately 32,000 to 34,000 nurses are in the system while 1,000 retirements is equivalent to 3% of the workforce. It is not unusual to have a 3% turnover in a workforce in any given year. In the most recent recruitment campaign by the HSE more than 4,000 nurses applied for positions. However, we are not complacent - I note the particular issue in mental health care as the Deputy mentioned - and active workforce planning will be necessary.
While the Minister made reference to increased bed numbers, it is very important to understand that this cannot be achieved with a static complement of nursing staff. It is very important that the crisis we have recently witnessed and which continues, is addressed holistically in the round. It cannot be done simply by the introduction of additional beds on wards. If the same complement of nurses remains, then not only patient care will be impacted; despite the best efforts of the heroic nursing staff, the truth and the bottom line is that patient safety can also be compromised. It is hugely important that we have adequate nursing staff recruited. We have to recognise and realise that there are competing locations for our highly qualified new, young nursing graduates. It is very important that every effort is employed to make the opportunity and the contract here as attractive as possible. As I said earlier, it is not just a case of monetary return, but also there is the importance of career path development. The Minister of State, Deputy Kathleen Lynch, very rightly highlighted this situation that in the coming months will compound the problem we have been discussing. What steps is the Minister taking to ensure that existing staff are retained? What further steps is he taking in order to ensure that not only applications are received but that actual recruitment is the result? On the back of the situation regarding the flu vaccine revelations last Thursday, what steps are now being taken to ensure if it is at all possible that all hospital staff - despite the fact that the flu vaccine is not of the exact match for the flu virus presenting - and all staff across our hospital sites are vaccinated in order to help avoid any loss of service due to contracting the flu virus? Is there a situation now in hand or planned?
I am not sure what the Deputy means by revelations with regard to the influenza vaccine. The vaccine used in Ireland is the same as is used all around the world and as recommended by the World Health Organisation. The reason we have to be vaccinated against the flu every year is because the virus changes and mutates every year. It is the case that this year the vaccine only has about 25% to 30% coverage.
It is the responsibility of infection control and occupational health units in every hospital to ensure that staff are vaccinated. Individuals also have a personal responsibility in this regard and the vaccine is available to staff free of charge. The other advice we are giving to people revolves around infection control, whereby we are encouraging them to "catch it, bin it, kill it". In addition, GPs are being advised to prescribe Tamiflu antivirals to the members of high-risk groups in order to reduce the duration of the illness.
The Minister did not respond to my other question.
My time is up. The Deputy can only ask so many questions and I can only respond to so many.
How convenient.
The Deputy can ask his question again. It is a case of fewer questions more answers.
Hospital Waiting Lists
Joan Collins
Question:3. Deputy Joan Collins asked the Minister for Health his views on waiting lists at Cappagh Hospital, Dublin, in respect of knee replacement surgery; if he will provide a breakdown of the length of time patients are waiting; and if he will make a statement on the matter. [2437/15]
I tabled this question because Cappagh Hospital has come onto my radar on a number of occasions - I am sure the position is the same with other Members present - in the context of waiting times relating to knee and hip surgical procedures. There have been reports to the effect that operating theatres at the hospital are sitting idle because the authorities there do not have the resources available to allow procedures to be carried out in them. Question No. 27 in my name relates to an elderly and very ill woman in my area who has already been to St. James's Hospital and who has been informed that it will be almost 15 months before she will be operated upon. This is a serious matter. What is happening is not acceptable and I do not believe the Minister would stand over it. Will he indicate what is being done in the context of reducing waiting times?
There are currently 686 patients waiting for knee replacement surgery at Cappagh Hospital. Some 15% of these patients, approximately 100, have been waiting between nine and 12 months and 12%, in the region of 70, have been waiting for more than a year. I met representatives from the hospital late last year to discuss the challenges it faces. In 2014, there was an increase of approximately 40% in the number of overall patient referrals. This increase in demand, coupled with a reduced budget, cessation of National Treatment Purchase Fund, NTPF, funding, and a reduction in private income limited the availability of suitably qualified staff and this led to a reduction in surgical capability at the hospital and an increase in waiting lists. The HSE has been engaging with Cappagh Hospital on an ongoing basis in order to identity potential initiatives that would allow for a reduction in waiting times for patients for surgery. Further funding was provided in late 2014 which allowed the hospital to undertake additional workloads.
I am happy to inform the Deputy that the HSE has also provided Cappagh Hospital with additional resources - in the form of an expanded budget - for 2015 to allow for an increase in inpatient procedures. The 2015 budget allocation process has enabled the opening of closed and under-utilised capacity at Cappagh Hospital. This will enable the opening of an additional 1.5 theatres per day - bringing the total number in use to four - and will allow the authorities at the hospital to increase activity levels. The hospital will target this new capacity to significantly address its current waiting list breach volumes. The HSE will continue to engage with the hospital to explore mechanisms to ensure optimal use of resources, including theatre capacity, at the hospital within the overall resources available to the acute sector.
I thank the Minister for his reply. I am sure people who are awaiting hip and knee surgery will welcome additional resources being made available. This matter comes down to the number of nurses and consultants available to carry out procedures. If sufficient staff are available, this ensures that referrals can be made and admissions facilitated as quickly as possible. It is a terrible tragedy that consultants are informing patients that they should contact their local Deputies for assistance if they are having difficulty in the context of waiting lists. That should not be the case. The HSE should be able to identify where problems exist and then, as the Minister indicated, it should be in a position to try to address them by putting the necessary resources in place. I welcome the fact that the latter is now happening. Steps should be taken to ensure that waiting lists are checked every two months in order to gauge the level of movement relating to them.
Waiting lists are checked every month or two months and are validated every three months. As a result of the modest increase in the budget for 2015, capacity and workload at Cappagh Hospital will increase and more procedures will be carried out there. Of course, demand is also increasing. It is my hope and expectation that - on foot of the expanded budget - activity will increase faster than demand. However, I cannot say that this will happen for certain and we will not know the exact position until later in the year. While what I have outlined will allow the hospital to open four operating theatres every day, there is still unused capacity there. If I had additional moneys available - I do not - we would be able to do even more. Like every other country, Ireland is obliged to operate its health service within budget.
One of the advantages for Cappagh Hospital is that it does not have an accident and emergency department and is not, therefore, obliged to restrict surgery when surges occur. This must be borne in mind when discussing the reconfiguration of accident and emergency departments at hospitals throughout the country. More elective work can be done at hospitals which are not obliged to deal with unpredictable surges at accident and emergency departments.
HSE Investigations
Colm Keaveney
Question:4. Deputy Colm Keaveney asked the Minister for Health the action being taken in response to events at Áras Attracta; if closed-circuit television, CCTV, and covert inspections will be introduced in nursing homes to monitor standards of care; and if he will make a statement on the matter. [2648/15]
I take this opportunity to wish the Minister, Deputy Varadkar, a belated happy birthday. I was shocked on Sunday last when I discovered that he is 36 years of age. Obviously, the pressures of holding a senior Ministry are taking their toll.
The Deputy should not worry about the pressures under which I am operating.
The object of Question No. 4 is to establish the actions being taken in respect of the scandal that emerged in early December regarding events at Áras Attracta. Will the Minister or the Minister of State indicate what is being done in the context of putting in place procedures to prevent a recurrence of the scandalous behaviour which occurred at the facility in question?
I thank the Deputy for tabling this question. Like others, I was shocked and distressed by the revelations of extremely poor and unacceptable standards of care and mistreatment of vulnerable adults at Áras Attracta. Every person who uses our disability services - as the Deputy is aware and as I have stated regularly - deserves not just the best standard of care but also to be treated with respect and dignity. The safeguarding and protection of vulnerable people in the care of the health service is of paramount importance and the director general of the HSE has written to all staff instructing them to take personal responsibility for ensuring that individuals supported by the HSE in any setting are treated with dignity and respect.
In December, the HSE initiated an expert investigation, chaired by Mr. Christy Lynch, and an independently-chaired review, led by Dr. Kevin McCoy, of services at the facility. Mr Lynch's investigation team is working independently of the HSE and its findings will facilitate any disciplinary process the HSE may undertake. I welcome the fact that the Garda has cleared the way to allow Mr. Lynch's investigation to commence. I have asked the HSE to keep me informed of progress. Dr. McCoy is undertaking an assurance review of the services at Áras Attracta and his final report will include an individual plan for improvement in each bungalow within the complex. The review will identify system-wide learning, involving engagement with relevant experts as well as input from staff. The HSE has undertaken a number of additional initiatives to ensure that quality and safe care in residential services for people with disabilities is appropriately implemented and monitored. These initiatives include the establishment of a national implementation task force, including a series of national summits to improve client safety, dignity, respect and culture; implementation of the national policy and procedures on safeguarding vulnerable persons at risk of abuse; development of an advocacy service, which is vitally important; implementation of an evaluation and quality improvement programme in disability residential centres; development of an implementation plan for any recommendations arising from the McCoy review of residential services at Áras Attracta, when complete; and development of long-term, sustainable and evidence-based safeguarding practices and training programmes specific to residential settings.
The Minister of State's time is exhausted.
If the Leas-Cheann Comhairle does not object, I wish to make a final point which is key in terms of answering the question the Deputy tabled.
The HSE is considering plans to monitor practices at social care facilities through the use of surveillance cameras, undercover persons or any other means. However, we are very conscious of potential difficulties that could arise in the context of privacy and data protection. Given the complex issues involved, we have decided to engage expert consultants to advise on the best way to proceed.
I am delighted the director general of the HSE has written to all staff to remind them of their obligations. Their obligations and responsibilities in the context of the type of work they do with the most vulnerable people in society are implied in their contracts.
On Tuesday, 9 December, Mr. Tony O'Brien, the HSE's director general, confirmed on "Prime Time" that he would roll out undercover inspections at facilities like Áras Attracta and was to consider the introduction of CCTV. The following day, the Minister of State said on national radio that she supported that initiative. However, she mentioned in the national media last week that the initiative was not going to go ahead. What has happened in the reference period since 9 December to cause the HSE not to consider using CCTV or anonymous investigations into or spot checks of service delivery?
I am always conscious of what I say in the media, but especially in the Chamber where I am more accountable. I did not quite say what the Deputy stated I said. Rather, I said that we were considering all mechanisms in order to ensure the safety of vulnerable people. These may include technologies of which we do not yet know. We have employed consultants to advise us. We have not rolled back from the commitment or from ensuring that, when the Health Information and Quality Authority, HIQA, is not present - I believe that HIQA would never have found this instance - we will be able to put in place a mechanism that is not easily obscured or doctored in any way. I stated what I did last week because we are not experts in this technology. We must ensure that vulnerable people in particular rather than all settings are protected on an ongoing basis.
This morning's discussion demonstrates the need for a debate in the House on the issue. We have had little time since early December to discuss it with respect to Áras Attracta. I welcome the Minister's initiation of an investigation, but I am concerned that the person leading it has business interests that are dependent on the HSE. In terms of issues like fair procedure, due process and independence, is it appropriate that the person leading the investigation is financially linked to the HSE in his domestic circumstances? It is where he earns his money. The HSE and an agent of the HSE is investigating the HSE.
I have had dealings with Mr. Lynch on several issues since getting my post. He has never been behind the door in telling us where he believes we have done something wrong. I am not certain that he feels he has any dependency on the HSE. The job he does for the Government is second to none. It is we who owe him, not the other way around. We may pay for the service that he provides, but it is an excellent one. He has the expertise in governance and practice that we want for every service provided directly or indirectly by the State.
Nursing Home Beds Data
Joan Collins
Question:5. Deputy Joan Collins asked the Minister for Health the number of patients who have accessed beds in nursing homes from hospitals with the €25 million extra funding for the fair deal scheme; and if he will make a statement on the matter. [2438/15]
This question relates to the problem in recent weeks of the large number of people on accident and emergency beds. People who need care in the community, be it hospice care, public nursing home care or home care, remain in acute hospital beds because they cannot access those outlets. No one who does not need to be in hospital should be there. People should be where they are most comfortable.
I thank the Deputy for her question. Delayed discharges arise when a patient has been judged clinically to no longer have a requirement for acute hospital care but remains in an acute hospital bed, thus rendering that bed unavailable for patients who need admission. In budget 2015, the Government allocated €25 million to tackle the problem of delayed discharges. This additional funding is being applied across residential and community services to reflect the varying needs of patients.
Of the €25 million, €10 million has been allocated to the nursing homes support scheme, resulting in 300 extra approvals and a shortening in the waiting time for approval from 17 weeks to 11 weeks. Some 145 approvals were in acute hospitals and 107 were for long-term residential care. Some €8 million is being used to augment short-term residential care capacity and has provided for 50 additional short-stay beds sourced from the private sector. An additional 65 beds are to come on stream on a phased basis from March 2015. Some €5 million is being used for home care services, which will provide 400 additional home care packages to benefit 600 discharges across targeted hospitals. Some €2 million is being used to strengthen community intervention teams, which to date have facilitated 571 people in being seen in their own homes.
The HSE is considering every possible option for alternative accommodation, including vacant beds in private nursing homes, to address delayed discharges. Since 5 January, the HSE has been working to match patients whose acute care has been completed but who require ongoing residential care with suitable placements. This will see a potential movement of a further 250 patients from acute hospitals to other suitable facilities and is in addition to placements already approved under the €25 million delayed discharge initiative.
I thank the Minister of State for her reply. Matters certainly seem to be moving, but how many beds have been released by discharging patients from acute hospitals? How many does the Minister of State expect will be freed up for people by March so that those who do not need acute hospital care can receive the care most suitable to them and with which they are most comfortable?
This crisis in general hospital and community care owes to cuts. Losing 5,000 nurses in recent years is bound to have had an impact. Beds have been closed. Can we open more hospital beds to take in people from accident and emergency departments, which is where the main problem lies?
Later, I would like to hear from the Minister his opinion on the problem of the registration fee for nurses. They will not be able to pay the €150.
As the Deputy rightly stated, the registration fee issue is for another discussion.
The €25 million has resulted in 300 extra approvals, with 65 approvals to come on stream in March. On top of these is the ongoing fair deal scheme allocation of 515 beds per month, as I outlined before Christmas when this issue was being discussed. The initiative should make some impact, but we must realise that we have an ageing population and this is winter, when even we get little infections that can be difficult to shift. We are determining what long-term plan needs to be in place to deal with this issue. I refuse to call it a problem, as it is simply part and parcel of what happens as we age. We need to plan for that, which is what we are doing. We have the statistics but planning is important and we are dealing with the issue in a comprehensive way.
As far as I know and apart from in community hospitals, which are non-acute, no beds are closed other than those that have been closed for reasons of infection control and so on.
I accept the Minister of State's comments, but if the Government is planning, it should have planned for what happened a number of months ago. Why are we in this situation if the Government has the statistics?
We know from yesterday that, by June, a number of public nursing homes could face bed closures.
Has the Government planned for that and the fact that, within six months, there could be fewer beds for people who need the care — I hate saying "step-down care" — that they cannot get in the acute hospitals? I refer to the care they need in their communities or homes. How are we planning for that? Is it being factored in for six months down the line? While I acknowledge it is winter, I believe we still need increased care for an elderly, ageing population. I will be elderly some day and hope we will be able to have in place the care that is needed.
It is a different subject but it is all connected. I understand we have a plan in regard to HIQA, standards and nursing home units, or long-stay units. As we all know, events can happen completely unexpectedly, or out of the blue, in the area of health that we do not know about and for which we are not planning. The difficulty is that there are times when we know exactly what we need to do but unfortunately do not always have the money to deal with the problem in a timely fashion owing to the circumstances the country finds itself in. However, we know about the issue being raised and do have a plan. My mantra seems to be that we know about the matter and have a plan but sometimes do not have the money. It is only with great good luck that Deputy Collins and I will reach later life, and we should accept that.