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Seanad Éireann debate -
Tuesday, 9 May 2006

Vol. 183 No. 13

Accident and Emergency Services: Statements.

The Tánaiste cannot come to the Seanad today and I convey her apologies to Senators. I am pleased on her behalf to set out for the record of the House some facts about the actions under way to improve patients' experience at the accident and emergency departments where there are problems and delays.

I reiterate to the House the Government's total commitment to achieve sustained results by working with the Health Service Executive to address the issues that cause problems at certain accident and emergency departments. These are complex problems which require to be addressed by a full spectrum of actions. The problems will be solved by a combination of reform and resources, management actions and improved efficiency, tailored to each individual hospital.

The Government must take responsibility to lead reform for real improvements and we are giving this our highest priority. We are providing all necessary funding, have empowered HSE management to act and are backing up its actions. We plan to recruit many new consultants in the coming years. We are providing funding for new beds in hospital wards, in accident and emergency departments and in the community.

Last year, more than 1.2 million people attended accident and emergency departments nationally, an average of almost 3,300 per day. On average, 75% of these patients are treated and discharged without the need for admission to an acute hospital bed. There are 53 acute public hospitals in the country. Some 35 of these have accident and emergency departments, between ten and 15 of which have experienced consistent problems. The problems can differ by hospital, and that is why the solutions must be identified on a hospital by hospital basis.

The Tánaiste said she wanted the accident and emergency situation to be treated as an emergency, to speed up the actions required to achieve better outcomes for patients. The HSE continues to implement the accident and emergency action plan which was introduced last year, and I will provide an update on the progress of the plan later. The HSE is implementing a number of other initiatives. The objectives are to reduce the numbers waiting for admission, the time spent waiting for admission, and the turnaround time for those who can be treated in accident and emergency departments and who do not require admission to an acute bed.

The HSE has set targets for each hospital to drive continuous improvement in waiting times. The immediate target is for nobody to wait for more than 24 hours to be admitted. The ultimate objective is to ensure that no patient will wait any longer than six hours to be admitted after the clinical decision to admit has been made. Our challenge is to support those hospitals which succeed in meeting the targets, to ensure they maintain this standard, and to bring all hospitals up to the same levels of performance.

The HSE is taking the following approach on a hospital by hospital basis. It is developing specific, time-based targets for accident and emergency and delayed discharges. It is putting in place financial and other incentives linked to performance and it is developing targeted initiatives aimed at delivering an immediate and sustained impact on attendances, delayed discharges and efficiency.

The board and the management of the HSE are fully focused on accident and emergency improvements as a priority. The board agreed that the allocation of hospital budgets for 2006 would include financial incentives linked to specific, time-based performance improvements. In addition, specific funding is being set aside for projects to advance innovation and reform in the areas of efficiency and throughput. Each hospital network manager has been instructed to treat accident and emergency as his or her top operational priority and to deliver a measurable improvement in services. It is intended that this will be reflected in the performance-related pay scheme.

The performance targets for individual hospitals relate to the number of patients on trolleys awaiting admission, and the time those patients spend waiting. The HSE will shortly publish the waiting times at accident and emergency departments so that improvement can be monitored and encouraged by all concerned. The hospitals will be assisted in achieving their targets by the task force which has been established by the HSE. The task force includes among its membership emergency department consultants, a consultant geriatrician, a respiratory physician, a director of nursing, a hospital chief executive as well as full-time representatives from the National Hospitals Office and primary, community and continuing care services. The task force advises on how improvements can be made to the effectiveness of some emergency departments, and will work with the individual hospitals to identify the specific issues which adversely affect accident and emergency performance so as to identify potential solutions.

We will also free up hospital beds by helping people leave hospital as soon as they are medically ready. We are providing more care in the community, in step-down beds and nursing home places. There is no question of discharging people who are not medically fit for discharge but those who are medically ready to leave hospital should be able to avail of appropriate care outside a hospital setting.

This year the Government is providing funding for the largest ever expansion of services for older people, amounting to €110 million in 2006, equivalent to €150 million in a full year. Under this funding, we will treble the number of home care packages, some of which will be used to assist older people who would otherwise have their discharge from hospital delayed. Care at home is still the preference of the vast majority of older people. Long-term nursing home care is also necessary for some patients after their hospital treatment.

The HSE is working to access as many public and private nursing home beds as required to free up beds for patients awaiting admission. The acute beds that become available as a result of this initiative will be ring-fenced for those patients awaiting admission in accident and emergency departments.

It is not just the number of patients on trolleys awaiting admission that is important, but the time those patients spend waiting. This is why targets for the individual hospitals are focused very much on waiting times. It is also important to ensure that patients' comfort and dignity are preserved while they wait for admission to a ward bed.

We are providing more appropriate facilities for patients awaiting admission. The 32-bed transit unit in the Mater Hospital has been operational since January of this year and is working well. Transit units are now being fast-tracked with capital funding in Tallaght Hospital, where a 40-bed transit ward is being developed, in Cavan General Hospital, Wexford General Hospital, at Our Lady of Lourdes Hospital in Drogheda and elsewhere. These initiatives are designed to provide immediate support to accident and emergency departments. However, it is essential that they are supported by significant changes, within and outside the hospital system, in capacity, the optimal use of capacity, practices and procedures, and non-acute hospital services.

There have been continual calls for more hospital beds as the solution to the accident and emergency problems. I will point out a few facts to the House. There are now 13,255 beds in public acute hospitals and 1,800 in private hospitals. Since 1997, the number of public acute hospital beds has increased by 1,528, up from 11,727 inpatient and day treatment places. Most of the increase — over 900 — comprised inpatient beds. The record of this Government is therefore nearly 200 more beds each year. This contrasts with just 33 beds per year in the years of the rainbow coalition Government.

Our five year capital investment programme for the future includes provision for 450 more acute beds. In addition, 1,000 new public beds in public hospitals will be created. With private investment, we will move existing private beds to new buildings and save €520 million in capital costs for taxpayers. It is interesting that Deputy Kenny condemned this proposal at the Fine Gael Ard-Fheis. He clearly is not committing his party to value for money solutions to the difficulties we face in the management of the public finances.

The HSE is currently reviewing the long-term acute bed requirement nationally and the outcome of this work will help to inform decisions on the future approach to be taken on this issue. We must broaden the debate beyond the need for additional acute capacity. We need additional acute capacity but we also need to ensure that existing capacity is utilised to maximum effect and, at the same time, determine the most appropriate configuration of services in both the acute and sub-acute sectors.

The HSE commissioned a process mapping exercise across ten acute hospitals. The project focused on the maximum utilisation of existing acute capacity and, in particular, the blockages, causes and potential solutions in the patient's journey through the hospital, from the decision to admit through to discharge. The exercise has shown that a patient arriving in an accident and emergency department with a letter from a general practitioner can have up to five separate contacts with medical personnel before eventually being admitted to a bed. Some hospitals have simplified this process with very positive results. We must examine the processes and procedures in other hospitals to make sure that they operate in the most efficient way to avoid wasting time and resources.

Difficulties in accessing diagnostic services outside normal working hours contribute significantly to delays for patients. The HSE is very clear that access to diagnostic facilities must be broadened so they can operate 12 to 15 hours a day as a rostered service. In addition, private sector diagnostics will continue to be used where they can contribute to faster patient services.

Consultants play a pivotal role in the efficiency of hospitals across virtually all departments. They are the senior decision makers and the importance of their clinical decision making skills in speeding up the patient's journey through the hospital system cannot be overstated. We must have far more consultants available at all times, both in accident and emergency departments and in hospital wards.

Hospitals cannot be the only setting for medical care. Many persons with chronic illnesses such as diabetes or heart disease regularly attend hospitals but could, with a well developed community service, get most of the treatment they need from their general practitioner and primary care team. With enhanced primary care services, patients can get local care from health professionals such as physiotherapists which otherwise would require hospital referrals. The HSE is establishing community intervention teams in Cork city, west Dublin, north Dublin and Limerick. These teams will provide services to enable dependent people to remain at home, rather than be admitted to hospitals or other care facilities. Nationally, all general practitioners have been invited to become involved with the HSE in the further development of primary care services and there has been a very positive response to this invitation.

I mentioned earlier the accident and emergency action plan which was introduced last year and which the HSE is continuing to implement. I will outline the progress that has been made under the plan. With regard to Action 1 of the plan, a number of new or significantly upgraded accident and emergency departments were commissioned in 2005-06, including those at Connolly Hospital, Blanchardstown, Cork University Hospital, St. Vincent's Hospital and St James's Hospital. These facilities provide for minor injury clinics to stream patients through accident and emergency, thus increasing the efficiency and effectiveness of the service provided to patients. Outside of Dublin, funding was provided for the expansion of minor injuries services at St. John's Hospital in Limerick and the provision of a minor injuries unit at Waterford Regional Hospital.

With regard to Action 2, a second MRI scanner is due to be commissioned in Beaumont Hospital by the end of 2006. Following a tendering process, interim arrangements with a private provider have been put in place. Additional capacity is also available at weekends to deal with urgent inpatients and 320 patients have benefited under this initiative since November 2005. Under Action 3, the planning for the provision of acute medical assessment units, AMAU, in Beaumont and St. Vincent's Hospitals is now under way. In Beaumont, a 29 bed AMAU is being developed to be ready for commissioning by the end of the year. In St. Vincent's Hospital, the AMAU is already partially developed. The aim is to have 20 beds fully operational by the end of June 2006.

With regard to Action 4 progress, a number of patients with very demanding care needs have been discharged to high dependency beds contracted from private nursing homes. Under Action 5, intermediate care beds were provided to allow the discharge of 560 patients from acute hospitals in 2005. A total of 302 patients have been discharged to intermediate care beds so far in 2006. Under Action 6, additional home care packages facilitated the discharge of 409 patients from acute hospitals in 2005. A total of 191 patients have been discharged with homecare packages to date in 2006.

Under Action 7, the HSE hopes to have an out-of-hours general practitioner service for north Dublin in place by the summer. Under Action 8, the first national hospital hygiene audit took place in all 54 acute hospital sites during July and August 2005. The audit was carried out by a UK based contractor and the report of the audit was published in November 2005. The second national hospital hygiene audit is currently under way, using the same methodology as last year. The results of the audit will be available in June-July.

With regard to progress with Action 9, palliative care services have been developed at Our Lady's Hospice, Harold's Cross, and have been in operation since early October 2005. Six palliative care beds have been commissioned at the Blackrock Hospice. Under Action 10, arrangements were put in place with private providers for the commissioning of CT scans and MRIs to facilitate direct access to diagnostics for general practitioners. During 2005, more than 1,000 CT scans and 100 MRI scans were carried out under this initiative.

Tackling the current difficulties in accident and emergency departments is the Government's top priority in health. The service being provided to patients in some accident and emergency departments is unacceptable and must be improved. The measures being examined by the HSE include improvements in the processes and procedures in hospitals to ensure they operate in the most efficient and effective way; the introduction of rigorous admission and discharge planning processes; the broadening of access to diagnostic facilities and the enhancement and development of primary and community care services.

By improving hospital processes and procedures, by providing additional step-down beds for those patients who do not require acute hospital care and by expanding and enhancing primary and community care services, I am confident we can achieve the sustained improvements in our accident and emergency services that patients and their families deserve. I urge all involved in medical and other organisations to contribute to the implementation of ideas and actions to improve these services.

The Minister, Deputy Harney, has been in office for 19 months and things could not have got worse. She spoke about magic wands when she was appointed but if there ever was a need for a magic wand, it is now. She has managed to make the accident and emergency services crisis worse and has finally admitted that it is a national emergency. Approximately 400 people were on trolleys recently and many of them were afraid to go to the toilet in case their beds were taken. We have also heard the stories about patients being left on chairs in hospitals.

I have travelled a little since I was elected to the Seanad. I have been in African countries and one would not expect such a service there. The worst aspect——

Senator, please.

A country as wealthy as Ireland should provide a far better service. The worst aspect is that members of the public seems to have resigned themselves to believing that nothing can be done. That is an indictment of all of us. Something can be done. I was in Taiwan recently, a country that has the same size population as Ireland, and it has no waiting lists. That proves it can be done. It has a different health system. I appreciate that we will never solve all the problems in the health service but the service should not be as bad as it is at present.

When Deputy Harney was appointed Minister for Health and Children, one would have thought she had been absent from the Cabinet meetings for the previous seven years when the health service was discussed. She appeared to imply at the time that she had little confidence in the previous Minister, Deputy Martin. Now, however, Deputy Martin seems to have been a better Minister than Deputy Harney, given her mishandling of the health portfolio.

It is almost impossible to get answers to questions about the health service. The Tánaiste attended a recent Fianna Fáil parliamentary party meeting at which backbenchers were complaining about the difficulties in accessing information on the health service. I was encouraged to hear this because I am conscious of it too. I was glad to hear Fianna Fáil backbenchers are having the same problem as their Opposition counterparts. Replies to Members' parliamentary questions take months. The Health Service Executive has a new service for Members that is slightly better but Members still find themselves constantly chasing answers. Often the replies are incomplete forcing a Member to resubmit another parliamentary question.

The freedom of information request facility is not working either. Last September I submitted a freedom of information request yet only received a half answer last month after 15 telephone calls. There is much frustration on both the Government and Opposition sides about accessing information on health services. A conspiracy of secrecy exists in the Department of Health and Children that does not enable us to do our job. Members are trying to find out the actual position of the provision of health services but the information is not forthcoming. If Members find that difficult, what hope do the general public have? This issue must be addressed immediately.

Several years ago, the Department of Social and Family Affairs had a bad reputation for replying to questions from Members. Now the Department is considered superb. Not alone will it give an answer in a few days, but it will provide a full answer. That is the same standard that should be expected from the Department of Health and Children.

I am glad the Minister of State followed the Fine Gael Party's Ard-Fheis along with the many thousands there and at home. Fine Gael is concerned at the privatisation by stealth of the health service by the Progressive Democrats. I am not a socialist but I am concerned at the privatisation of basic services. The direction of the health services is unsure. Cost analyses of public private partnerships have not been good, as friends in the Department of Finance have informed me for years. The use of PPPs in school-building has seen projects becoming more expensive and delayed. I challenge the Minister of State to go before the Committee of Public Accounts to put the facts before the Comptroller and Auditor General, Mr. Purcell, to ascertain if PPPs are good value for money.

The committee will soon conduct a cost analysis of the Kilcock-Kinnegad bypass. The contrast between the amount invested by the PPP company and its expected revenue from the high tolls it charges will be scandalous. I would be careful about going down the road of PPPs unless every detail has been worked out. Understandably the private sector gets involved in projects to make money yet certain services must not leave State hands. The sale of Eircom is a classic example. I challenge any Member to claim that Eircom is a more efficient service than it was in the past.

I recently requested information on revenue from charges for attending accident and emergency departments since 2000. The answer, which I only received this morning, was that revenue came to €3.5 million with €1.5 million outstanding. This could indicate the Health Service Executive's accountancy practices are shocking and it is not in charge of its brief. Alternatively, the Tánaiste is blatantly wrong when she claims people are in accident and emergency departments who should not be there.

The Minister of State claimed 3,300 people attend accident and emergency departments every day. The revenue figures show that in the past five years, €5 million has been taken in revenue by accident and emergency wards, some €1 million per year. The charge for attending an accident and emergency ward is €60. Using simple arithmetic, last year 25,000 patients who were eligible for charges attended accident and emergency wards. That stands at 500 private patients a week and 70 a day. When considered nationally, it appears only two patients per day, eligible for the charges, are attending each of the country's accident and emergency wards. Either the Health Service Executive's reply is wrong or the Tánaiste is incorrect when she claims people are attending accident and emergency wards who should not be there. I ask the Minister of State to investigate these figures as they seem amiss.

The Tánaiste agreed with me at a health committee meeting that the turnaround times for patients in accident and emergency wards are not known. A friend, a chef, cut his finger one day at work and needed to attend his local accident and emergency ward for what should have been a routine procedure. He was there for over 14 hours. After requesting information from the Department of Health and Children on patient turnaround times, I have discovered the information is not available. With the limited information the Department has, there are large variations. Some wards are quick in admitting and discharging patients while others are not so good. It is hard to compare health service provision in an effort to suggest improvement when this information is lacking.

I was given much information on the numbers of patients who attend accident and emergency wards and remain in hospital. The length of stays in Dublin hospitals, compared with other areas, has increased over the past several years. It suggests that work practices could be improved to achieve a greater turnaround of patients.

I recently requested information on the number of social workers for the elderly. I am still awaiting a reply. It is incredible that the Department knows how many social workers there are but not how many are specifically appointed to care for the elderly. I suspect many elderly people who attend an accident and emergency ward are not discharged because there is no backup for them outside the hospital. It is incredible the State employs people to do a job but it does not know exactly what they do.

The Tánaiste stated 29% of patients in nursing homes should not be there. She claimed the home care package of €150 million a year would allow these patients to be discharged back into their communities. Is there any indication of how many people have been discharged from nursing homes?

The Government always refers to 1997, as if the world was a dreadful place then. The economy, however, was going well with the State having its first ever budget surplus. More important, there were 500,000 fewer people in the State. Why then should the Government not claim it is increasing bed numbers when there are more people living in the State?

I note the Minister of State watched the Fine Gael Party's Ard-Fheis.

I would not go that far. That is pushing it.

Does the Minister of State have an idea how many elective procedures are cancelled on a daily basis? Having people on trolleys in accident and emergency wards, which is bad in itself, also has a knock-on effect on elective procedures.

The Tánaiste has now annoyed everyone in the health service. It was regrettable that she was unable to attend the nurses' conference last week. I appreciate the pressure on her diary and the efforts made to facilitate her at the conference. The nurses working at the coalface in the accident and emergency wards, however, deserve to be heard and not spoken down to, as the Minister of State did. We need to bring everyone on board and it was a pity that she missed the chance to attend and listen to their concerns.

I welcome the proposal made at the Fine Gael Ard-Fheis about drunks. It is time to get real; when people deliberately go out and spend €100 on drink, drinking fat frogs and vodka and Red Bull, and are then injured, they should be fined in some way if they arrive in an accident and emergency unit as a direct result of overindulgence, as opposed to someone who might have a glass of wine and fall. The Minister of State, Deputy Tim O'Malley, was mocking this idea on the radio yesterday, saying that the gardaí are called anyway. How many prosecutions have arisen from public order offences in accident and emergency departments? The staff are demoralised and it is time to side with them and the genuine patients. Discretion could be used to ascertain if someone deserved a fine.

I also welcome the Fine Gael proposal that all children under five years of age should have a medical card. That will eliminate parents' concerns. It must be terrifying to see a rash on a young child, trying to ascertain if it is meningitis or something else. By visiting a GP they will be able to avoid a trip to the accident and emergency department.

The ten point plan announced by the Tánaiste has not worked. The lack of beds is the major problem. We must put back those beds that were taken out in the late 1980s and allow for the fact that the population has increased substantially and aged.

Fine Gael is proposing a number of 24 hour urgent care centres in areas that do not have a local accident and emergency ward, including Carlow, something I would argue for if I am elected to the next Dáil, and in areas where accident and emergency wards are under particular pressure. They would be staffed by GPs and nurses and would offer the option to patients in accident and emergency to be treated in properly equipped primary care centres which include diagnostic services such as blood tests and x-rays.

The patients who arrive in hospital are entitled to dignity and should be treated with such when facing illness. There should be no excuse for having patients on trolleys. The hygiene audit recently took place in our hospitals but maybe it is time for the Health and Safety Authority to go back into accident and emergency units and inspect them from that point of view. It is mad that a patient could arrive in hospital to face a greater risk of injury as a result of an assault by a drunk patient or overcrowded conditions.

Fine Gael will promote a general health screening programme to encourage people to be checked out regularly. Senator Glynn has often made the point that we do this with our cars and that makes sense. If we had a check up every year, it might eliminate problems down the line. The 60 primary care teams will improve access to local health care.

I look forward to a full debate on this issue and the Minister of State's answers to the questions I have raised.

I welcome the opportunity to debate accident and emergency services. Regrettably, in some cases we are talking about abuses of the service. This is a social problem, it is not new. I worked in the health service as a nurse for many years and I recall having to wait eight hours with a person for treatment because he or she was not in as urgent a need as those already there. It is important to remember that people attending accident and emergency wards must be prioritised with those in greatest need being dealt with first. A system to achieve that is in place.

The role of the general practitioner is central to the accident and emergency system. The MidDoc service was launched in Laois with funding for Westmeath and Longford during my chairmanship of the Midland Health Board between 2001 and 2003. I chaired meetings in Laois and in Mullingar which were attended by all elected public representatives from the area together with health professionals to advise people what the service meant and how to use it. It works very well and assists the accident and emergency services. It is related to emergency services because those who want a doctor at any time of the day or night will get one. It is not like the old days, when a doctor on duty who got up at 6 a.m. to reply to a sick call would be 20 minutes in bed when he would have to get up again and go on another sick call. Doctors now have a better quality of life and people have a service when they need it.

I am not, however, blaming general practitioners in any way. There are people who deliberately go to the accident and emergency unit because they do not want to go to their GP if they do not have a medical card.

The figures say otherwise.

Any statistic that muddles the figures for accident and emergency attendance is unhelpful. We have excellent general practitioners and people should present to them in the first instance. We all know the use being made of the accident and emergency units.

Having been a health professional in the midland region and having dealt with Mullingar Regional Hospital, Tullamore Hospital and Portlaoise Regional Hospital, I know they provide an excellent service. Part of the problem with acute beds has been referred to by the Minister of State and others. When the acute phase of a person's illness passes and he needs further treatment, it is imperative that facilities be provided for that.

On people causing difficulty in accident and emergency wards, I have said in the past, and I am glad Deputy Kenny used my phrase, that we must hit the thugs where it hurts — in the pocket — whether they are drunk or on drugs.

It is also important to remember it is not only accident and emergency units that have problems. To a lesser extent, acute psychiatric units have problems with people applying to be inappropriately admitted. On one occasion I had to notify gardaí during my time working in that area. It is the responsibility of the person in charge of a unit to notify gardaí as they are not inspired and will only come when notified. My profession received great assistance from gardaí, often much needed assistance. This is not a new phenomenon nor is it just pertinent to accident and emergency units. There is no question but that these people must be dealt with efficiently. People who have a social drink or have a small amount of drink and are involved in accidents should be treated differently, but the thugs full of drink should be treated as thugs.

The Government is committed to improving patients' experience of health care and of accident and emergency services. Meeting the challenges in our accident and emergency units means a whole system approach which will tackle problems across all aspects of the health care system. The volume of activity in our hospitals has increased significantly and various factors impact on the service provided, including the increase in population, longer life expectancy, a greater inclination to avail of services and undergo elective procedures.

During my chairmanship of the Midland Health Board from 2001-03, I was delighted that we got three accident and emergency consultants appointed in the region, one for Mullingar and two for Tullamore who also provided sessions in Portlaoise. The system in the region works very well. We cannot overstress the value of accident and emergency consultants to an area as they are vital to a good service.

We must accept that some people access hospitals through accident and emergency departments because they cannot access an appropriate outpatient department. These various factors must be assimilated into our system. Our health reform plans will bring a new coherence to the services. It is recognised that a range of short, medium and long-term measures are needed which will transcend immediate operational issues in accident and emergency departments and be integrally linked to the development of primary and support care services for the elderly. It is axiomatic that these services be developed as they are complementary to the development of a good accident and emergency service.

Tackling the current difficulties with accident an emergency services must be the Government's top health priority. The service being provided to some patients in accident and emergency departments is unacceptable and must be improved. Our objectives must be to reduce the numbers waiting for admission, the time spent waiting and the turnabout time for those who can be treated in such departments but who do not require admission.

The Health Service Executive continues to implement the ten-point action plan. In addition, it has been agreed that a number of additional measures will be implemented by the executive, including the setting of performance targets for individual hospitals, which is important. In terms of implementation, the HSE is taking the approach of tackling the issue on a hospital by hospital basis. There must be a reason that a number of hospitals experience serious difficulties in their accident and emergency departments while others do not.

The HSE will develop hospital-specific time-based targets for accident and emergency departments and delayed discharges, develop financial incentives linked to performance in these areas and develop additional targeted initiatives aimed at delivering an immediate and sustained impact. In the immediate term the executive will introduce a series of measures to improve facilities for patients and staff in accident and emergency departments. Long-term care beds will be secured from within the private sector to facilitate the discharge of patients who have completed the acute phase of their care.

The acute beds that become available as a result of this initiative will be ring-fenced for patients awaiting admission in accident and emergency departments. Funding will be made available within the capital programme to develop admission lounges to ensure patient privacy, dignity and comfort are preserved while awaiting admission to an acute bed. I will not defend what is not true and admit that in some accident and emergency departments waiting facilities for patients are less than acceptable.

Funding has been provided for an additional 900 acute bed day places since the publication of the review of acute hospital bed capacity in 2002. More than 800 of these are in place and the HSE has advised that the remainder will come on stream over the coming months. A further 450 acute bed day places are in various stages of planning and development under the capital investment programme.

The achievement of improvements in accident and emergency services is dependent on fundamental changes in both hospitals and other areas of the health service. It is not just a question of increasing the number of acute beds. We should not be afraid to push out the boat. If we are involved in the provision of a service that is not working as well as it should be, we should not be afraid to change it. Everybody has a role to play in the change.

As a former member of the nursing profession it will not come as a surprise to hear me praise it. Nurses working in accident and emergency departments and throughout the general medical services deal with ongoing and increasing pressures. Different challenges confront them day after day. They are dealing with those challenges, sometimes with difficulty.

The HSE has established a dedicated task force to oversee the implementation of the framework for improving the efficiency and effectiveness of services in our accident and emergency departments. The task force will support individual hospitals in identifying and addressing specific problems. In other words we will have a team that will look at and try to address what is going wrong in different hospitals. The HSE will work with hospitals to try to introduce a system of whole hospital performance measures to improve patients' journeys not just through the accident and emergency department but through the hospital system from admission to discharge. By improving hospital processes and procedures, by providing additional step-down beds for patients who do not require acute hospital care and by expanding and enhancing primary and community care services we can achieve a sustained improvement in accident and emergency services.

I am aware of a further problem with regard to patient discharge. On many occasions I found that people who had gone through the acute phase of their illness but who required further treatment were a problem because of the need for step-down beds. However, there was a further social problem. Some people did not have a decent home to which they could return or their relatives did not care whether they lived or died. I have seen this as a real problem, one from which we cannot walk away. In the past six or seven months I was made aware of the case of an individual in an acute hospital, whose wife did not want him home under any circumstance. I went through seas of sorrow trying to find a private bed for him. The nub of the problem was that the family were people of means, but they did not want to pay a cent for the person's care. This type of problem may not be a significant problem in the overall context, but it is still part of the problem.

The Health Service Executive is advancing the implementation of a series of measures to improve the delivery of accident and emergency services. It announced in March 2006 that it is establishing a dedicated accident and emergency team to tackle the individual issues affecting a core group of approximately 15 hospitals among the 35 hospitals providing accident and emergency services. While improvements have been achieved through the accident and emergency ten-point plan, this group of hospitals will be supported by the newly-established team to identify the particular issues impacting their accident and emergency performance and the way to address them. The HSE has stressed that improving accident and emergency departments is its number one priority this year. This task force is about practical actions to improve patient care in accident and emergency units and in hospitals.

It is important that hospitals have been given targets for improvement to ensure everybody can measure progress. Targets are important. Patients are to be seen more quickly at accident and emergency departments and fewer are to experience long waiting times on trolleys. I visited France last year on business as a member of the Joint Committee on Health and Children and in one of the bigger hospitals in Paris there were people on trolleys. It is not a phenomenon that is pertinent to Ireland alone, therefore, but it is still not acceptable. If there are people on trolleys for long periods, which is the case, we must resolve that problem. There is little point in saying that a similar position obtains elsewhere. If people elsewhere jump in the water, there is no reason we should do likewise. We must try to address the problem and improve it.

These targets for improvement will be a minimum. They are to be breached, not just reached. The Government and the HSE are prepared to do all they can to provide acceptable standards of care in accident and emergency departments and they will not hold back on any practical action that will work. Everybody must work together positively to achieve that aim. It is not only a Government or health service problem; it is a societal problem and it can only be resolved in that context.

There are short-term actions as well as long-term solutions. As a Government and people delivering service, we must do both. That means that targeted resources for improvements will be made available by the HSE. Changed practices and better patient care will be rewarded. Diagnostics and tests will be provided at weekends and evenings. That is welcome because in the service in which I worked there were no CPN services at the weekend. Nobody was supposed to get sick or develop florid symptoms over the weekend. One could only get sick by appointment, which is nonsense.

New beds will be assigned immediately to accident and emergency areas to ensure that old people do not sleep overnight on trolleys. That is welcome. People will be discharged each day of the week to keep beds available. Patient discharges will be planned to ensure home care will be ready when they are medically fit for discharge. That involves a pivotal role for our public health nurses and liaison nurses. People will be helped to move out of hospital beds by the provision of many more home care packages and nursing home places. The HSE will step up the pace of availability of home care, which is also important.

The fourth commandment might not go astray because there is a view among many people that "they" will look after them but who are "they"? It is important that the people who are the pillars of this society, the old people who have now reached the winter of their years, be treated with the dignity and respect to which they are entitled. As I have said on more than one occasion, perhaps in different fora, it is imperative that the dependants of those people be reminded of their obligations. Those people will always talk about their rights but, in many cases, they carefully ignore their obligations.

I welcome the Minister of State to the House. There was a letter in The Irish Times of Wednesday, 26 April this year from a Mr. Frank Bannister of Morehampton Terrace, Dublin 4, on solving the accident and emergency crisis. In my view he got a good grip on the situation. The letter states:

Madam,

Let me see if I have this right. The problems in hospital A&E units can be solved if there are more hospital beds or consultants stop blocking hospital beds or elderly patients stop blocking hospital beds or there are more step-down care facilities or there are more A&E consultants or consultants work more flexible hours or consultants work longer hours or procedures in A&E units are improved or more people go to their GPs first or more GPs are available at anti-social hours or there is less alcohol abuse on weekend nights or the Government pumps more money into the health service.

He had a good grasp of the issue. He finishes by stating:

That seems straightforward enough. Should be sorted out in no time.

The good aspect of this debate is that we have stopped saying that the crisis is solely in accident and emergency departments because it is not. That is where it is erupting. We have a serious crisis in many parts of the health service and it is erupting in accident and emergency departments, particularly in regard to the long-term use of trolleys as beds for patients who require admission.

Some of our accident and emergency units have been improved greatly in recent years but many of them are over 30 years old and have had bits added to them from time to time and portacabins put in place. As the two previous speakers said, the population has increased by hundreds of thousands, both native and immigrant, the population has also got much older and, in addition, far more medical and surgical procedures are being carried out. Very rarely do I now hear anyone saying that a particular procedure should not be carried out on someone because of his or her age. It just does not happen anymore. People expect to get treatment regardless of their age and, in general, they have a very good outcome.

I welcome the fact that various improvements are to be made in those hospitals where action has yet to be taken but I am disappointed by some of the points in the Minister of State's contribution. I have been looking at the accident and emergency unit in Wexford hospital for some time. It was decided several years ago that the outpatients department would be taken into the accident and emergency unit, which is tiny — I think it has four beds — and that a new outpatients facility would be built on the very adequate amount of land nearby. Why is a transit ward being built and why not go ahead with speed with the outpatients department?

There has been a great improvement in both St. Vincent's and St. James's hospitals since their new units have been built. However, the Mater and Tallaght hospitals will only be given admission wards which, apparently, will give more comfort and dignity to patients but will not allow them receive the sort of treatment they would get if they had a bed in a ward, which is what they need.

The Minister of State rightly emphasised, and Senator Glynn referred to it also, that there has been a major improvement in the number and training of staff in accident and emergency units but they can only deal with what is available to them. Senators Glynn and Browne were present when the accident and emergency doctors came before the Joint Committee on Health and Children and said that the problem with having people on trolleys is that they require admission but they have nowhere to send them. They produced one very interesting fact that I thought we should note. The first time there was a complaint about patients being on trolleys overnight, inappropriately kept in an accident and emergency department, was in 1991 in the Meath Hospital. Some of the staff working in the department wrote to the consultant in charge of the department to say that the way those people were being kept overnight was unsuitable.

It is worthwhile remembering that Dr. Steevens Hospital, which did an enormous amount of accident and emergency work for this city, had been closed down just two years previously. It said it could not cope with the budget it had been given by the then Department of Health and had been told that if it could not cope, it could close down. The manner in which the situation in this particular hospital was dealt with was a precipitating or tipping point in the beginning of the accident and emergency crisis in this city. Accommodating people on trolleys is a disgraceful practice which increases the mortality rate of these people when they are eventually admitted to hospital.

Our population has aged considerably. Those of us who are 65 and over occupy 46% of all bed days in acute hospitals. The older people become, the longer they must remain in hospital because they take longer to recover and because of the difficulty involved in obtaining step-down facilities for them.

Senator Glynn spoke about the difficulty of ensuring that people are brought home by relatives. When the population contained a very large number of married women who did not work outside the home, there were carers available to whom such patients could be discharged. However, we now have a much higher rate of employment outside the home among women who might have been in a position to care for people, and we will not see the resurgence in the number of such carers unless the economy changes considerably.

The number of community beds has decreased over the years, a situation which I was delighted to learn was to be addressed. I was also pleased to see that the situation regarding home helps is to be improved. Very many people want to go home after they recover and do not wish to occupy a community bed or enter a nursing home. If one can obtain home help services for them, this is often sufficient to meet the needs of such people. I recall attempting to obtain a reasonable answer as to why a woman in her 80s who had considerable physical disabilities but whose mental faculties were intact and who was happy to remain at home, was eventually forced to go to hospital. There was no one to replace the home help when they took the holidays to which they were rightly entitled.

I asked the HSE whether people were entitled to a locum home help when their general home help took holidays. I was informed that they were entitled to a locum home help if one is available. What sort of reply is this? It is utterly useless. Either the system is set up in such a way that people can be kept at home or it is abandoned. The answer I received was Jesuitical in that it appeared to ask me what type of question I was asking and insinuate that I might not have asked the right question. This type of response is extremely disappointing.

The Minister of State's speech refers to the introduction of a rigorous admission and discharge planning process. I would like to see the introduction of a rigorous admission process because it is certainly not happening at the moment. The discharge process is interesting in that people frequently may not be medically fit for discharge. How will one obtain beds in such a scenario where one is already working at over 100% capacity? A total of 85% bed capacity is considered safe and appropriate in an acute hospital because one must allow proper time for the cleaning of beds and the preparation of the surrounding area for the receipt of another patient. One does not wish to see patients getting into beds that are still warm from previous occupants but this is happening at the moment.

Senator Glynn spoke about examining general hospitals on a visit to Paris. I visited Barcelona at the same time where I visited a hospital where staff told us that when they examined discharge rates and the time people with similar conditions or complaints were kept in hospital by different consultants, they were very careful to examine the re-admission rate of these patients. We should examine this issue very carefully. If one has high re-admission rates, the situation is even worse than before because the person has spent time in hospital and must now occupy another acute bed.

I am glad to see that the situation regarding general practitioners is being addressed. The fact that experienced GPs must send patients they know require hospital admission, for example, a person with acute appendicitis or who has had a stroke, to accident and emergency departments is ridiculous. These people, who should be admitted to hospital straight away, form part of the group lying on trolleys in accident and emergency departments. Such a scenario wastes GPs' time.

It is clear from the Minister of State's speech that people who come into accident and emergency departments with a letter from their GP are sometimes seen by five people before they are admitted to hospital, representing a waste of five more people's time. In what I would describe as the good old days, if an experienced GP telephoned a hospital and told staff there that he or she was sending a patient with acute appendicitis there, hospital staff began to organise the operating theatre so the person was operated on at the earliest opportunity.

I am also pleased to see that GPs will have greater access to diagnostic facilities. It is utterly ridiculous that they have so little access to facilities like skeletal X-rays but the number of GPs who have access to skeletal and chest X-rays has decreased in the past seven years. This surely cannot be considered a positive development.

The broadening of access to diagnostic facilities will be welcome. However, can the Minister of State clarify whether negotiations have taken place with staff such as radiographers, physiotherapists or the porters who run various departments and their unions regarding the increased hours of access? If such negotiations have already started, it would be a welcome development.

Negotiating hours of access is one of the first matters that must be decided because increased access to any facility can be provided. People could easily work on in the evening until 8 p.m. but one cannot expect hospital staff, be they admission clerks, consultants or radiographers, to work from 8 a.m. to 8 p.m or 10 p.m. The Minister of State surely agrees that such staff must have a sensible working day and that this must be negotiated before any other progress can be made. To my knowledge, no negotiations have taken place so far.

Much has been made of the fact that it is impossible to contact a GP during what are described as anti-social hours. However, 75% of attendances at accident and emergency departments take place between 8 a.m. and 8 p.m. when it is possible to contact a GP. The assertion that people cannot contact GPs is a red herring.

I am delighted that there will be an enhancement and development of primary and community care services. I remember how the general practitioners and primary care services were offered tax initiatives if the quality of their primary care facilities improved. However, these initiatives have all gone to private hospitals.

There is considerable concern among many of us about the establishment of private hospitals. Will we end up running two parallel systems of health care in this country? Running two systems would be extraordinarily wasteful because approximately 70% of people are admitted to acute hospitals from accident and emergency departments. If the Minister of State, the Leas-Chathaoirleach or I were ever involved in a car accident, we would want to be taken to an accident and emergency department in an acute hospital. We would not want to be taken to some unit which might be incapable of dealing with our injuries.

The situation regarding alcohol abuse and accident and emergency departments is interesting because accident and emergency consultants who appeared before the Oireachtas Joint Committee on Health and Children did not appear to think it was as grave a problem as has been made out. I acknowledge that alcohol abuse is a dreadful problem in some hospitals. The accident and emergency department in the Mater Misericordiae Hospital suffers considerably as a result of alcohol abuse because the hospital is situated at the top of O'Connell Street and any problems caused by people carousing in the city will affect the hospital.

Unfortunately, a considerable number of people who end up at the Mater have medical problems. Nothing is more of a nightmare than trying to keep an eye on inebriated people who appear to have head or abdominal injuries. One does not know whether they fall asleep because of the head injury or because of the alcohol they have consumed or whether they are vomiting because of abdominal problems or alcohol. Therefore, inebriated people present major problems and it is wishful thinking to suggest such problems will be easily solved.

Some hospitals are described as coping better with the accident and emergency situation than others. How are they coping? Is it by cancelling elective operations? This is a serious issue because some hospitals have admitted they do it in this way. Recently, a constituent wrote to me to tell me that her operation for a possible ovarian tumour had been cancelled for the fourth time. She may have been operated on by now because her gynaecologist, who works at two hospitals, put her on their waiting lists. I asked her to let me know once she has been operated on. Operations for someone like her should not be cancelled.

At one time a surgeon in Beaumont Hospital used to telephone me every Monday if his theatre list had been cancelled because of people in the accident and emergency department who needed to be dealt with over the weekend. In the Minister of State's speech, he referred to ring-fencing beds for people admitted through accident and emergency units. It would be better and fairer to ring-fence beds for elective admissions. Hospitals such as the Bon Secours can be very organised because they do not have accident and emergency units and can keep working on their elective admissions. These admissions were not given enough consideration by the Minister of State in his speech.

Palliative care was mentioned. It is disturbing that the Tánaiste did not seem to know how thinly spread palliative care is in the country. Some units are marvellous. For example, Our Lady's Hospice at Harold's Cross and the new unit at Blackrock Hospice were mentioned. Regarding the latter, someone told me that the food is wonderful and the chef is great. Is it not marvellous that someone is taking such care of food for people who may be in their last days? I was pleased to hear of this. We should also expand the palliative care home care service. Many people would prefer to stay in their homes. The number of people who say that one of their greatest wishes is to die in their own beds is amazing. However, it will not happen unless we manage to help our public health and palliative care nurses. It is important we give the home care teams our support.

A matter raised by the accident and emergency consultants when they appeared before the committee related to the association between hospital overcrowding and mortality among patients. They quoted from a paper on three Western Australian emergency departments published in The Medical Journal of Australia on 6 March 2006, which showed a direct link between the mortality rates of people admitted from accident and emergency units and overcrowding in hospitals. The link could be as high as a 20% to 30% increase in mortality rates, which is significant. How many people admitted to wards would have survived if they had not needed to wait in our accident and emergency departments?

We have a considerable problem. While I welcome the Minister of State's comment that it is being tackled in a multifaceted way, I am anxious about the jargon used in respect of performance targets. If financial rewards are given, it will be difficult to ensure that people are not discharged too early and readmitted. At one hospital, readmissions were counted as new admissions. What type of figures are such places getting? Different figures will come from different places. People will become demoralised because some of our major hospitals will need to take tertiary referrals from other hospitals. How will their performances be balanced, as we will describe it, against the performance of smaller and more localised units? How will the situation of cancelled elective operations be factored in? How will we allow for the fact that there are more senior consultants in a number of accident and emergency departments than in others? For example, Senator Glynn said that there was one senior consultant in Mullingar General Hospital and two in Tullamore General Hospital.

These factors make a considerable difference and it would be better to encourage rather than financially penalise people if they do not reach a certain standard in respect of discharges or the number of people on trolleys in wards. I am a great believer in "mol an leanbh agus tiocfaidh sí". It would be better to encourage people in this way, namely, that we understand what they are doing in terms of getting people out of accident and emergency units.

Bringing people in is not a large problem. Many people are treated every year in accident and emergency units and do not cause much of a problem. The real problem is that of people who need to be admitted to hospital but for whom there are no beds. If beds are not there, what can hospitals do except keep people on trolleys? Something must be done to encourage the whole health service to progress matters instead of having assessments, which will involve penalising people.

I wish the Minister of State well in what he hopes to do, as the issue is serious. Examining figures such as those from Western Australia should make us realise that not only is there dreadful discomfort for patients, there is also increased mortality. We cannot allow this to continue for any longer.

I welcome the opportunity to take part in this important debate. I also welcome the Minister of State and echo the regret that a Seanad scheduling conflict did not allow the Tánaiste's attendance.

There is a great deal that must be said about the challenges facing us in the accident and emergency situation, but a politically hostile environment is not the most appropriate context in which to discuss them if the interests of the patient are to be served. I intend to follow the standard approach adopted by the Tánaiste and the Progressive Democrats, namely, put the patient first and take constructive criticism and suggestions on legislation and policy.

There are problems but let us not waste time stating the obvious. Approximately ten accident and emergency departments in this country have consistent difficulties. Of the 53 acute public hospitals and 35 accident and emergency units, it is ten too many. Our accident and emergency services will be improved, as they must, hospital by hospital because the public rightly demands it and patients deserve it. Each of the ten accident and emergency units with persistent problems is being addressed urgently by the HSE. It knows what is required, namely, solutions for patients through better use of the increased resources. Patients must be seen faster at accident and emergency departments and must have real alternatives to these units both in the evenings and, importantly, in the daytime. This is what is needed rather than the standard call for more resources.

In politics, it is standard practice for opposing parties to portray the same facts differently. I have no problem with that. When a poll says that 75% of people are happy, some will say one in four are discontent. What is important is not the interpretation, but what one proposes to do with the information or how it helps or hinders problem solving. Problem solving is predicated on the accurate assessment of the current situation.

Objectivity is a particular problem when it comes to health services. As such, today's statements are welcome.

An article in last weekend's edition of The Sunday Business Post stated:

[T]here is little attention given to the good news in health — cancer and cardiac services have seen massive improvements, new hospital units are opening all the time and health sector workers have benefitted from benchmarking deals.

Instead, headline stories about delays in breast screening in the south and north west mask the existence of a high quality service being rolled-out in the midlands and the south east. The stories fail to mention that it is not money, but a shortage of radiographers, that is delaying the continuing rollout nationwide.

This debate will provide a good illustration to the electorate as to whether problem assessment and, more importantly, solution skills have developed among the would-be Government parties. Will they follow, lamb-like, down the well-trodden and fruitless path, or will they surprise us? Will they mimic the shameful personalised campaign of others against a Minister who works tirelessly with, as the aforementioned article noted, "a huge bureaucratic organisation grappling with a massive reform agenda and a struggling infrastructure" or will they reveal a secret enlightened and nuanced side? Members will see as the debate continues.

The Government has given top priority in policy and funding to improving accident and emergency services and the diverse range of factors that contribute to difficulties and delays experienced in that regard. As I noted, the Government and the HSE are addressing all such factors in a determined and patient-centred manner. Members should be crystal clear that all the suggestions made thus far by the Opposition to improve accident and emergency services are already being implemented.

That is not true.

It was simultaneously sad and amusing to hear Fine Gael's spokesperson on health commit his party to delivering four 150-bed units with step-down beds. That constitutes a pessimistic and limited total of just 600 beds, whereas the Tánaiste has already stated explicitly that the HSE should use as many public and private nursing home beds as required to release beds for patients awaiting admission. The acute beds that become available as a result will be ring-fenced for those patients awaiting admission to accident and emergency departments. The numbers will not be limited to 600 beds.

While every suggestion from the Opposition that would improve accident and emergency services is already being implemented, the flaky suggestions put forward by Fine Gael are not. For example, Fine Gael's proposal to fine drunks in accident and emergency units and to turn already busy doctors and nurses into policemen is as preposterous as it is desperate.

That is not true. The Garda will administer fines.

If the Senator wishes to rebut the argument, he will have his opportunity to speak in a moment.

The Senator should be truthful.

I listened to Senator Browne's description of his "Out of Africa" experience and to his remarks regarding, not heart bypasses, but the Kinnegad bypass. I listened to him discuss the sale of Eircom as well as freedom of information.

It was all relevant.

I listened to him discuss the replies to his queries and the only contribution he made was that one would need a magic wand to sort out the accident and emergency services. He continued by welcoming Fine Gael's policy announcements at the recent Ard-Fheis. I did not interrupt him and I now propose to deal with the points he made.

To return to the subject of drunks, Fine Gael proposes to fine the passenger in a car being driven home by a sober friend who was involved in a car crash, the innocent victim of a street attack, or someone with a mental illness whose condition might not be instantly recognised.

The Senator knows this is not what Fine Gael proposes.

The problem is that Members do not know what Fine Gael proposes.

Fine Gael never made that proposal. This is outrageous.

The Acting Chairman might imagine my disappointment when I heard this showcase piece from the Fine Gael Ard-Fheis——

This is outrageous. The Senator is aware this has not been proposed by Fine Gael.

—— and remembered how I had described it as being superficial and nonsensical when originally put forward by Deputy Kenny in February. Fine Gael's proposal has not changed since February and it is as superficial and nonsensical now as it was then.

The Senator is being nonsensical.

Who will decide if the patient is drunk enough to be fined? Will all accident and emergency patients be breathalysed? If not, what will be the test of "drunkenness"? Members are aware of the tests which gardaí must administer when assessing whether a person is drunk. Will doctors be obliged to form an opinion that the patient is sufficiently drunk to be fined? Who will fine the patient? Who will go to court to testify against a patient if a fine is not paid or if a test is disputed? Have Fine Gael and its medical Deputies and candidates checked this with the Medical Council? Will homeless people or those suffering from chronic mental health problems who are drunk be fined if they go to accident and emergency units? What if such people have no money? Will those, young or old, who engage in self-harm and have abused alcohol also be fined at accident and emergency units, even as their lives are being saved?

Fine Gael has become a party that votes for crackpot Marxist motions which its own Members have described in the Dáil as being crazy. It now distances itself from the health policy views expressed by its candidate in Dublin North-West. God help us if the future of health policy making is to be placed in the hands of a small number of medical doctors with extreme and controversial views. While the Mullingar accord may have failed to deliver consensus on policy of substance between Fine Gael and the Labour Party, a voter might expect agreement between a party leader and that party's spokesperson on health.

Members should closely examine Fine Gael's other proposals. The so-called "urgent care centres" will do a sum total of zero for the 25% of people who come to accident and emergency units and who require admission to hospital. These are the people whose waiting times on trolleys are most unacceptable. Its proposal for children under five seems ignorant of the fact that children continue to get sick and require doctors at the ages of six and seven, especially when they go to school.

This is outrageous.

In contrast, the new GP-visit card, as well as the additional medical cards which are now available, help those who need assistance to visit their GP and receive medical care without any cut-off point for children based on age. The Government has not decided that children will not become sick after the age of five.

Those aged over 70 receive medical cards. Does the Senator suggest that 69 year olds do not become ill?

It is also regrettable that Fine Gael seems unaware that health screening programmes to catch diseases early must be carried out scientifically. A simple regular health check, as proposed by Fine Gael, does not catch diseases. While the Fine Gael leader claims he will save money, millions of euro could be wasted on useless checks instead of being spent on treatment. The Government has introduced screening programmes where they have been proven to work.

The Diabetes Federation of Ireland disagreed completely.

This Fine Gael proposal is, yet again, too vague and unconsidered and has been neither costed nor scientifically based.

The Diabetes Federation of Ireland disagreed. This is crazy.

As an aside, I noted, with a smile, that the leader of Fine Gael has given himself more time to address accident and emergency issues than he has given the Tánaiste. He has given himself 30 months.

While Fine Gael has produced buckets of negativity, no health policies whatsoever have been produced by the Labour Party since the general election, apart from scraps from the last election, such as free GP services for all, even for the richest in society. I find this incredible.

The approach taken by this Government is yielding positive results. Brand new accident and emergency departments have been established in Cork, Blanchardstown, Naas and Roscommon, as well as a new 32-bed unit at the Mater Hospital. The first ever national hygiene audits of hospitals has been undertaken. This is an example of how problem solving is being taken from an anecdotal stage to an evidence-based approach.

In co-operation with the HSE, the Government is addressing the issue of delayed discharges in a sensitive and appropriate manner by helping people into step-down and long-term care places. The HSE is also engaged in another first, namely, a tender process for out of hours GP services for the northside of Dublin. It will improve GP services for Dubliners and alleviate some pressure on accident and emergency services at night.

On foot of the commitment in the health strategy, funding has been provided to open an additional 900 inpatient beds and day treatment places in acute hospitals. At the end of 2005, a total of 804 such beds were in place. The remaining 96 bed places will come on stream in the coming months. Remarkably, Fine Gael made no commitment to providing new hospital beds in its new health policy. In contrast, we have projects for 450 more beds and we have introduced an initiative to create 1,000 new public beds by having the private sector build private hospitals on the sites of public hospitals. This will free up additional beds for public patients.

While we correctly call for the maximum to be delivered from current levels of resources, it does not mean more resources are not being provided. For example, the 2006 Estimates for the Health Service Executive included €60 million to open new facilities built under the national development plan. These new facilities will include additional inpatient beds and day treatment places in acute hospitals. Resource provision should not be an issue, but resource use must be for the sake of patients and taxpayers. As the Tánaiste outlined, if public spending grows in line with economic growth, and health spending remains at approximately a quarter of public spending, we will probably have approximately €7 billion more available for health by 2012. While we will have more resources, we must also have reform. We must not have reform for its own sake, but to ensure immediate improvements in practical areas like faster services in accident and emergency units, better GP cover out-of-hours, more efficient use of hospital beds, more fairness for public patients in public hospitals and more care in the community for older people. Would the Opposition honestly undo that process?

The Fine Gael leader appeared at the weekend to be unaware that the Irish Nurses Organisation has said it will stay out of benchmarking II, so he cannot rely on benchmarking to deliver change. Fine Gael has not said whether it would pay the INO demand for more pay and four hours less work a week, at a cost of €1.5 billion. The Opposition bizarrely objects to the plan to deliver 1,000 new public beds by private sector investment. Typically clouded by leftist Labour Party thinking, it managed to describe this as privatisation. Fine Gael appears to base its opposition on the mistaken view that public land will simply be given away. It will not. Public land will, of course, have to be leased or bought at commercial rates. The procurement process for these projects will begin soon throughout the country. Will Fine Gael oppose that project?

This afternoon's session is more than just an opportunity to engage in hand-wringing and rehearsed outrage. It is an opportunity to see who can objectively assess the challenges and propose workable, costed, detailed and evidence-based solutions. I have taken this opportunity to do just that on behalf of the Progressive Democrats. It is more with hope than with expectation that I look forward to the contributions from Members opposite.

I thank the Minister of State for coming to the House to debate the accident and emergency crisis, which is something most of us do not wish to encounter. One only arrives in an accident and emergency unit if one is ill or has an accident and one wants to get emergency care.

There are many pluses and minuses in the health system. Two years ago, my elderly mother went to Sligo hospital for a routine procedure. While everything appeared to be going well, she was in the accident and emergency unit for approximately ten hours. While I am not sure whether anything was wrong, it took ten hours from the time she arrived at the hospital to the time we left to have a routine procedure carried out. I do not know whether the problem was with the accident and emergency unit or the hospital, but obviously there was a serious problem on that day. I do not think that a lady of 76 or 77 years of age should have to wait ten hours in an accident and emergency unit. There should be other ways of dealing with these cases.

Last Saturday night, my mother had an accident in Dublin when she fell and cracked her hip. This happened in the CityWest Hotel. While I must praise the ambulance staff for their efficiency, professionalism and courtesy, it took approximately 35 minutes to get from CityWest to Tallaght Hospital. While it is no reflection on the health service or the ambulance driver, it is a reflection on the roadworks on the Naas Road. No one appears to be able to find their way off the Naas Road in order to get back to Dublin. Taxi drivers have been caught in this dilemma. The following morning, I was almost in Naas before I could turn for Dublin. We must examine how to carry out roadworks more efficiently. While ambulance drivers are very efficient and know the city well, the ambulance driver could not get off the dual carriageway to return to Dublin until he was almost in Naas.

When my mother arrived at Tallaght Hospital, I was very happy with the service she received. She was treated efficiently and well. However, there were one or two men in the accident and emergency ward, and while it was not very threatening, I was a little uneasy because they were under the influence of substances other than alcohol. While the nurse said it was a quiet night, I would not like to work as a nurse in that atmosphere in an accident and emergency unit on a busy night. I pay tribute to the nurses, doctors and emergency teams who must work in these units. I would never use this or any other situation to score political points and I pay tribute to the people working in Tallaght Hospital on Saturday night.

When I remarked to the staff that the unit appeared to be remarkably quiet, they said that Saturday night is no longer busy in the accident and emergency unit. The busy nights now are Friday night and Monday night, which was news to me. There is a problem with drunks, especially in the construction industry. These people finish work on Friday and then go boozing. They are young and healthy and may become aggressive as a result of drink and end up in accident and emergency units on Friday night. What is even more worrying is that they end up in accident and emergency units on Monday because they take Monday off and drink too much alcohol and perhaps take other substances.

Fine Gael has policies on how to deal with drunks in accident and emergency units. We must explore the issue further. We are talking about recurring offenders who are clogging up the accident and emergency units. There must be some penalties and deterrents when dealing with these people. I saw the logistics involved in bringing just one lady to hospital, including an ambulance crew and hospital staff. The logistics involved in dealing with these mindless people is difficult to believe, and some deterrent must be put in place.

The Fine Gael proposals should be examined carefully, and if they are good, they should be taken on board. No matter what resources are put into accident and emergency services, it will not be sufficient to deal with mindless characters who return to these units each week.

The accident and emergency crisis reflects a crisis in the wider health system. Any attempt to address the problems with accident and emergency departments will have to involve the primary care sector. Many people cannot believe that the number of home help hours available to people have been cut. Home help is, in some ways, the backbone of our primary care system. If elderly people do not have the home help they need, they may fall and end up in the accident and emergency department of their local hospital. We must provide more resources for primary care, particularly home help.

General practitioners are not prepared to work the same hours as in the past, when one could call them at any time of the day or night. Most general practitioners now work from 9 a.m. to5 p.m., five days per week. They are not prepared to work an excessive number of hours every week.

Ireland is changing. A lot of money has been invested in the health service in the past ten years but we have not addressed the problems therein. Our lifestyles have changed greatly in the last decade. Our diets have improved, we are more conscious of our general health and of the importance of moderate alcohol intake. Unfortunately, however, there are those who binge drink and take illegal drugs and such people must be diverted from their damaging behaviour.

The 24-hour urgent care centres proposed by Fine Gael are not intended to replace existing accident and emergency departments but to complement them and relieve some of the pressure they are under. This is a satisfactory idea and one which should be taken on board by the Government.

The subject is a difficult one. Nobody wants to be in an accident and emergency unit. When the experience is good, that is to be welcomed but when it is bad, it must be highlighted and that is what I intend to continue to do, as does my party.

I welcome the Minister of State at the Department of Health and Children, Deputy Seán Power, to the House and am glad to have the opportunity to speak on the subject of our accident and emergency departments. Undoubtedly, there are problems with accident and emergency units and as politicians and legislators, we cannot turn a blind eye to that fact. However, all is not bad. There are areas of the country where accident and emergency units are running quite well. As with everything, one always hears the bad story but not always the good one.

When the rainbow coalition Government left office in 1997, the budget for the Department of Health and Children was approximately €5 billion. If any rational person was told that nine years later, in 2006, the budget would be €13 billion and that an additional 40,000 personnel would be employed in the health service, he or she would rightly assume that there would be no problems whatsoever in the health system. The natural assumption would be that everything would be running smoothly.

There are many reasons the health service is not up to scratch despite the investment of €13 billion, which is an enormous amount of money. Our population has increased, as has life expectancy. Factors such as MRSA and the winter vomiting bug, although seasonal, can affect the entire health system from time to time. I will not be flavour of the month when I say there are other factors affecting our health service which relate to its employees, not least the members of the IMO and the IHCA. Those organisations block the Tánaiste every time she makes a good proposal that should be supported by all parties. Not alone does the Opposition in these Houses block her good ideas, but the unions responsible for consultants and doctors also block, hinder and delay progress. Until the mindset underpinning such blocking behaviour is changed, the problems within the health service will not be resolved.

As other speakers have pointed out, alcohol and substance abuse can often cause overcrowding in accident and emergency units. Senator Feighan related how his elderly mother had a bad experience in the accident and emergency unit in Sligo but had a much better experience when she was in Dublin. It is almost a countryside versus Dublin scenario. In my experience, however, the larger hospitals outside of Dublin have better accident and emergency units than those in the capital, which makes sense, given the proportion of the population using the hospitals in Dublin. I know from my time on the Joint Committee on Health and Children and on the Medical Council that areas like Limerick, Waterford, Kilkenny and Sligo have fewer problems in their accident and emergency units than is the case in Dublin, Galway or Cork.

I was annoyed to hear Senator Browne refer to secrecy and cover-up in the Department of Health and Children. The Senator is, like me, a member of the Joint Committee on Health and Children. The Tánaiste and Professor Drumm appeared before that committee approximately three weeks ago. They were scheduled to attend the meeting for an hour and a half. They arrived at 9.30 a.m. but did not leave until 2 p.m.

I am glad Senator Browne has returned to the Chamber. I am not attacking him but am picking him up on something he said earlier about secrecy and cover-up in the Department. When the Tánaiste and Professor Drumm appeared before the joint committee, they stayed from 9.30 a.m. until 2 p.m. There was no attempt to run away from any facts. They acknowledged that there are problems with the health service. If the Senator thought there was secrecy or some kind of cover-up happening, he should have said so. He asked very relevant questions, which I believe were covered in the media the following day. It is unfair to attack people who attended the joint committee meeting and gave so much of their time and who are available to appear again before it any time they are asked.

The Tánaiste only appears three times a year.

That is because——

The health boards have been abolished.

The Joint Committee on Health and Children is very busy. There are other bodies it must engage with in order to hear everybody's view. It is not the fault of the Tánaiste or Professor Drumm that the committee does not have more time for them to appear before it.

The accident and emergency consultants appeared before the committee two weeks ago. They argued that the solution is more beds but Professor Drumm does not seem to agree with that analysis. I thought to myself that day, but was not brave enough to say it aloud, that they were very quick to hang one of their own. Their attitude was that Professor Drumm would not know anything about beds because he was a paediatric consultant. However, when Professor Drumm was first appointed, all the consultants shouted loudly about what an excellent appointment it was and how they looked forward to working with him.

When the Tánaiste and Professor Drumm appeared before the committee, they talked about the problems in accident and emergency, as was to be expected. They also talked about the need for other health care professionals to work out of hours. There is no point in having an X-ray or pathology department in a major hospital that only operates from 8.30 a.m. to 5 p.m. because people do not get sick according to such schedules. There are many factors affecting accident and emergency units.

I wish to speak briefly about my own experience in Sligo General Hospital, a hospital of which I am very proud. All of the departments in the hospital are run very well by experienced, senior personnel. A sum of €1.5 million has been pledged to revamp our accident and emergency unit. I should tell the Minister of State that we still look forward to receiving that money. It was promised approximately 18 months ago. The accident and emergency department has a throughput of approximately 30,000 patients a year and two consultants. Those consultants are extremely stretched.

Sligo General Hospital is always compared with Letterkenny General Hospital. I spoke to a few accident and emergency consultants today and they stated it is bad to compare one accident and emergency unit with another. It may involve comparing a mediocre accident and emergency unit with a unit not quite as up to scratch, which delays the progress of the first accident and emergency unit.

While we are happy with our accident and emergency unit in Sligo, we would like it to be revamped and brought up to the standards of modern day medicine. It is approximately 12 or 15 years old. I know the money is there to do so. We would like a dedicated X-ray unit for the accident and emergency department and appropriate standards for a resuscitation unit. The accident and emergency department in Sligo has a small resuscitation unit, just off the main corridor. It is neither nice nor private that the main accident and emergency unit traffic flows up and down outside while someone's family member is being resuscitated.

The hospital requires a better IT system, and not merely a billing and registration system. It should include patient profile, length of stay and the type of patient who is readmitted. Approximately 80 patients per day go through the accident and emergency unit, which has 12 clinical spaces. Overcrowding occurs at certain times and creates huge pressure when it does. The busy times in Sligo are late morning to early afternoon and early evening to late at night. Weekends do not seem to be that serious.

Senator Feighan stated that the Government should take on board the good proposals coming from Fine Gael. I would be first to agree, and no one in the Government parties of the PDs or Fianna Fáil would object to it. Senator Browne mentioned that the Tánaiste stated some people in accident and emergency units should not be there. Perhaps that is so. However, the consultants I spoke with today felt that Fine Gael's proposal, made at its Ard-Fheis this weekend, to have a unit where drunks or people abusing drugs would be put to sleep it off or chill out was serious and dangerous. They felt it showed no understanding by the Fine Gael Party and the party had received bad advice.

The consultants would like to see a safe and appropriate setting for a person who is drunk or under the influence of an illegal substance. That is what is required. They considered the entire idea of fining someone attending in that state to be ludicrous and daft. It is difficult enough to obtain the €60 fee from these people, never mind asking them to pay a fine. It will not work. I say to Senator Feighan that we would take those ideas on board if they were workable, but they are not. Fine Gael would complain if somebody died in such a unit, not having received proper medical care. Perhaps when someone is shouting and going mad, they are doing so as a result of an injury. I would also like to see accident and emergency departments having a small space dedicated as a unit for children.

It is great to debate this issue today. I listened to the debate since it began and it is like every other debate I have heard on this issue, in that it is a constant rehearsal of the problems with few solutions offered. I will probably do more of the same. It reminds me of the debates during the past 20 years on agriculture. The game is to blame the Minister. I stated many times that I have seen Ministers do their best. In my view, the Tánaiste is as committed to this as anybody has ever been.

Hear, hear.

I thought the game seemed to be to blame Enda Kenny.

Whatever the problems are, they certainly have not been resolved. Simply politicising them does not help our case. It has been noticeable and attractive during the past year to find the HSE picking up the ball on health issues rather than the politician as it always was before. This allows people to grasp and grapple with the issues.

We could and should do certain things which we have not done. The consultants' contract has not been dealt with. My view is that the Tánaiste has not offered enough money. I stated before that I would offer them more than €300,000 to be available, to work the appropriate number of shifts and to make progress. I would tell the consultants we would protect their contract for as long as they wanted to keep it. I am certain we can afford to pay that amount of money to consultants. Even though it would be less than what they may earn in the private sector, by the time the cost of running an office is removed and the importance of a pension is added, it becomes an extremely attractive proposal.

One of the main problems regarding consultants is that we do not have enough of them. Consultants have a say in who is appointed. They seem to take the view that anyone under the age of 43 or 44 is not old enough to become a consultant on the basis that they suffered for that length of time and so will the next generation. That is my view and I do not speak on behalf of anybody. From the outside, that is where I see the problem.

I would resolve those issues by taking decisions and progressing in a way that protects the consultants. We must recognise they are under an agreed contract. The only way to deal with it in HR terms is to recognise, acknowledge and respect that contract and allow the consultants to have it for as long as they wish. We must negotiate a new contract for new people. Decisions must be made on that basis.

The same must be done for other people. Senator Henry asked what discussion has taken place with the unions and the organisation representing all of the other groups working in those services. My understanding, and I may be wrong because it is based on anecdote rather than on official information, is that no real negotiations or discussions have taken place on how to do this. Until we can operate a system where all of our assets are operational and available for at least two shifts a day we will never deal with the issue. That must be done.

We must invest more funding in health. Members of the Government always begin their speeches by outlining the amount invested since 1997. Nothing is gained by that. If somebody stated in 1997 that a deal would be done to treble the health budget and double the number of people working in the health services, everybody would have thought it would solve the problem but it has not solved it and will not solve it. The Tánaiste is correct when she states it is not only about money. At the same time, she should qualify that by stating more funding is required. We must set about getting value for money and the service required.

On a number of occasions, the Tánaiste raised the issue of GP clinics. That is an important part of the issue. I have no doubt that people do not of their own volition go to an accident and emergency department to queue for six, seven or eight hours in some cases. They do not do so lightly. In many of these cases people need some sort of reassurance that they, or a child or parent, are not actually dying. If they are examined there will be a certain reassurance. There would also need to be an assurance that any additional treatment required will be received.

My home town of Dingle, located on the west Kerry Peninsula, is in a difficult area. Somebody from Dunquin would have to drive more than 40 miles to the regional hospital in Tralee. That is a long and difficult drive. The GPs in the area recently put forward a plan to the HSE where they would provide 24-hour cover every day of the week. It needed the support of one additional person, which has not been given to the group. There may be good reasons for this, but to a person listening to the discussion, it seemed like a local initiative. I know some of the GPs involved and they would have very good reputations. They would not lightly put forward a proposal they felt would not work, and they felt they could provide a service.

There is no doubt that this would immediately take pressure off the accident and emergency department in Tralee hospital. An elderly neighbour of mine fell recently and had a minor injury to her face. The neighbours rang our house and my wife was one of two neighbours who helped out. There were some cuts and bruises and they cleaned the woman up. Nothing was broken as far as they could see but as it was an elderly woman, they thought they should contact the GP service.

As always seems to be the case when these incidents occur, it was the weekend so they had to contact a back-up service, which arrived two hours later. What I find extraordinary was that the doctor arrived with his bag, examined the woman and indicated that she only needed to have the wound dressed and to have her pain treated with a painkiller. He gave a prescription for this, although it was a Saturday evening out in the countryside. The doctor did not even have a bandage or dressing to treat a minor cut and bruise.

He suggested that the woman should go to the accident and emergency department to have the wound treated. I do not know who is right or wrong in such a matter. It is a nonsense that an hour of this doctor's time was taken to examine this person, indicating that she was okay but the wound needed to be dressed etc. He then indicated that he would give the woman two tablets, but the neighbours argued that he should provide the woman with enough tablets to keep her going over the weekend. He eventually did so.

This is a practical example which drives ordinary people mad. They question how such a case can occur. Who is at fault for this? It is daft to blame the Minister for Health and Children for that, although that is apparently what we are required to do as politicians.

It is Enda Kenny's fault then.

If a Fine Gael Minister is responsible for health matters next year, the doctor still will not have dressings in his case when he comes out. If there were to be a Fine Gael Minister responsible for health next week, the doctor will still be saying the same thing. As MalcolmMuggeridge said before he died, I hope to be surprised. As a rational human being, that is not something for which the Minister for Health and Children can be blamed. That is my view, and if I am wrong, I am wrong. I am sorry to spoil the political fun with a statement like that.

When people arrive at an accident and emergency department for an X-ray, for example, why do these people have to queue up in one place and cause a blockage at the beginning, before having to go to another queue at X-ray? Why do these people not simply go straight into the X-ray section? Apparently that is not allowed, and these people have to go through each step, creating clogs in each of them. Such issues are not being thought out at that level. I will not get involved in the political arguments of the drink issue, but as far as I understand, drunk tanks should be in police stations. They have nothing to do with hospitals. Why can people not go directly to an X-ray unit or wherever they are going on a particular day? Why do two or three checks exist along the way?

A previous speaker discussed personal experiences. Senator Glynn mentioned the accident and emergency system in France and Senator Henry discussed the system in Spain. I had an accident in France a few years ago during a very hot summer when the accident and emergency departments were clogged with elderly people dying from the heat. It was approximately three years ago. On a Saturday night I managed to injure myself, and I promise I did not have any substance or drink in me. An ambulance was called and I was brought to the local accident and emergency service.

The accident and emergency hospital is a separate entity in France. It is not part of a general hospital but is specifically for accident and emergency services. I was taken into a mill of people at 6 p.m. on a Saturday. I was there as a punter from the street with very poor French, trying to explain exactly what had happened to my wrist. Within an hour I had an X-ray, although it was a long and painful hour. Within another half hour I was sitting down with a consultant who explained that I had a broken wrist. After another half hour I was sitting down with a surgeon, who told me the injury required an operation. I had the option of having it treated before going back to Ireland, having the operation that night or on the following Monday. I thought of accident and emergency services in Ireland.

I was admitted to a general ward in the hospital that night, and I had the operation on the Monday. I went through the system and there were a large number of people there. Everybody must have been looked after. The consultant saw me at 9 p.m. on a Saturday, and this was the difference. Somebody was there to make the decision, and a surgeon was present at 9 p.m., who was operating until about midnight that night. It may have been possible to operate that night, although the surgeon was not working on the Sunday. I do not know what the arrangements were for that.

Those are the kinds of issues we should examine. We must resolve the problems in order to ensure we get the support and structures required to make the services work. It is not a purely political issue. Money and change is required, as is direction and commitment. I am sure that if Fine Gael provides the next Minister responsible for health, he or she will also be a person of quality who will give his or her best. If that happens, Fianna Fáil will sit on this side of the House, telling me and the rest of us what a bad job the Fine Gael Minister is doing. That has gone on for 20 years and is not the way to resolve the problem.

The Minister of State will be relieved to know I have no complaints for him. If I had, I would have to take them elsewhere. I offer some observations on the basis of experience in the field of health policy and management. We should listen carefully to many of the sensible statements made by Senator O'Toole. These are practical, although not quite straightforward, issues. I take some heart from the statement from the Minister of State, Deputy Brian Lenihan, earlier on, and I believe we are moving in the right direction. These are complex issues, and nobody can wave a magic wand to get a change overnight.

Investment is required in primary and community care rather than the hospital field. The problems in clogged accident and emergency departments arise from people presenting there who could be treated more appropriately elsewhere, and the fact that hospital beds are taken up by people who would receive more appropriate treatment in the community. Those two sides of the equation need to be reviewed. Investment, in the form of money and organisation, is necessary.

The HSE is correct to state that each hospital is different and needs to be approached differently. There is much to be said for the appointment of a "bed unblocker" in a hospital. Many of the reasons for people remaining in hospitals unnecessarily are administrative, there being a lack of staff to discharge them. If patients cannot be seen on a Friday they remain until Monday. There are a number of hospitals — I know of one in Manchester — where satisfactory triage at an early stage and the presence of a specialist accident and emergency nurse assists the flow of patients through accident and emergency units.

As Senator O'Toole said, the attendance of consultants must be reviewed. Most serious accidents happen late at night after the pubs have closed and when hospital staffing is inappropriate. There is much to be said for ensuring consultant cover and the availability of diagnostic services. There is no point in having CAT scanners, MRI scanners and operating theatres if they are only used for seven or eight hours a day. I remember an awful case in Belfast a few years ago where a man died within a mile of three scanners but none was open until 9 a.m.

I notice the term "rostering" was used. I hope it does not mean staff being on call-out or stand-by allowances but that it involves a shift system. That is necessary for laboratory technicians and radiographers, among others. Such personnel issues must be dealt with.

I am not against hospital league tables as long as they are used sensibly. Managers will say it is impossible to compare a particular hospital with others but the figures are useful if people use them to interrogate themselves and to ask why they are different this week from last week. A hospital may have good systems but it is important that a dialogue takes place.

The out-of-hours doctor service where I live is an enormous help and has transformed demand. A procedure called "NHS Direct", where people could telephone for assistance, was introduced in England a few years ago and is worth considering. People often bring a child to the door of a hospital in fear and want somebody to talk to, somebody who will tell them what action to take. If the child's condition does not improve they can bring the child back. It can be tremendously helpful.

I welcome the establishment of minor injury units and admission wards, which I take to be the "transit wards" mentioned in the statements today. These afford some breathing space for a hospital and allow it to adjust to an influx of people, especially early in the morning before beds can be cleared. Minor injury units have enormous potential because, according to all the studies I have read, some 80% of people presenting at accident and emergency units could be dealt with in properly staffed minor injury units. I would set up four such units in Dublin, one each in the north, south, east and west of the city. I would staff them with junior doctors and specialist accident and emergency nurses. That would take an enormous strain away from the system and would mean high tech hospitals, with heavy equipment to be used for real trauma, could be fully staffed on a 24-hour basis.

Drunks are an enormous problem for staff at accident and emergency units. Senators should visit an accident and emergency unit late at night and witness conditions under which nurses and other staff work. I am sure Dublin is no different from Belfast, with which I am more familiar. I do not think the answer is to keep drunks out. Drunkenness can very often disguise the symptoms of a serious head injury. Part of the answer is to have adequate portering and security staffing. Larger units in a city should be staffed by trained psychiatric personnel late at night because they are better used to handling such people. The people who work in these units late at night, particularly in urban hospitals, are heroic at times and deserve any support and help we can give them. The Minister of State is moving in the right direction and I wish him well.

I will make a few points on the difficulties in accident and emergency. I welcome the Minister of State at the Department of Health and Children, Deputy Seán Power. I understand that the Minister of State at the Department of Health and Children, Deputy Brian Lenihan, deputised earlier for the Tánaiste and Minister for Health and Children, Deputy Harney, who could not make it to the House today. That is understandable, because it is not always possible for a Minister to attend a debate.

This is an important discussion and Senators have made reasoned contributions, with the exception of Senator Minihan, whose disgraceful comments have provoked me into making some remarks on the subject. I have not heard such comments in my time in the Chamber. What is the rule of the House on Members reading their entire contribution from a script? I am fed up with certain Members, including Senator Minihan, reading their entire contribution. I understand that it is necessary for Ministers.

There may be an old rule but it is not enforced.

I object to listening to someone in this House, or even in my office for that matter, giving a reading. This is a Chamber for debate, not for reading. Senator Minihan could make a contribution with the benefit of a few notes, to which we all have to refer from time to time, but he should not read everything he says.

The only thing the Senator did not read was his personal attack on Senator Browne. He opened his remarks by saying the debate should not involve personal abuse of the Tánaiste and Minister for Health and Children and I agree. Nobody said anything abusive about the Minister. There are many things for which I could reproach the Minister but I have no intention of being personally abusive towards her. Senator Minihan's contribution, from start to finish, was to personally abuse the leader of my party, Deputy Twomey and Dr. Bill Tormey at every opportunity. This debate is not a suitable occasion for him to launch into such personal attacks and he should apologise for some of the things he said.

Senator Minihan spoke about rehearsed outrage but he had rehearsed his speech and used a prepared script to give it. He also spoke about workable, costed and detailed solutions, of which he put forward none. Whether he likes them or not, Fine Gael came up with a number of workable solutions over the weekend. Other Senators on the Government side suggested solutions, as did Senator O'Toole and Senator Maurice Hayes. I am not an expert on health but I regularly meet people who work in the health services and others who seek to avail of them throughout the country and they have serious problems. The role of the Opposition is to ensure that those reservations and problems are raised in the Houses of Parliament and if Senator Minihan has a problem with that, he should not be here.

There is a crisis in hospital accident and emergency departments throughout the country. The Tánaiste acknowledged that after a year in office although we had been screaming about it for a great deal longer. She has endeavoured to make some positive moves towards resolving the problems.

A number of Senators made good contributions to this debate. Senator Henry was correct that the crisis in accident and emergency departments is but a symptom of other, deeper problems that exist in hospitals and in the health service. It is the most visible symptom. A number of proposals were made over the weekend which I will discuss in further detail. I disagree with Senator Feeney about the issue of drunks in hospitals. My second cousin, who is also a very good friend, is a nurse in St. Luke's Hospital in Kilkenny. He frequently works in the hospital's accident and emergency department and he has been assaulted on a number of occasions. This man plays hurling with the local team and is a couple of years younger than me. Accident and emergency staff are regularly assaulted.

People should take the time to read what Deputy Twomey said. He did not say that drunks should not be admitted to hospital but that they should be examined to ascertain if there is something more substantial wrong with them than just drunkenness. If not, they should be put into a wet room. That is the practice in many countries. The Fine Gael proposal is not about keeping them outside the door. Often these people are suffering from serious injuries of some type and need to be treated in hospital. However, in many cases they are not.

I have witnessed this. Approximately 18 months ago my father fell ill at home one Saturday evening. I brought him to Ardkeen, the regional hospital in Waterford. We waited for ten hours in the accident and emergency department for him to be seen. Eventually he was seen at 4 a.m. or 5 a.m. and I left. I witnessed the behaviour of some of the individuals there that night. My father is 80 years of age and he probably could have driven to the hospital himself but he could not have been left in the accident and emergency waiting room with some of the thugs that were there. There was nothing wrong with most of them.

I spoke to many of the staff and they told me they regularly confront this situation. It is all very well for us to pontificate and for people in the media to say, with lily livered liberalism, that these people might have serious problems but if they want to abuse themselves and get out of their tree with alcohol, they have a right to expect that people will examine them before admitting them to accident and emergency units. That is the correct approach. The staff who work in these units have a right to some type of protection when they do their work. Like other Senators, I applaud the people who work in accident and emergency facilities. They do great work.

Senator Minihan also referred to the Irish Nurses Organisation. He should not have done so. The Tánaiste decided not to attend the organisation's conference. I presume she had to attend another event. The INO made an important resolution at its conference. For the first time the organisation passed a vote of no confidence in the Minister for Health and Children. That organisation has had many rows with Ministers in this and previous Governments but this is the first time it went so far as to propose a vote of no confidence in a Minister. The Tánaiste has serious questions to answer with regard to her handling of the health portfolio.

I wish to mention the county hospital in County Kilkenny, St. Luke's. Fantastic people work in the hospital's departments but the accident and emergency facility in the hospital is antiquated beyond belief. I do not know how many years it has been that way. There are four or five cubicles in the unit. Of those, one was originally to function as a dedicated acute cubicle but it is operated as a general cubicle. Another cubicle occupies the space before the exit from the unit. The exit is obstructed by a trolley which acts as a cubicle for the unit. One cannot get through that exit in the event of an emergency. I saw this recently when I went on a tour of the hospital with the hospital's director.

Despite this, the people there do great work. The accident and emergency unit is quite successful in getting patients through the unit. It does not have major problems because the hospital also has a medical assessment unit. Senator Feeney and other Senators referred to these units in their comments. St. Luke's had the first such unit in the country. Dr. Courtney was instrumental in setting it up, despite strong opposition from some members of the old South Eastern Health Board. Eventually, a few million euro were provided and the unit has been most successful for St. Luke's.

The Tánaiste has spoken about establishing such units throughout the country but it has not happened in most hospitals. Establishing medical assessment units is one way of alleviating the difficulties in accident and emergency departments. These units assess people who are neither accident nor emergency patients and determine whether they need to be admitted to hospital. Setting up these units is a positive proposal.

Critical care units were mentioned during the debate. This is something new and I had not heard about it until the proposal was announced by Deputy Kenny last Friday night. I welcome it. It could be useful in this city, where the problem is most acute, and in large towns throughout the country that do not have accident and emergency units. The national health screening strategy announced by Deputy Twomey was a very positive proposal which is eminently workable. Elements of it have been rolled out already but if it were implemented across the country for different illnesses it would work well.

It is clear that we must provide, and soon, additional step-down beds. Senator Henry also mentioned this. The Government says it is in the process of tackling this issue but it has not yet delivered. Another promise that has not been delivered is the provision of doctor only medical cards. It is over a year since their introduction was announced but only 20,000 have been issued although it was projected that there would be a total of 200,000. If they were available fewer people would be presenting at accident and emergency departments. The Tánaiste and the Government have dragged their heels on this. That is a legitimate criticism. I ask the Minister of State to ensure that something is done about it.

I agree with Senator O'Toole's comments about the consultants' contract. The contracts that exist must be honoured. However, it is also clear that a new contract is needed for the people taking up consultancy positions. Whatever format that takes and whether more money must be offered, a resolution to the problem must be found as soon as possible.

The crisis in accident and emergency departments is probably more acute in Dublin than in other parts of the country but there are problems in many of the big regional hospitals. This should not become a vehement political issue but, as an Opposition, we have a role in pointing out the difficulties that exist and the problems people encounter. I will not be silenced by outbursts such as Senator Minihan's today. I will use every opportunity I have in this House and elsewhere to make my opinion on this and other issues known.

I wish to share time with Senator Kitt, who wishes to speak about Portiuncla and other hospitals in Galway.

Is that agreed? Agreed.

I thank the Minister of State, Deputy Seán Power, for the work he is doing on care for the elderly. He recently visited County Clare and he is aware of the problem with Alzheimer's disease. The people in Clarecastle and Carrigoran are anxiously awaiting the Minister of State's return with some support to enable them to continue the work they are endeavouring to do in a difficult situation.

One cannot divorce many of the problems in accident and emergency departments from the general problems in hospitals and, in turn, the problems that arise for elderly people and people with various other problems, such as dementia, that need attention. I will focus my contribution on the situation in Ennis.

Ennis General Hospital is part of the regional structure of the Health Service Executive, mid-western area. The Minister of State must direct the attention of the Tánaiste to the hospital's uncertain position. It is over a year since a high-powered delegation, which included Members from County Clare and the representatives of the Ennis General Hospital development committee, attended a meeting with the Tánaiste in Dublin to emphasise how important it was to press ahead with the hospital's development. The hospital was built in the 1940s, at a time when its design was adequate for the needs of the people of Clare. The nursing and medical staff have given an outstanding service to the people of Clare. That is why there is widespread apprehension in Clare as to the hospital's future.

Over the past six years, the then Mid-Western Health Board worked on an overall hospital development plan for Ennis which included the upgrading of the accident and emergency department. The department is a small unit in the hospital complex, inadequate to meet the needs of those attending it. Approximately 22,000 people a year attend the department, of which 5,000 are admitted to the general hospital. One problem that is delaying the throughput of patients is the absence of a CAT scan facility. A patient requiring urgent X-ray facilities must be transported to Limerick which clutters up the hospital system. It is of vital importance that the CAT scan facility for Ennis General Hospital, which was included in this year's capital budget, is approved. A location in the existing hospital complex has already been set aside for it. Arrangements must be made immediately for its installation.

Ennis hospital has the same problems as others. In recent times, there has been an escalation in the aggressive attitude of patients at its accident and emergency department. They attend the department, invariably accompanied by friends and relatives, in an aggressive mood brought about through the over-indulgence in alcohol and, sometimes, drugs. The hospital has had to employ security personnel to keep law and order there at the weekends. On several occasions, the Garda has had to be called to restore law and order in the department. This is unacceptable. No Member can expect nursing and medical personnel to put up with such behaviour. Any solution to deal with this will be welcomed. In so far as it is an issue, it is not a major one in Ennis but it is becoming more prevalent. The Minister of State at the Department of Health and Children, Deputy Brian Lenihan, will be familiar with this in his work with children's issues.

An assessment unit for the elderly has been established in Ennis General Hospital where the particular needs of individual patients can be quickly assessed. In many cases it is found that a patient may not need acute hospital facilities but some form of hospital accommodation until such time as he or she is fit to return home. The Minister of State will be aware of the high level of dependency there is in west Clare. In the communities, voluntary organisations endeavour to provide care facilities for patients in these circumstances. A network of community facilities exists such as the community hospital in Kilrush which has 55 patients and is run by a local charitable organisation and business people. When the hospital was closed, the group organised a good facility to provide accommodation for 55 patients who would otherwise be in a desperate situation.

The same applies to the Friends of Ennistymon Hospital with local people working together in the old district hospital, providing accommodation for people who are not fit to return home. The Friends of Ennistymon Hospital raises funds to match funding from the Health Service Executive. The same applies to Raheen in east Clare which has an excellent facility with respite beds for elderly people.

The solution to the many problems experienced in acute hospitals is through having more partnerships and co-operation between community voluntary organisations and the Health Service Executive in providing community hospitals. It would take pressure off acute services and enable those patients who require acute treatment to be dealt with effectively and speedily. I pay tribute to the work being done by these voluntary organisations such as the Friends of Ennistymon Hospital, the Friends of Raheen Hospital, the Kilrush community hospital and the private organisations such as St. Theresa's nursing home.

I appeal to the Minister of State to use his good offices with the Health Service Executive to expedite the development plan for Ennis General Hospital which has been hanging around for five years.

The Senator has no trust in the Tánaiste.

It has been a merry-go-round of discussions for the past two years with hospital, departmental and executive officials. The people of Clare want to see the hospital's development begin as soon as possible. The plan has been costed, evaluated and cleared by the Health Service Executive and the Department of Health and Children. The first phase of the development will cost €30 million. The red tape that is holding up this excellent plan must be removed.

Senator Kitt now wants to highlight the dire straits in which Ballinasloe's health service finds itself.

I am afraid Senator Daly has used up all of Senator Kitt's time.

I am sorry.

Senator Ulick Burke will give him five minutes of his time.

That has been known to happen.

I have listened to the Government side as to who must take the blame for the crisis in accident and emergency services. Senator Feeney referred to the doctors, the unions and the nurses as part of the problem because they resist the best efforts of the Tánaiste to implement change. Senator Daly mentioned as many more. When the Tánaiste took over the health portfolio, she blamed departmental officials. The Department has no friends left to carry out the services people need so badly.

The Tánaiste said her ten-point plan would solve the problems in accident and emergency services. We are still waiting, even though the Tánaiste has been at the Cabinet table for ten years. This is not all new to her because there have been serious problems in each of the ten years.

The Minister of State can judge for himself the problems in accident and emergency services in University College Hospital, Galway. In the past two years, 60 beds have remained permanently out of service. The reason for this is best known to the management of the hospital. The same ward is never out of commission for a long period. We are supposed to believe it is closed for decoration but, when it re-opens, the paint has not changed. All it would take to release the 60 beds, which would have a major impact on accident and emergency services, would be 50 units of personnel. The Tánaiste knows that and has bobbed and weaved on numerous occasions, as have the Fianna Fáil Ministers from the constituency.

Fine Gael had its own magic carpet out over the weekend.

Perhaps if some of the eminent medics come into the Oireachtas, they will resolve the situation with the help of those already in place. We will welcome them in.

We work longer hours here.

What about our out-of-hours claim?

If 60 beds in University Hospital Galway have remained out of commission for two years, what is there other than a crisis in the accident and emergency system?

Some of the comments made by the Minister of State, Deputy Tim O'Malley, about the Fine Gael proposals were scurrilous. He brought into question the situation for those with mental illness. They were never involved in this and he was going overboard, coming out with a knee-jerk reaction to hit the headlines. This is too serious an issue for that.

Four months ago, I was in the accident and emergency department in University College Hospital, Galway. Having waited for eight and a half hours, at 12.30 a.m., the doors opened to a commotion. Six people entered supporting someone who was shouting and roaring in pain. They forced their way into the treatment centre and that man was dealt with.

There was an elderly man beside me from Ballindyne in County Mayo with a broken collar bone. He had been there since 11 a.m. and had not been asked what he was doing other than to check in. At 3 a.m. that man had to phone someone in Ballindyne to take him away. The other people had got in. Four of them had been thrown out but they came out laughing at the idea that they had beaten the system. Those who question Deputy Kenny's remarks at the Fine Gael Ard-Fheis are questioning the reality of what is happening, the threats that medical professionals in accident and emergency departments face from those who are intoxicated. Something must be done and I fully support Deputy Kenny's suggestion.

The only holes the Government can pick in the proposal is how to decide who is drunk. It does not take a PhD to see who is drunk and who is not. Everyone in the accident and emergency hospital in Galway that night knew who was drunk. The backup the person had to get in were the real culprits, the people about whom Deputy Kenny was speaking.

Under the HSE we only have an emergency ambulance service. Services for the elderly to bring them from their homes to clinics and the care they needed are gone. In most of County Galway, where there is no public transport service, there is now only an ambulance service for emergencies and the chronically ill. How are the elderly to get to hospital for check ups and appointments? Any service that previously existed, with taxis and non-acute ambulance services, is now gone, as no finance exists for it.

The national ambulance service is based in Naas. If there are problems in rural areas, who should people contact? They will not get any service because local autonomy is gone. People said things would be great following the abolition of the health boards and that we would have a single, streamlined service. We now know that streamlining means no one is accountable at local level. Members of this House were members of health boards and could identify a person to get work done for a client. That cannot happen now, particularly with regards to the ambulance service.

Yesterday I asked the HSE headquarters in the west about the waiting time for home improvement grants for the elderly. A HSE official told me that people should not apply. I asked if the scheme had finished and he replied that it had not but all of this year's money had been used in the overspend last year and there would be no further funding. However, three weeks ago a Minister and a backbencher said there was so much money available for these schemes that the nursing homes were no longer under pressure to admit people because there were adequate funds to help them stay in comfort in their homes. There is not a penny in the western HSE region to help people stay in their homes, even in an emergency situation.

We have talked about the problems in the accident and emergency units, but the problems have extended beyond that. Elderly people cannot access an ambulance service or access funds to help them upgrade facilities in their homes to help them stay home. The paltry effort to provide a home care service is unbelievable. In the past the service amounted to a few hours, but it has almost reduced to minutes at this stage.

The Minister suggested the ten-point plan would solve these problems. However, the problem has moved out of the accident and emergency units into the community where it affects the elderly. It is important to take note of the statement made by an elderly person that it is the thought of going to hospital that is really frightening. This is the current situation and it is especially the case with regard to the elderly. They are afraid to even think about going to hospital.

I welcome the Minister of State at the Department of Health and Children, Deputy Brian Lenihan, to the House. The Fianna Fáil parliamentary party had a very good meeting with the Tánaiste, Deputy Harney, last week. The meeting went on for three hours and we raised several issues, including many related to accident and emergency facilities.

There has been much mention of University College Hospital, Galway, which is in the news locally and nationally. The Tánaiste announced an extra 32 beds for it some weeks ago, a positive development, although I agree we need even more beds. I am amazed sometimes that the two Galway hospitals are on call every second day and every second weekend. I do not know which day they are on call but I am sure the doctors do and that if people go to one to be assessed they are sent on to the other. This issue needs clarification.

As well as the need for more beds, the availability of doctors is important. In Galway, most of the specialties are dealt with in UCHG while Merlin Park is a fine orthopaedic hospital. However, there is a question with regard to its management and to the availability of doctors. These questions should be addressed. Let me give an example of the situation in Portiuncula Hospital in Ballinasloe. It is not a small hospital and it serves the midlands as well as the western region. Recently, Galway Bay FM visited it and noted it did not have the same problems with regard to queues or waiting lists, which is a positive sign of how the hospital is managing.

Doctors' letters are important and should mean something when a patient takes one to a hospital. They could help alleviate the current situation where many people come straight to accident and emergency units. Deputy Kenny had some interesting points to make in this regard.

Senator Feeney addressed some of the issues I intended to raise, in particular the issue of getting fines from people who must already pay €60 to attend the accident and emergency unit. The Fine Gael Party leader, Deputy Kenny, used the phrase "weekend warriors"— an unfortunate phrase — when referring to how to deal with them. The situation is difficult. Sometimes gardaí must be called when patients or their friends are aggressive with staff. The matter must be addressed.

It is interesting that people who receive a service in our hospitals show a high satisfaction rate of up to 90%, while over 90% show a high satisfaction with their general practitioner service. This is very positive. Senator Feeney suggested we should have a dedicated unit for children. That is important.

Last week the Tánaiste spoke about the problem of the out-of-hours service, particularly in north Dublin. I pointed out that there is also a problem in rural regions with regard to this service — Westdoc in the western region. The area covered by Westdoc is too large. Westdoc doctors from Roscommon and Mayo serve the people of Galway. This is unacceptable. We should have a Westdoc cell in the Mountbellew region, quite a large region. When we had a rota of approximately five doctors, we were probably spoiled for choice. Senator O'Toole made the point that there is sometimes no medication in the doctors' bag. It is not good that when outside doctors come in to offer a service they do not find the proper medication available.

Senator Ulick Burke mentioned the ambulance service. One of the issues in the west is duplication of the services. In an emergency people sometimes phone the ambulance service and Westdoc. It is a case of which service arrives first. Galway city is supposed to look after rural areas but its ambulance service is so busy that it cannot deal with north east Galway. The Minister of State has been very good about providing cancer beds in Tuam. Perhaps he could give us a positive indication on the ambulance service, which has been at the top of the list for a long time. I understand €2 million would provide two ambulance crews to serve the Tuam and north Galway area. Tuam also needs a primary care unit, which could provide excellent backup for people who want to visit general practitioners. Galway, the second largest county in Ireland, has a bad service with regard to community hospitals. The Leas-Chathaoirleach's county of Mayo has far more smaller hospitals, which are essential when it comes to discharging people from the acute hospitals.

The islands off the Galway coast must also be considered. At the recent doctors' conference one doctor mentioned that it was proving difficult to replace her for her maternity leave. In my time on the health board we had a video link between UCHG and the islands, an interesting way for people to see their doctor.

The discharge of patients is a relevant issue with regard to housing aid for the elderly. We must ensure that if the elderly want to remain in their homes that there are schemes which will carry out refurbishments and repairs. Senator Ulick Burke is right that the allocation for Galway is already spent. The allocation for Mayo is under-spent, but it does not seem the system will allow us to move the surplus from one county to another. In the past people used to blame the health boards when one county got more than another. That is not the situation since the HSE took over the region of Galway, Mayo and Roscommon.

We need extra funding for the housing aid for the elderly scheme, which is a successful scheme and I will mention this to the Minister for the Environment, Heritage and Local Government this week. The only other scheme catering for the elderly is the essential repairs scheme. It is necessary to have such schemes so that people who want to stay in their homes can get work done through the local authorities or the HSE.

I thank the Minister of State, Deputy Brian Lenihan, for his work. As someone who has roots in the west, he is aware there are issues to be addressed. I and others have made many proposals. As long as they are practical and workable we will support them, regardless of the side of the House from which they come. If we put those proposals in place, we will have a better system. I hope more progress will be made in dealing with accident and emergency services in particular.

I call Senator Scanlon.

With the Acting Chairman's permission I would like to speak before my colleague, Senator Scanlon.

I presume that is acceptable.

I will be brief. I join with other speakers in welcoming the Minister of State, Deputy Brian Lenihan, and his officials to the House to speak on the important issue of accident and emergency services. Undoubtedly, there are problems in accident and emergency units throughout the country. There is little point in pretending that is not the case. Since 1997, the budget has increased from €5 billion to over €13 billion, almost three times what it was in 1997, and 40,000 extra people are employed in the health service. As Senators O'Toole, Feeney and other Senators said, if we said to somebody in 1997 that the budget will have almost trebled and that there would be 40,000 more people working in the health service in 2006, they would believe that all the problems that existed in 1997 would have disappeared. Sadly, that is not the case. I acknowledge the great efforts that have been and are being made by the Tánaiste, the Minister of State, Deputy Brian Lenihan, and the Health Service Executive but more needs to be done.

There are many reasons the accident and emergency units are in their current position. These include an increase in our population, people living longer, the unfortunate appearance of MRSA and the winter vomiting bug and the failure of the employees, particularly the consultants, to embrace change. My colleague, Senator Feeney, alluded to that in her contribution and to the major increase in the rates of alcohol and substance abuse, resulting in the crowding of accident and emergency units at certain times.

I did not hear Deputy Kenny's speech at his party's Ard-Fheis at the weekend but drunk tanks were mentioned. Senator Ulick Burke said one would not need a Ph.D to decide whether somebody was drunk. Perhaps not but one has to be an MD to know if there is something wrong with them. It is ludicrous to suggest that because somebody is drunk or under the influence of drugs they should not be treated for their injuries.

We did not say that. In fairness, that was never said. The Senator is worse than Senator Minihan.

I am well able to speak for myself. I do not need help from Senator Browne or any other Senator in regard to this matter.

The experience of accident and emergency units throughout the country is not all bad. There are some good examples where the service is working well. For instance, Waterford, Sligo and Kilkenny hospitals, about which Senator Phelan spoke so passionately, appear from reports to be working very well. In his contribution the Minister of State stated:

Last year, more than 1.2 million people attended accident and emergency departments nationally, an average of almost 3,300 per day. On average, 75% of these patients are treated and discharged without the need for admission to an acute hospital bed. There are 53 acute public hospitals in the country. Some 35 of these have accident and emergency departments, between ten and 15 of which have experienced consistent problems.

I regret to say the general hospital in my area of Cavan is one of those. It is important to point out that the problems can differ by hospital, and that is why the solutions must be identified on a hospital by hospital basis.

Senator Feighan outlined the unfortunate circumstances of his mother being injured at the Fine Gael Ard-Fheis at the weekend. I sympathise with her. It is not a nice experience for anybody to have their mother in hospital. My mother is currently in hospital. She took very ill three weeks ago while visiting a sister of mine in Belfast. I have visited her in Belfast almost on a daily basis at different times of the day and night. She is attending the Mater Hospital on Crumlin Road in Belfast and I want to pay tribute to the consultant looking after her and the staff of the hospital for the excellent treatment she is receiving. To gain access to her ward in coronary care, one must go through the accident and emergency unit and at no time during my visits at different times of the day have I observed any more than 15 people waiting to be seen. I inquired about this and discovered there are a number of reasons. There are a number of hospitals in various locations in Belfast — north, south, east and west. A triage nurse sees the patients when they arrive and she decides the department to which they should go. Patients are sent to various departments in the hospital depending on their illness. That is something on which we should concentrate and the Minister of State mentioned the possibility of investigating it.

Cavan General Hospital is experiencing some difficulties but only in the accident and emergency unit. I urge the Minister of State and the Tánaiste to consider the possibility of better co-operation between Enniskillen Hospital and Cavan General Hospital to ensure they could deal with emergencies from the west Cavan region in future. I welcome the fact that the Health Service Executive recently informed me and my colleague, the Minister of State at the Department of Agriculture and Food, Deputy Smith, that the planning brief for the development of an additional 21 beds and a fourth theatre at Cavan General Hospital will be put out to tender in June of this year at a total cost of €7 million. I hope that will help alleviate the difficulties being experienced in accident and emergency in Cavan.

The proposal to provide a new modular building for the cardiac rehabilitation outpatients department at the hospital is being progressed. The provision of this building will in turn facilitate the conversion of a five bed ward for inpatients, which will also help alleviate the current situation in the accident and emergency unit of the hospital. I take this opportunity to pay tribute to the staff of the hospital — the consultants, nurses and other staff — who do a fine job.

The Minister of State may recall that prior to the Easter recess I raised on the Adjournment of the House the position in regard to Hume Street hospital, known as the Dublin skin and cancer hospital. I mentioned on that occasion that a 31 bed ward in that hospital was closed at the end of August 2005, allegedly for insurance reasons. I again take this opportunity to appeal to the Minister of State to make contact with the Health Service Executive on this matter.

Hundreds of people throughout the country who suffer from severe forms of psoriasis and eczema have no option but to visit accident and emergency departments from time to time because of the closure of beds in Hume Street Hospital. They must queue to be seen by staff to obtain some relief from their ailments, which can become severe at times. On their behalf, I implore the Minister of State to try to ensure that some beds in the new dermatology unit proposed for St. Vincent's Hospital are ring-fenced for those with severe forms of psoriasis. I thank the Minister of State and the Tánaiste and Minister for Health and Children for the work they have done and in which they are engaged. I have great faith that, given time, the situation in those accident and emergency departments which are experiencing difficulties will improve.

I am glad to have the opportunity to comment on accident and emergency services, particularly in my home county of Sligo. I am sorry to have missed the full debate. I understand that the problems facing Sligo General Hospital are not as serious as those facing major hospitals in Dublin. I welcome the fact that changes are being introduced by the HSE and that the executive is developing specific time-based targets in respect of accident and emergency services and delayed discharges. One of the most significant complaints people have is the length of time they must wait to be examined. Even in Sligo General Hospital, a person can sometimes be lucky enough to be seen and discharged within two hours, but, at other times, he or she can be forced to wait between six and ten hours. It depends on the number of people presenting for treatment and the seriousness of their complaints. I am referring to people who come to accident and emergency departments with letters from their doctors. I have heard of widely varying cases.

I wish to put on record my appreciation of the work done by staff in accident and emergency departments. In June 2005, as I drove into Sligo, my sister telephoned me to tell me that her good friend and neighbour, who was a widowed grandmother, was involved in a head-on collision with another car as she drove her three young grandchildren home from the seaside. The first reports were very serious. The road was blocked and three ambulances were called to the scene. The three children, who were aged eight, ten and 12 years of age, were rushed to the hospital and their grandmother was also seriously injured. I rushed to the hospital to see if I could be of any assistance because the injured people were very close friends of mine.

I could not praise the accident and emergency staff at that hospital highly enough. It brought home to me the fact that these people work at the coalface. They do not know what kind of problems, such as serious road accidents, they will face. I was struck by the way in which the staff at the hospital helped the family, all of whom have thankfully recovered. One of the injured children was transported to a hospital in Dublin, while another child was transported to Galway. The grandmother made a full recovery. Nobody fully understands or appreciates the work carried out by accident and emergency staff, their commitment and the service they provide. I refer to both nursing and administrative staff. The administrative staff could not have been more helpful when the father of the injured children arrived at the hospital. The work carried out by accident and emergency staff is unbelievable and no amount of money could adequately compensate it.

The issue of bed shortages was debated at our group meeting. I was a member of the North Western Health Board a number of years ago during which time the board ran a pilot scheme involving caring for elderly people at home. A subvention was provided to elderly people to allow them to pay someone to care for them in their own homes. We should possibly examine such a scheme because it would relieve bed shortages. I understand that the problem in accident and emergency departments in Dublin is caused by the fact that people currently occupying beds could go home if they had someone to look after them. Elderly people wish to be cared for in their own homes and we should do everything in our power to ensure that this can happen.

People cannot afford nursing home care because it is expensive. I am aware that the Government spends a considerable amount on nursing home subventions. This money should be directed more towards care in the home and a subvention large enough to make it worthwhile for an elderly person to employ someone to care for himself or herself and ensure that he or she can remain at home should be introduced.

I welcome the Minister of State to the House and compliment him on the ongoing work carried out in the health sector. When one examines the total figures in accident and emergency departments, it is clear that great credit is due to those who have ensured that a considerable number of people are being cared for in accident and emergency departments. Speaking as one who served on a health board for a considerable number of years and often visited hospitals and accident and emergency departments, I am struck by the changes that have taken place and the changes the Department of Health and Children has been forced to introduce in accident and emergency departments.

A few years ago, accident and emergency departments cared for people who were injured or required medical attention. The scene has changed to the extent that security is a major cost in accident and emergency departments. Hospitals are forced to install cameras to make accident and emergency departments more secure. I support the call by a number of speakers today for charges to be introduced. A range of different accident and emergency charges should be introduced to distinguish between genuinely injured people or those injured in road accidents for which they bear no responsibility and other people who attend at accident and emergency departments. The gardaí are regularly called to accident and emergency departments to protect staff and patients because of the actions of people who, in many cases, should not be there.

The issue of care of the elderly and the attendance of elderly people at accident and emergency departments has been raised. I have encountered cases which involved patients with multiple sclerosis — a disease which can, unfortunately, strike at any age — who cannot access long-stay care because they are under 65 years of age. I ask the Department to re-examine this issue because these people require regular attention and, therefore, regularly attend accident and emergency departments because they cannot access full-time, long-stay care because of their age. I encountered one case involving an individual who was seriously ill with multiple sclerosis and attended accident and emergency departments for 11 years because they could not access long-stay care. This person required intensive nursing care which, unfortunately, placed considerable strain on other members of the family, who were forced to leave work early to come home to care for the person in question. Using age as a criterion for entry to a nursing unit discriminates against a range of patients.

The Department is developing different GP services and such services are very good in the midlands. In some cases, it is not patients' general practitioners who are present, rather GPs who are filling in. They will not take any chances because of litigation and so on and will send patients to accident and emergency units. Often, those patients hold up that system.

I compliment the nurses and doctors in accident and emergency departments on their excellent work. At Christmas, I was an accident and emergency unit patient in two hospitals, Tullamore General Hospital and Tallaght Hospital. The latter was very busy but the staff gave the best of care and attention and are due much credit.

With the increase in the size of our population, we will never get the situation perfect, but significant improvements have been made. Many extra services have been brought on stream in many hospitals across the regions. We can never please all of the people all of the time but we are doing a good job. I apologise for exceeding my time but I compliment the Minister of State, his officials and the frontline professionals on their work.

Senator O'Toole uttered words that characterised the spirit of the debate when he said that political blame cannot be attached to the position obtaining in accident and emergency departments. However, this does not mean that political responsibility should not be taken and exercised. If one point has been made loud and clear by this debate, it is that the conditions prevailing in our accident and emergency units in public hospitals are a reflection of the underlying condition of our health service. If there are difficulties, they stem from a varied number of causes, which must be addressed.

The figure of 1.2 million persons attending accident and emergency departments on a national basis mentioned by Senator Moylan, an average of nearly 3,300 per day, is worth reflecting on. When opening the debate, I pointed out that 75% of these patients are treated and discharged without the need for admission to acute hospital beds. This is a tremendous record of service and delivery by all of the health service professionals involved, of whom Senators were unanimous in their praise. By and large, Senators also took the view that difficulties must be addressed and suggested various remedies.

The matter of step-down beds was raised. Clearly, if one wants to improve conditions in accident and emergency units, which are frontline posts in the public hospital service, one must examine the issue in terms of how people enter the units, how they are cared for therein and how they can be discharged if they require further treatment in the public hospital system. These are the different elements that must be tackled if one wants to get the accident and emergency unit situation right.

A number of Senators touched upon the fact that everything we can do to develop our community services, such as doctor and primary care services, is essential. The HSE has been insistent on this point. If one does not build up one's primary services and have them as the first line of defence there will be a crisis in accident and emergency units. For this reason, the Tánaiste has attached much importance to primary care and its improvement. She is anxious to make an announcement in this regard and have a roll-out in north County Dublin this summer, for example.

We must ensure that patients' first port of call is a general medical service, a service that is readily accessible to them. There are new models of primary care provision. Some have been developed on a public basis while others have been developed on a private basis. Not only do they bring together the general practitioner side of medicine, they also bring together other frontline disciplines involved in the patient's primary care in the community. The Government is committed to the development of these services, which is a vital need if we are to tackle problems in accident and emergency departments. We must examine how patients are cared for in these units and determine what initiatives can be taken to deal with minor injuries on a separate basis, including triage to ensure that patients are treated in as efficient a way as possible by the person who should be treating them, which was mentioned by numerous Senators. This is the second stage.

An element of controversy was introduced to this subject by the leader of the Fine Gael Party, Deputy Kenny's, suggestion in his presidential address to his party's Ard-Fheis at the weekend that some form of drunk tank should be constructed to accommodate persons who arrive at units in an inebriated or intoxicated condition. This point gave rise to substantial concerns that were referred to by Senators Daly, Moylan and others. I join with them and others who saluted the courage of the nursing and medical staff of accident and emergency units in the face of the physical threats they must endure. Senator Moylan outlined the steps that public hospitals have needed to take to install security cameras to survey the scene and provide a high degree of protection. It is a sad comment on the standard of behaviour that obtains in Ireland today.

To state the problem is not always to state the solution, which I accept we must find. I have taken an interest in this matter. The tank option as canvassed by Deputy Kenny is a non-runner. It may have generated some interesting headlines and public discussion but it is not an option. The ethics of the medical and nursing professions have always been clear — they will treat any patient who presents with physical or mental difficulties irrespective of his or her condition. One will not be able to persuade the professions to make a judgment about whether a person should be in a drunk tank or an accident and emergency unit. They will not make this distinction because it is against their ethical standards. They would not accept——

Has the Minister of State ever been to an accident and emergency department at 3 o'clock on a Saturday or Sunday morning?

The Senator had an opportunity to speak on this debate. I am well aware of conditions in these units and acknowledged a few moments ago that we must devise appropriate solutions. Examining the charging structure, to which Senator Moylan referred, is an option to which I am open.

We should be clear on one aspect — the medical and nursing professions are not prepared to stigmatise patients because they are inebriated. They are caring professions and must care on an equal basis for patients who arrive for treatment. One speech at an Ard-Fheis producing a magic carpet will not change this position. We must all work with this position. We all know the reality. I made it clear that we must review and address the problem.

There is a 75% discharge rate into the community. Some patients cannot obtain treatment in the accident and emergency units.

The Minister of State's time has concluded.

I thank the Acting Chairman for his indulgence. Such people will require a public bed in the hospital. Again, there was considerable discussion as to whether we have an adequate number of acute beds. However, there are now more than 13,255 beds in public acute hospitals, which constitutes an increase of 1,528 beds since 1997. I am glad to have the opportunity to put that figure on the record because it is not frequently mentioned in either public debate or in print. Clearly, the management of such acute beds is in turn a vital issue. The point was made by all sides of the House that a greater provision of step-down beds is required.

Hence, there is a great deal of practical agreement, irrespective of all the political smoke which members of the public are obliged to witness with regard to this issue. The Government has invested and is prepared to invest resources in this respect. It must also manage the major logistical issues involved. I welcome this debate and I thank Members for the spirit in which it was addressed.

When is it proposed to sit again?

Tomorrow at 10.30 a.m.

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