Emergency Department Waiting Times: Statements

I welcome the Minister and ask that he forgives that little disturbance.

I thank the Members of the Seanad for the opportunity to make a statement in this House today.

Trolleys and waiting lists are critical measures of how our health service is functioning and in recent weeks I have referred regularly to the pressing need, once and for all, to break the vicious cycle that leaves patients waiting in unacceptable circumstances. There are four fundamental issues to be addressed to break this cycle. These fundamental issues are four priorities of mine for 2018: bed capacity; implementing reform through the Sláintecare report; recruitment and retention of health care staff; and making that decisive shift to primary care a reality, once and for all.

As well as dealing with emergency department performance, I will provide an update on some of the short-term, medium-term and longer-term measures I wish to see implemented in order to drive improvement in how we deliver our health services and promote better health outcomes for the people.

At the outset, I acknowledge the distress for patients and their families, and the impact on staff, caused by cramped and overcrowded conditions in some of our hospital emergency departments. There is no doubt that we are facing increased demand for health services. A total of 1.3 million people attended emergency departments last year and more than 330,000 were admitted to hospital from emergency departments during the same period. This represents an increase of 2.3% in emergency department attendances and a 2% increase in emergency department admissions, when compared to 2016.

Despite the intensive efforts of staff, management and the HSE through the course of the winter, since the beginning of January this year we have seen a rise of 8.4% in the number of patients waiting on trolleys. This reflects an increase of 5.6% in the numbers attending emergency departments - that is 1,247 more patients being seen - and an increase in delayed discharge figures as compared with the same period last year.

Each winter, the system must also deal with the increased demand for services due to the prevalence of the flu, which is currently at its height. Our system is also working hard to grapple with the challenge of infection prevention and control, specifically the emergence of virulent antibiotic-resistant bacterial strains or superbugs.

This has been a difficult January for our hospitals. Let me share something with Senators that they may not have heard. In the face of increased demand, staff across the State continue working to improve performance and the overall number of patients on trolleys over the whole of winter so far - from 1 November to 31 January - is actually down almost 1,500 year on year. This is a result of significant progress made by our front-line staff, especially in the November when 1,864 fewer patients were on hospital trolleys, and in December when there were 447 fewer patients on hospital trolleys. On a bad day in a bad month we will always see it well commented on in this House and we always see it well commented on in the media. We do, however, also have to comment on and acknowledge the progress that staff have made, particularly the progress made in November and December. Despite their incredible efforts and despite the extra resources we provided, when it reaches the tipping point in January it is very clear to me that we have a health system that is not an appropriate size or model. Despite the good work and progress made, despite the fact that fewer patients were on trolleys in November and December and despite the fact that more patients had been seen in hospitals, when we reach that tipping point we see that we do not have a health service that is the appropriate size or model for our demographic composition and our growing population. This is why I bring the Senators back to the four key areas of reform on which I want to see progress this year.

I assure the House that the Government is committed to further investing in health and to increasing the health budget. That investment is having an impact. I do not accept the logic that when funding is increased to the health service we do not see tangible benefits. Tell that to a man or woman who got an extra home care package as a result of the increase investment, or tell it to a man or woman who has seen the benefit of the more than 170 additional beds already opened this year in the health service or tell it to the person who has seen the benefit of the extra transitional care. While there is a lot more to do, the benefit of the extra investment has seen 170 additional beds already opened this winter: 22 in St. Vincent's Hospital; 25 in Our Lady of Lourdes Hospital, Drogheda; 17 in University Hospital Limerick; 28 in University Hospital Galway; 20 in Beaumont Hospital Dublin; 23 in St. James's Hospital Dublin; 24 in the Mater Misericordiae University Hospital Dublin; and 11 in Naas General Hospital. Further beds will open throughout 2018, including at St. Luke’s in Kilkenny, University Hospital Waterford and Cork University Hospital. In addition, new critical care beds will come on stream this year in Cork University Hospital and the Mater in Dublin.

Other capacity developments funded this year will include the new emergency department in Our Lady of Lourdes Hospital, Drogheda, which will come on line in 2018, and the development of a modular build for South Tipperary General Hospital, which I hope could be a model for short-term modular interim measures at other locations around the State. We will also see the expansion of services at the Roscommon medical assessment unit this year.

Bizarrely, even in times of great prosperity - and long before I was in Government - Ireland had a policy of reducing the number of beds in the health service. Ireland now has fewer beds in its health service than in the early 2000s. We saw a situation where the number of beds decreased in 2007, decreased in 2008, decreased in 2009 and decreased in 2010. Since the Taoiseach was the Minister for Health, and in my time as the Minister for Health, we are increasing the number of beds in our hospitals, but quite frankly it is not at an adequate enough pace.

We have to do more in respect of additional capacity and we must do it more quickly. This is why last week I was delighted to bring to the Cabinet - and to publish for everybody to see - the health service capacity review, which outlines the projections of demand and capacity for our health services now and out to 2031. This kind of analysis is integral to future planning. We can all tell the important story of our own locality and if people believe they need more beds in a particular part of the country. It is very important, however, to have an evidence base. It is important that we look at international best practice and look at the impact on hospital bed capacity of moving more towards primary care.

It is important that we do in health what we have done in the Department of Education and Skills and other Departments. In that context, we must link the number of beds and the size of our health service to our population and the need that exists. The Department of Education and Skills has done a very good job in recent years in that every year it knows that a certain number of children will require school places and it matches largely that demand with the provision of schools and teachers. We need to do that in the health sector. The heath service capacity review, which was internationally peer reviewed, provides us with a solid evidence base which will now inform future investment and policy decisions. It is clear from that report that we will need approximately 2,500 additional acute hospital beds over the period out to 2031 and that we need to front-load some now and deliver some in as quick a manner as possible. I am committed to doing that but it is also clear that if we just do that and do not reform the health service that it will not be adequate enough.

That brings me to the second key reform, Sláintecare, I would like to highlight. One of the first actions I took upon becoming Minister for Health was to work with the Opposition to establish the all-party Committee on the Future of Healthcare, chaired by Deputy Róisín Shortall. That committee worked for almost a year to come up with a plan for the future of the health service. What is unique and important about the report it produced is the fact that it enjoys support from across the political spectrum, and this should not be squandered. Political consensus is a great achievement. Perhaps it is a creature of a minority Government but it is one that I am committed to ensuring is not wasted. The Government has affirmed its commitment to implementing a significant programme of reform, as outlined in the Sláintecare report. We had a special Cabinet meeting on the issue in Cork a few months ago. I expect to present a response to the report along with a proposed detailed implementation plan to Government very shortly. This will set out our ambitions for the next decade and will put concrete plans in place for the immediate years ahead. Effectively, we will have an action plan where the Members will be able to see what we have committed to doing, when we have committed to doing it by, who is responsible for doing it and how that is progressing. Importantly, this work, in line with the recommendations of the report, will be overseen by a new Sláintecare programme office. The Members will have seen in the national newspapers that the recruitment process, under our Public Appointments Service, has commenced for an executive director for this office and that is expected to be completed by April of this year. I have already taken a number of actions on foot of the Sláintecare report. In line with it, I have established the Donal de Buitléir group to carry out an independent impact assessment of how we would remove private practice from our public hospitals. This is under way in line with the report and that group will conclude its work later this year. I have prepared legislation to introduce a governing board for the HSE to strengthen performance and accountability in order that people who are being funded to deliver our health services have a structure of accountability and oversight. I have also announced a consultation process on alignment of our hospitals groups and community health organisations. Therefore, we will end the siloed way of delivering health care. We all talk about wanting to deliver integrated health care but we have separate structures for primary and social care and for our acute hospitals. I have also taken a number of measures in regard to Sláintecare such as having a dedicated primary care fund, dedicated waiting lists funding, reducing the cost of prescription charges and reducing the cost of the drug payment scheme. These actions are important first steps in a long-term reform process and demonstrate the Government’s commitment to driving real change and reform in the coming years.

I want to touch on two issues, which I am sure will come up in this debate. We can have all the beds we want in the health service but we need to staff the beds. I am very pleased that the public sector pay agreement was accepted by all our health unions and that the benefits of the agreement will now be seen in the pay packets of our health care staff. I am also conscious that more needs to be done. I am conscious of the fact that we see particular recruitment and retention challenges in the health care sector. That is why I am particularly pleased that myself and the Minister, Deputy Donohoe went to Government and got approval to have our Public Sector Pay Commission do a specific piece of work on the health sector on recruitment and retention challenges. That will give all our representative bodies and everybody else a chance to feed into the process with respect to what we need to do to keep Ireland competitive and attractive in terms of recruiting and retaining our health care staff. That work is under way.

On general practitioners, GPs, which I know is an issue close to the hearts of many people here. Senator Swanick speaks about this issue with a great degree of expertise. We need to deliver a new GP contract. To do that, we need to look at how we can unwind the Financial Emergency Measures in the Public Interest, FEMPI, legislation. I now have Government approval to engage with GP organisations on the unwinding of FEMPI and I expect that process to commence very shortly. We need to have a conversation about how we resource general practice. There are matters that I need General Practice to do, matters that are currently done in the acute hospital setting that could be done in primary care. I know that GPs are up for that but they want to know that the model is sustainable and that it will be resourced. There is great deal more I could say, to some of which I will return in my closing statement. I want to hear the views of Senators on all sides of this House. We know the challenges in our health service. I believe we know what the solutions are, namely, bed capacity, Sláintecare, recruitment and retention, and moving more to primary care through community nursing and a new GP contract. They are my priorities for 2018 and I look forward to working with all of the Members to advance them.

I call Senator Swanick and he has eight minutes. Does the Senator wish to share time?

Yes, I wish to share time with Senator Gallagher.

What way does the Senator wish to split the time?

I will take six minutes and Senator Gallagher will have two.

Is that agreed? Agreed.

It is timely we are having these statements on emergency department waiting times given that our health system hit a new low on Monday last. The Euro Health Consumer Index 2017, on which I understand people place different weight, ranked Ireland among the worst in Europe for waiting times for health care. Ireland is now in 24th place, down two since last year's index. The mismanagement of our health system is now being blatantly exposed.

In 2011, the former Taoiseach, Deputy Enda Kenny, vowed to bring to an end the overcrowding crisis. Seven years later, however, the problem is worst than ever with record breaking numbers of patients languishing on trolleys across the entire country. This has been a persistent problem but the Government has simply failed to take the required steps to tackle the crisis.

During a meeting of the health committee last year, I mentioned to the Minister the progress Macedonia has made by implementing the e-health platform, Pinga. Macedonia has reduced hospital waiting times to approximately six months by means of a simple online live system. GPs can go online during a consultation with a patient and access consultants' diaries, see what physicians have vacancies and refer appropriately. That system can also be used for diagnostic scans. In 2013, Macedonia was placed 27th in the Euro Health Consumer Index rankings. In 2014, it rose to 16th place. I asked the Minister at that time if we could look at adopting or investigating such a system. At the time the Minister said:

I will certainly look at the suggestion regarding Macedonia. We need all the suggestions we can get on this. If there is good practice, we will look at it.

I understand that these matters cannot be dealt with overnight. However, the Minister has asked for suggestions and they have been provided.

I do not believe that the problem with our health system can be the subject of an easy fix but it is infuriating to see areas where improvements could and should be made but in respect of which action has not been taken. In my district, Mayo University Hospital was on course to have a piloted scheme for modular buildings last February. Many local authority members, including councillor Michael Loftus, have contracted me about this. The idea is that modular units would be put in place as extensions to existing emergency departments in some hospitals in order to relieve pressure. This has not happened. In fact, the plan, which was much sought after, appears to have fallen off the face of the earth. Mayo University Hospital has used its budget wisely. It has struggled on and been frugal with what it was given. As a result, it appeared to have been punished through the withholding of the promised modular buildings. Can the Minister advise me when it can expect those modular units to be delivered? This is another solution to chronic overcrowding of an accident and emergency department but it has not been acted upon.

There is an urgent need to increase the number of beds available in our hospitals to help ease the burden. Ireland has one of the lowest numbers of acute hospital beds - 2.4% per 1,000 of population compared with an average of 3.6% per 1,000 in 2015 - in the OECD . We need to see an increase in the number of beds in our hospitals. That is the only way overcrowding will be tackled in the long run. The Irish Nurses and Midwives Organisation, INMO, trolley watch-ward watch figures for the first week in January showed overcrowding records being broken. The daily average so far this year is 560 people on trolleys. This is the last day of January and I hope that it will be the last day of record breaking figures.

Currently, the HSE target for patients in accident and emergency departments to be seen by a doctor is six hours. That is our target but in reality it should be an absolute limit. International research suggests that there is an increased incidence of adverse outcomes for patients who have been in emergency departments for more than four hours. Long waiting times, that is, greater than six hours, should be an exception; it should not be the norm.

I will conclude with a quote from the Irish Association of Emergency Medicine which states:

This was always going to be how 2018 started in our EDs. Everyone, from the Minister for Health to the clinician on the frontline, knew it - yet little of substance was done by the DoH and the HSE to address it.

Knowing what I know and having spoken to people on the front line, I can only conclude that people's medical outcomes are being compromised. People are dying as a result of chronic overcrowding in our hospitals.

I do not say that lightly, but it is a reality. I would be grateful if the Minister would revert to me regarding the situation at Mayo University Hospital.

I will be brief. The Minister of State, Deputy Jim Daly, was in the House last week to respond to a Commencement matter I tabled in respect of this issue. He talked about new thinking and new ideas to try to tackle this problem. He said that if we continue to do what we have always done, we will continue to get what we have always got. He put his finger on it. We need fresh thinking on this issue. I raised it in the context of taking a fresh look at smaller hospitals - I had Monaghan Hospital in mind - and the role they could play in helping to alleviate the overcrowding being experienced in accident and emergency departments throughout the country and in my region of Cavan and Drogheda. This follows comments made by Professor John Hyland, president of the Royal College of Surgeons in Ireland. He said that the normal response during a trolley crisis is to cancel non-urgent and elective surgery. He spoke about the repercussions of that and the heartache, pain and suffering people go through for years only to get a telephone call in the week they are preparing themselves for an operation to tell them it is cancelled. We cannot lose sight of that. He made the point that their conditions deteriorate so much that they end up in accident and emergency departments again, which brings us back to square one.

I asked the Minister of State, Deputy Jim Daly, to visit Monaghan Hospital and see what potential the facility has to offer. It has a state-of-the-art theatre that is not being utilised to its full capacity. It has what was an accident and emergency department at one time and is now a minor injuries unit. Again, it is the same size as the department in Cavan. I believe that campus could be doing more to help alleviate the problems being experienced country-wide. I wish to extend to the Minister the same invitation I extended to the Minister of State, Deputy Jim Daly. The Minister could visit with his colleague, hopefully in the not too distant future.

I welcome the Minister. I appreciate the work he is doing in the health care sector. It is a huge challenge given the large number of hospitals providing services. It is interesting to look at the figures. A total of 1.3 million people attend accident and emergency departments, which is 25,000 per week or 3,571 per day. Over 6,346 people per week are admitted to Irish hospitals through accident and emergency departments. Those figures represent the challenges we face.

We should also consider the demands that exist. In my area of Cork city and county, the population has increased from 410,000 to 542,000, a rise of 130,000 over the past 30 years. In that period, the number of beds in the county and city has decreased. As a result, there is a challenge to ensure that there is an adequate number of beds into the future by planning for a new hospital facility. Such a facility was proposed in the 1960s. The Fitzgerald report referred to two major hospitals for Cork, but the city only ended up with one. We are still trundling along with two hospitals, which have been there for over 100 years, trying to provide a service. As regards waiting times in accident and emergency departments, unless there is an adequate number of beds to be able to admit people and care for them the logjam in those departments will continue. I spoke to management at one of the hospitals over 12 months ago. At that time the hospital was cancelling 40% of elective surgery because the number of people over 80 years of age arriving at the accident and emergency department had increased substantially. That is due to the change in demographics that has occurred in this country. We must plan and cater for that. One good message is that people are living longer. Life expectancy has increased by 2.5 years since 2000, so something is being done correctly in health care. However, much more must be done.

Another issue for accident and emergency services is that the GP contract must be prioritised. We need to get the people who are working in the community to take on an additional workload. They will not take it on unless the necessary support is in place. I can give examples. A GP approached me over two years ago and told me that his practice was offering to provide a service for people who have haemochromatosis. Those people are currently going to hospital outpatient departments. He and his colleagues were prepared to provide a service for those patients, and it is a service they could provide. They offered to set it up, but two years later no progress has been made on it.

The position regarding nursing homes is similar. I have a big issue with the care of people in nursing homes. It relates to where caution is being exercised, and rightly so if the GP is concerned, but admitting an elderly patient from a nursing home through an accident and emergency department should not be the way to deal with it. We should have connectivity between nursing homes and geriatric services in the hospitals. That is something we must do. We also must do far more to help GPs deal with the concerns that nursing homes have about the people in their homes. Rather than bringing them to the accident and emergency department, if enough supports were given to GPs they could look after many more people in the nursing homes. It is all about ensuring that there are adequate supports and remuneration so the GPs can provide the service they currently find it difficult to provide.

Recently, the HSE suggested allowing GPs to provide gynaecological services. The GPs who contacted me said there was no problem doing that but pointed out that it is not covered by the medical card system. That is another area where services could be provided by GPs. Another issue, and I raised it in the health committee this morning, is not properly using the people who have skills. I gave the example of people who have trained up in an area within the hospital system and for one reason or another, be it family commitments or other pressures, they have decided to opt out. I was referring in particular to two doctors who had trained up, one of whom had six years in obstetrics and gynaecology and the other who had nine years. They dropped out of the system to go back to working as GPs. There is no reason that they should not be able to provide an additional service in obstetrics and gynaecology for the community, but they are not allowed to do that under the current GP system. This is something we must work on, where people have huge expertise but are not able to use it at the coalface in the community because the system does not allow them. We must start engaging on that matter. That is why it is so important we put a new and innovative GP contract in place.

I have a final comment with regard to building hospitals. It was 1998 when a major hospital was last built in this country. In the ten years between 1998 and 2008, when there was plenty of cash, not one was built. This is something we must ensure does not recur.

I thank Senator Colm Burke for sharing time. The Minister will have a fair idea of what I wish to raise. It is the urgent need to build a 96 acute bed unit in University Hospital Limerick. The Minister is aware of that. A new accident and emergency department has opened and it is making an enormous difference, but there is still a bed capacity issue. The new accident and emergency department consistently has the highest number of people on trolleys. That is mainly related to the lack of bed capacity. It is a historical legacy from the reconfiguration of the services when Ennis, Nenagh and St. John's hospitals were closed in 2009 by a previous Fianna Fáil Administration. The Teamwork consultants report on reconfiguration stated that there were to be 136 co-location beds located on the grounds of University Hospital Limerick.

That never came to pass. Consequently, from a situation where we had 35 accident and emergency beds in total between the four centres, University Hospital Limerick, Ennis, Nenagh and John's, our number was reduced to just 17 bays in one accident and emergency department. We now are up to 35, which will be welcome, but we still have the lack of beds.

The Minister will be aware that I succeeded last year in getting €100,000, both working with the local HSE management of University Hospital Limerick and through the Minister and the HSE, to allow the design work to get under way on this 96 acute bed unit which will be located adjacent to the new ED on the grounds of University Hospital Limerick. I have two requests for the Minister, that this 96 acute bed unit will be included in the capital plan that is shortly to be announced and that funding will be provided to enable construction to get under way. Has the Minister looked at other means, by way of modular facilities, to increase bed capacity in the region because I believe we in Limerick are relatively unique nationally in that our major issue is bed capacity and I want to see the 96 acute bed unit built on the grounds of University Hospital Limerick as quickly as possible?

I wish to share time with Senator Mac Lochlainn.

Does the Minister realise he has been gagged? I need to bring it up again. The Minister has been gagged by this House, in particular, Fine Gael and Fianna Fáil Senator. An hour ago, supported by my colleagues and Senator Kevin Humphreys, I tried to get the Minister to answer as to why no parents were given a voice at the table for the national steering group on children with complex medical needs and the development of policy but, unfortunately, the Minister has been gagged. The Leader stated he did not want to play political football with this. He has actually done that, as have Fianna Fáil Senators who went against their own sense of what is right in allowing participation by parents, who are the experts on this. The Minister does not have to answer it. I will resubmit the amendment to the Order of Business on Tuesday next but I am so unclear as to why it was not allowed. I still do not know. That is probably due to my naivety but also the political football that is being played out in this Chamber by Fianna Fáil and Fine Gael Senators. Shame on them all.

Returning to the statements on ED waiting times, a fortnight ago in the Dáil, Members recognised the absolute severity of hospital overcrowding, including emergency department overcrowding, when a detailed comprehensive Sinn Féin motion was passed noting the current state of the health care system, the causes of this chaos and real solutions that the Minister should address.

The shocking statistics around emergency department overcrowding include that there could be between 300 and 350 excess patient deaths each year due to the trolley crisis and the overcrowding. The scandal of patients waiting on trolleys was declared an emergency by the former health Minister, Ms Mary Harney, in 2006, when the trolley count reached 469. Twelve years later, on 2 January 2018, 677 patients were left on trolleys - the highest number ever recorded. Throughout 2017, almost 100,000 patients were left to spend a night or more on a trolley in hospitals throughout the State. I could go on and on.

I have been watching the situation carefully in my area of Dublin South-Central on behalf of the community. In my local hospital, St. James's, in 2017, a total of 47,500 patients attended the emergency department. A total of 2,178 of these were left on trolleys. Yesterday, there were 18 patients waiting on trolleys in that hospital. In reply to a parliamentary question, the HSE outlined that in the event that all possible escalation steps have been exhausted and overcrowding persists, a package of measures, referred to as the full capacity protocol, is to be activated. The beds given are not always the appropriate beds. St. James's Hospital initiated full capacity protocol in February of 2017. That is unacceptable.

Even the most vulnerable children, including those with complex medical needs, are not safe from the ED chaos. A total of 34,735 children attended the emergency department of Our Lady's Children's Hospital in 2017. They are not being seen to with the care that they deserve. Nine were on trollies yesterday. We need more beds. There are capacity issues.

There is a curiosity that perhaps the Minister could sort out for me. In St. James's Hospital, it appears there has been a significant decrease in the number of beds over the past year. In January 2017, the HSE advised me that there were 837 inpatient beds and yet a parliamentary question reply that came in yesterday states that as of September 2017 there were only 686 inpatient beds, an anomaly of 151. I am not sure if that is correct. Is it anything to do with the development of the national children's hospital? If so, it is no wonder we are seeing an increase in waiting times.

I have long stood in this Chamber as a advocate of a community-owned approach to our health and well-being. There is a certain level of attendance at ED which does not need to be there simply because there is no other place to go. One such pertinent example is the presentation of psychiatric patients in the emergency departments. The 2017 review of the National Clinical Programme for the Assessment and Management of Patients Presenting to Emergency Departments following Self-Harm, argued that "...a high number of patients without physical health needs have been presenting to the ED. They would be better assessed by a Community Mental Health Team."

This is the age-old call from me, Mental Health Reform and others for the desperate need for 24/7 crisis intervention and home-based management mental health teams within the community run for and by the community. The lack of this service is damaging our people and placing them in an already full-to-the-brim emergency department which is inappropriate and dangerous on all levels.

The Minister will be aware of recruitment and retention. Unfortunately, what we are spending on nursing budgets is going towards private health care. Our Lady's Children's Hospital in Crumlin spent five times the entire annual agency budget for 2013. We need a great deal of step-down facilities. I suppose the Minister just needs to get on with it.

I want to put on the record my absolute concern, and worry from a clinical perspective as a nurse by trade, at how dangerous this emergency crisis is. The INMO called it a humanitarian crisis yesterday. Over half of the population who cannot afford private health care are the ones at risk of this health care chaos and we need to address that.

Lastly, Senator Swanick is well able to represent GPs and medics. My emphasis is on the largest sector in the health services. There is no competition here. I refer to the nurses. We really need commitment to funding of the taskforce on nurse staffing to determine, on an evidence-based patient dependency scientific tool, the numbers of nurses required. It is at pilot stage. Can the Minister confirm its roll-out, the additional nursing posts required for increased capacity and the ratio of nurses to patients?

I would appreciate if the Minister would ungag himself and answer the question on having parents at the table for the national steering group on the complex needs of seriously ill children.

The Minister will be familiar with the situation in Letterkenny University Hospital. I can tell him that last year almost 5,000 patients in Donegal found themselves on trolleys at Letterkenny hospital. That is double the number of 2016. It is the highest number since INMO records began. There is a real crisis at the hospital.

There are so many stories every day but one story that sticks in my mind is that a 92 year old man gravely ill with pneumonia spent 23 hours waiting to get through into the hospital. There are so many other stories but that one really stood out. It is appalling. When we talk about 5,000, it is not just a number. That is 5,000 human beings who have not got what they needed from the health service. They were not given their dignity. That was their experience.

I say all of that because I am outraged to have learned recently that the €1.8 million applied for by the management of Letterkenny hospital last summer under the winter initiative was turned down. It was money needed to reopen the short stay ward, which is a 19-bed ward lying empty in Letterkenny hospital at a time of crisis. A full capacity protocol has been in place for almost a month in that hospital. That is the scale of the crisis. The staff, doctors and nurses work in impossible conditions and that is why that money was desperately needed. Will the Minister comment on that today and clarify why that money was turned down? Why is this 19-bed short stay ward lying empty at a time when it is critically important to have those beds available? It would avoid situations like that of the man who was waiting 23 hours and would take the pressure off the nurses and doctors who are performing a heroic service in very difficult circumstances.

Does Senator Grace O'Sullivan wish to share time?

I will facilitate Senator Murnane O'Connor by giving her a minute and a half of my time.

The Senator is caring. I would not do that for Fianna Fáil; I am not talking to its Senators at the moment.

The Minister swanned in here this morning to share with us something we may not have heard this winter, that is, that the number of patients on trolleys over the winter is down. In the month of December, the number on trolleys was down by 447. The Minister spoke about 170 additional beds being open this winter. He does not mention University Hospital Waterford. He says there will be beds open there but what criteria were used for the hospitals that were allocated beds? I ask that because last week I spoke on the Order of Business about the last days of Michael Gallagher, a citizen of Waterford city, who passed away in December at University Hospital Waterford. Mr. Gallagher’s children, Catríona and William, wrote an elegant, thoughtful and open letter to the Minister, which was informed by their abysmal experience in the last days of their father's life in University Hospital Waterford. Both Catríona and William have medical backgrounds; Catríona is a nurse in London and William is a professor of cancer care in UCD.

I recently met Professor William Gallagher to discuss the situation his father faced and the issues facing University Hospital Waterford, and all hospitals in Ireland. We talked about the true nature of the trolley crisis and that while we know the total number of people on trolleys at any one time, we do not know the average or total duration that each patient spends there. We discussed getting to the bottom of the existing Health Information and Quality Authority, HIQA, rules regarding maximum stays on trolleys and how the existing rules for people aged over 75 years are enforced. To solve the crisis in our health service and to prevent its annual recurrence, we have to know exactly what it is we are up against.

I want to focus as much on solutions. No more speeches are needed about how tragic the crisis is; we all now know this well enough. We do not need and must not repeat the endless cycle of decrying these endless crises every winter only for them to return the next year. The problem in University Hospital Waterford is that it is not a winter crisis, but a continual one. Even in the summer it is a big crisis in Waterford. I hear that from consultants. What is needed is solid solutions and that means changes, some of which will undoubtedly be difficult and uncomfortable. Over the past month we heard from health professionals working on the front line about what they think needs to change, including the way we handle diagnoses, the way referrals through accident and emergency are handled and the absence of more solid primary care paths in our non-hospital health system. It means reorganisation from ground level of how hospital admissions operate and it also means providing adequate resources for the expansion and reorganisation of our health system as laid out in the Sláintecare report. Getting new beds into operation in our hospitals involves not just money, but also training, employing and keeping medical staff, as the Minister referred to. This is a major challenge.

This week, I heard the personal story of a Waterford doctor, who was trained by the Irish university system and is now set to buy a house in Australia, where he can be assured of better conditions as a junior doctor and enjoy a much clearer career progression. To guarantee such conditions for our junior medical staff, we will have to examine the balance between the private and public work of our hospital consultants and the pay and conditions of their junior staff. One thing I have seen with dismay over the past month or two is resignation that this is just the way health care is and always will be in Ireland. We cannot accept it. We can and must do better, which means listening to patients and our regions, health care professionals and front-line staff and making it possible for them to deliver excellent health care services for all our people.

The Minister mentioned a parochial attitude but if it was a member of his family who had died recently, he would be talking about his town and his hospital. That is why I am talking about University Hospital Waterford.

I can only speak for my area of Carlow-Kilkenny. This year, the number of patients on trolleys in Kilkenny hospital was up. The staff are worn out. They are excellent and do a great job. Over Christmas, there was one particular unit where there were 44 beds but 52 people being cared for. They were on couches. That is how bad it was. We need to look at this because it is getting worse. I often wonder about figures and I have to question them at certain times. They do not add up when there is a unit with 44 beds treating 52 people.

People are living longer and the system is not catering for that. I visited people in Kilkenny hospital who were sick over Christmas. When they were on a trolley and got into a ward, they were in a ward with ten people; there could be six men and four women or five men and five women. It is at the stage where people do not have their dignity in hospital. The staff are working hard and trying to put many people into the wards, but people's dignity and pride are gone. They are sharing wards with strangers. Men and women are sharing wards. It is unacceptable.

The Senator should conclude. There are two more speakers.

I ask the Minister to look at Kilkenny hospital again. It does a great job but the staff and the doctors are put to the pin of their collars.

I will be sharing one minute of my time with my colleague, Senator Byrne. This is an all too familiar problem. It is something we - the previous Administration, the ones before, and this Administration - have been dealing with year in, year out. Hundreds of citizens across the country are without hospital beds. Their dignity, as Senator Murnane O'Connor said, is compromised. Staff are working heroically against a backdrop of extremely difficult situations and conditions to do their very best for the patients for whom they care. I have no doubt the Minister is working extremely hard to try to resolve this issue as all of his predecessors have. We all acknowledge that. There is no shortage of sympathy and expressions of regret about the experiences people have in our emergency departments up and down the country. We know the nuts and bolts of this issue are being addressed with additional resources and supports, although they are not growing at the rate we would like.

I can only speak with any great authority about the experience in my local hospital. I reassure my colleague from Limerick city that Limerick is not unique in the problems it experiences. In my local hospital, Our Lady of Lourdes Hospital in Drogheda, there are 18 patients on trolleys. That is significantly down from the number on equivalent days in recent years. There were 30 people being accommodated on trolleys yesterday.

The figures are as I have described. The reasons for that are manifold, but one reason sticks out; the lack of investment in new facilities and in hospital beds. The Government in which I served invested very heavily in expanded services and capacity for Our Lady of Lourdes Hospital. The Minister correctly points out that there are now additional acute beds in Our Lady of Lourdes Hospital and additional beds being made available this year, but that is nowhere close to what is required to address all of the many problems experienced by staff and patients in that hospital. However, this investment has made a very strong contribution towards making the necessary beds available.

However, I need to warn the Minister of something. That investment must be escalated very dramatically and very shortly. It was alarming for the people of Louth and east Meath to read Mr. Martin Wall's recent front page report in The Irish Times. Drawing from documents in the Minister's possession which came from the pen of the director general of the HSE, Mr. Tony O'Brien, it stated that this year alone Our Lady of Lourdes Hospital has an unmet critical need for 82 additional hospital beds and five new theatres.

I want to ask the Minister very clearly whether he will make that investment, which is required for the people of Drogheda, Louth, east Meath, and the communities right across the north east and north County Dublin. Will he make that investment available for Our Lady of Lourdes Hospital in Drogheda this year? As I understand it from the correspondence the Minister has received from the HSE, investment is also required in Beaumont Hospital, facilities in the west of Ireland, Mayo General Hospital, and in the University Hospital Galway dialysis unit. I understand that this investment has been costed at approximately €12 million this year and an additional €30 million next year, in order to meet all of those critical needs across our acute hospital service. That also includes five new theatres that are required in Our Lady of Lourdes Hospital. I want to receive a clear response from the Minister on this. Will he make those resources available this year?

Of course, acute hospital beds are not the only dimension that we need to deal with when it comes to the operation of emergency departments in this country. The delays in boosting primary care provision are well known. In 2013, two separate investments were announced in my own community. One of these was the Bettystown Primary Care Centre, intended to accommodate the needs of the people in east Meath. The other investment was in the north side of Drogheda, the area I am from and in which I continue to live. It has taken until 2018 to see the opening of the new primary care centre in north Drogheda. That is four or five years after it was originally announced. Meanwhile, there seems to me to be little sign of the development in Bettystown. This is something I am continuing to pursue with the HSE. We know that investment in primary services addresses some of the issues that we are experiencing day in, day out on a year-round basis in emergency departments across the country.

In addition, in 2013 and 2014 I was central to the repurposing of what was a residential nursing home for older people in the Drogheda area called the Cottage Hospital. That facility was re-purposed and retooled to become a transitional care unit. This was largely to accommodate frail and elderly people who were leaving Our Lady of Lourdes Hospital. These patients were no longer acutely ill but required additional supports before they went home into long-term nursing homes. Our ambition was that there would be additional beds available there for older people, to accommodate them in the context of the traditional care service. That was our vision, and the vision of the HSE; to assist Our Lady of Lourdes Hospital, and importantly to assist those older people.

There was only a maximum of 24 beds in that particular unit. That simply is not good enough. In addition, the capital plan that was announced at the end of 2015 envisaged a new redeveloped public nursing home service in the Boyne View House facility and the St. Mary's Hospital facility on the Dublin road in Drogheda. The boots were due to be on the ground in that development now. There is no sign of any construction of that particular unit. I use these local examples because the principles apply to the system right across the country. We need investment in primary care, frail elderly programmes, transitional care units and residential nursing home units to take pressure off our emergency departments. Those departments are staffed by people who are working heroically, often against the odds, to provide good services to the people for whom they care.

I thank Senator Nash for sharing his time. I know that the facts surrounding University Hospital Limerick and the issues there have already been highlighted to the Minister. An 84 year old gentleman and his family contacted me yesterday. He spent 70 hours on a trolley, and he had heart failure and other complications before he was actually put into a bed. There are issues of which the Minister is very aware. He has visited the hospital. I cannot highlight enough to him, as my colleague has done, the issue of the 89 beds. This must happen, and it must be complemented by the 90 replacement beds in St. John's Hospital. St. John's Hospital carries out small operations on a daily basis and only has ten beds. If its capacity for carrying out small procedures could be increased, it would help to ease pressure and to free up other beds. However, they need replacement beds. The two measures have to happen together. It is very important for the region. I welcome the fact that extra beds have been opened, but I note that Limerick had the smallest number of extra beds with only 17. I cannot highlight enough Limerick's needs to the Minister.

The Minister was meant to have five minutes. He will be squeezed, but we will do our best.

I speak quite fast, and I have never been gagged, so I will not start now. I did not mean you, a Leas-Chathaoirligh.

Another five minutes for the Minister.

I did not mean the Leas-Chathaoirleach at all. I was responding to Senator Devine's comments. In response to her query, although the HSE's primary care steering group does not include a parent representative, as part of its ongoing work around paediatric home care packages it will hold two focus groups with parents in receipt of such packages in 2018. This will be a recurring annual process to make sure that parents' voices are heard. I am sure we can engage further on that matter if the Senator wishes.

I want to thank everybody for participating in this debate. It is important that I hear Members' views. I have heard them, and they very much align with the policy programme that I am pursuing in regard to reform and capacity in our health service. It is important for those working in our health service, and it is important for our citizens to hear also.

There are several positive aspects of the Irish heath service. I think it was Senator Murnane O'Connor who pointed out that our life expectancy is increasing in this country. Our survival rates from cancer, stroke and cardiac arrest are increasing. That is due to the Irish health service, the HSE, the people working in our health service, the policies being pursued by the Department of Health and the investment Government is making.

We hear a lot of chatter about health. We hear from people representing, people working in the health service, people like me and from commentators, and it is all very important. Often, we do not hear enough of the patient's voice. This is the first year in the history of the State that we carried out a national patient experience survey, where almost 14,000 people who had spent one night or more in an acute adult hospital actually gave their views on the health service. A total of 79% of them said that they had a good or very good experience in being admitted to the hospital while 85% of them categorised their overall experience in our hospital as good or very good. I absolutely accept that there are very serious challenges, but I also accept, and I think it is very important that we all accept, that many people who go in and out of our hospitals on a daily basis have a very good experience. That is also part of the Irish health service.

Senator Swanick raised a number of matters. I will not have time to go through everybody's issue, but I will address the issue of ehealth. I fully agree about ehealth as does Sláintecare. We are obviously in conversations about our capital budgets at the moment. I want to see ehealth as a very strong component. We need to move away from a situation whereby files are stored all over the health service, and towards an electronic health record that can actually help reform the health service and improve patient outcomes.

Modular units were referred to. This is something I am looking at as a temporary solution. I have already outlined that in South Tipperary General Hospital I have provided funding and approval for that. I expect that to be in place this year. We will provide 40 beds, and I have asked the HSE to see if we could do that in other hospital sites, which is the point Senator O'Donnell raised with me. This is not just about capacity. It concerns capacity plus reform. No Senator mentioned that some hospitals actually have fewer patients on trolleys in 2017 than in any other year since the Irish Nurses and Midwives Organisation, INMO, began counting. However, that is true. Why are some hospitals doing better? There are complex reasons, and every region and hospital is different, but it is not all about capacity. Every issue in the health service is not about writing another cheque. It also involves work practice and managerial grip. It involves asking why a diagnostic facility might be closed after 5 o'clock in the evening.

It is about ensuring the hospitals are appropriately staffed by senior decision makers outside of what might be perceived as more regular or routine hours. It is a multifaceted issue of which resources and investment are part of the solution, but not the only part.

The issue of the GP contract as raised by Senator Colm Burke is a priority for 2018. Senator Burke is very passionate about the issue and I take his point in respect of nursing homes. I had the pleasure of speaking at the Nursing Homes Ireland conference at his request. As the Senator said, the issue of frailty and how we differentiate between older and other patients in terms of hospital admission needs consideration. We have started pilot projects to address that issue in several hospitals and need to do more in that regard.

Senators Kieran O'Donnell and Byrne raised issues relating to Limerick and I agree there is a capacity issue in University Hospital Limerick. Beds that were promised during the boom years were never delivered. We are going to deliver extra capacity. I also take the point in respect of St. John's Hospital. The 96 acute bed unit is under consideration but a capital planning process has to be gone through in that regard. We will consider the interim solutions that were mentioned. However, it is not just about capacity. We must consider why there are sometimes very few weekend discharges in that part of the country and whether more can be done in that regard.

I will directly revert to Senator Devine in respect of the beds situation in St. James's Hospital when I have a factual answer to her question. She is correct that there is much discussion of GPs, which is important, but that nursing has a very important role to play. I will soon be meeting the Irish Nurses and Midwives Organisation, INMO, to discuss several of the items the Senator highlighted.

As regards Letterkenny University Hospital and the 19 beds in the short-stay ward, I appreciate the point raised by Senator Mac Lochlainn. I will be looking at capacity across the wider health service and we will consider the issue in Letterkenny and Donegal along with the rest of the country. I take on board the points made by the Senator in that regard.

I thank Senator Grace O'Sullivan for her points. She wants to focus on solutions, as do I. The first solution on which I wish to focus is the reversing of failed policies, such as the decision during the boom years that we had too many hospital beds, leading to some being taken out of the health service. We need to put in more beds and couple that with reform.

I thank Senator Nash for his comments regarding Our Lady of Lourdes Hospital, Drogheda. I acknowledge his role and the work he carried out in that regard during his time in government. I had the pleasure of visiting the hospital not very long ago and noticed significant improvements that had been made by the staff and management team. Senator Nash made the point that the investment, together with the work of staff and management has made a difference. I accept that a significant amount remains to be done. I am not here today to make announcements about specific projects but I appreciate what the Senator said regarding the need for new theatres and critical care beds. If I were in his position, I would be asking the same questions. We are finalising our capital planning and I am aware of the need to do more in respect of Drogheda as well.

I have tried to respond to as many issues as I can-----

Will the Minister address the issue of Monaghan Hospital?

I understand Senator Gallagher raised that matter with------

Senator Gallagher got in under the wire.

-----the Minister of State, Deputy Jim Daly, who told the Senator that he will visit the hospital. I take the Senator's point on smaller hospitals. Decisions regarding Monaghan Hospital were taken long before I became Minister for Health. I am actively considering the role of smaller hospitals at a national level and what they can appropriately do.