The Minister for Health is well aware that since I took on this portfolio I have been at pains not to provide what I perceive to be a dated and ineffectual version of Opposition — to be stridently opposed to anything and everything a Government does. I have not failed to acknowledge when the Minister has taken appropriate action.
However, when it comes to the issue of overcrowding and bad management of patient numbers in our big, publicly-funded hospitals, it is imperative, not only that the Opposition oppose, but that the Minister changes what he is doing in response to that opposition.
Since the start of this year there has been a failure by the Government and the Department of Health to recognise the crisis in hospitals. That crisis has led to industrial action by nurses, a group of workers that normally do not take to our streets unless there is a serious problem, there is no doubting how real and substantial the problem is. Accident and emergency care has reached breaking point, particularly in Dublin but also in hospitals all over the State.
In the past, Casualty as it used to be called, was precisely what it sounded. It was the place to which a mother brought the toddler who had fallen off his or her bicyle and who needed more treatment than the mother felt competent to provide. Similarly, the person who had been involved in an industrial mishap, or the student in school who was injured on the sportsfield were brought to casualty. Casualty was the place where broken bones were set and bleeding wounds staunched. There were some times of the day or, more specifically, of the night, that caused particular pressure, and there were some nights of the week when, for obvious reasons, casualty was more crowded than others.
However, we do not talk about casualty any more; we talk about Accident and Emergency Departments. What now happens in what we used to call "Casualty" is so different and so complex that the sign "Accident and Emergency" does not really fit the bill.
It might be simpler to put an entrance sign over the Accident and Emergency Department sign because, increasingly, that is what it is serving as; an assessment and induction point for the seriously ill who need admission to acute care wards. In other words, the role of Accident and Emergency Departments has changed beyond recognition and it will not change back.
If hospitals were just businesses, merely in the profit and loss area, the implications would be obvious; our marketplace has changed, therefore, our facilities and management expertise need to change quickly. However, hospitals are not just businesses, they do not simply deal with money, they deal with people and that is all the more reason to change the way the operation is managed. Why should the imperative be less simply because the focus of a hospital is on patients, rather than profits?
That change has not happened. The Department of Health has not examined this recurring issue which has been happening again and again at the beginning of each year. The Department has not accepted that the position has changed and that the change must be managed. On the contrary, the Department seems to be hoping that the position will somehow change back, to let it off the hook of doing what it is supposed to be doing — providing health care for the nation.
What the Department of Health has done over the past three months is a sorry saga. The loudest sound has been the washing of hands as the Department has shrugged, portraying the disgraceful conditions patients are enduring as an haphazard outcome of old, unpredictable pressures rather than the inevitable outcome of a change in the way hospitals are used by the patients who need treatment.
There has been an implication — never quite spoken, but there, nonetheless — that bad, manipulative patients are trying to subvert good hospital systems by getting themselves improperly admitted through Accident and Emergency Departments.
Let us consider that in real terms, as opposed to Department of Health terms. An Accident and Emergency Department, in any hospital, is not the place to go to have a Teddy Bear's Picnic. It is not a place to go for a chat because you were a little bored with "Coronation Street" or "Glenroe". Accident and Emergency Departments are Dickens crossed with Kafka. There is constant activity and anxiety, but no apparent end result. There are sights, smells and sounds that would put you off your food for a week. There are machines being wheeled into curtained cubicles. There are trolleys, clanging prisonsides, which are imitations of beds designed for someone to lie on for an hour or maybe two.
When you cross Dickens with Kafka you get something that is grim and scary, something that makes no sense to the patients or to the professionals who are doing their best to cope with it. A doctor in charge of a major Accident and Emergency Department in one of our largest hospitals described it to The Irish Times just before Easter by saying “it is like Puck Fair”. He was putting it positively. That is what we are subjecting patients to. It is no wonder that nurses are striking to draw attention to their desperation in the face of this madness. There is patent mismanagement.
Nursing staff say that Accident and Emergency Departments have become makeshift wards. There is no throughput of patients because of the shortage of acute beds throughout the remainder of hospitals. This results in patients spending several days on trolleys.
For instance, in Beaumont Hospital recently, a pregnant woman with a history of miscarriage had to spend two days on a trolley in the Accident and Emergency Department. She was waiting for a bed to become available on a ward. She was one of the lucky ones. On some days, some patients do not even get a trolley. Often there are three or four ambulances held up at the door of the Accident and Emergency Department while patients are treated on stretchers until trolleys become available. Sometimes patients are laid on mattresses on the floor, others can spend hours sitting in armchairs. The constant fear for nursing staff is that someone will die on a trolley or in a corridor. It is also practically impossible to nurse somebody if you are down on your knees on the floor.
There have been cases of elderly patients dying a couple of hours after moving from a trolley to a bed. These people and their families deserved to be treated with greater dignity.
Accident and Emergency Departments are clogged because beds on wards are not being made available quickly enough. There is a chronic shortage of step-down facilities where non-critical patients are taken out of acute hospital beds and cared for in nursing homes or in their local communities. If these facilities were available, up to 20 per cent of beds in hospitals around the State would be freed up.
Problems have arisen in Dublin because of the lack of co-ordination of the city's two ambulance services. The Mater and Beaumont Hospitals currently take 50 per cent of ambulance calls. These hospitals are located in areas where there are large populations, especially of elderly people, who require medical services. It means that these two hospitals are under incredible pressure all the time just from their local areas. Therefore, there has to be co-ordination of hospitals and ambulances within the Dublin area.
However, this is not happening. For instance, when the Mater is full, it sometimes takes up to three hours for that to be communicated to the Dublin ambulance services, resulting in patients arriving at the Mater and then having to travel to another hospital.
The crisis in hospitals and casualty departments led to the recent industrial action by nurses. They are not looking for extra pay but will not tolerate constant overwork and overcrowding. They want to provide a quality service to patients. They also want to be able to do their work without being abused about the overcrowding which is not their fault.
Nursing staff do marvellous work and it is unfair that they should be the victims of inefficiencies and inadequacies of the health boards and the Department of Health. The problems in accident and emergency departments have not arisen overnight. But there appears to have been a persistent failure by the Department of Health to address them and this Government and Minister for Health have failed to recognise the crisis or get to grips with it.
If the Department had any sense of responsibility, it would, within the past three months, have taken two kinds of action. It would first have put emergency funding into the hospitals under pressure to allow for the opening of more beds and the taking on of extra staff to cover what might be called the ‘first quarter curve' in admissions. Second, it would have moved in quickly to examine what was going on and developed new systems to cope with it. Instead, it played "blame the patient": sending out the message, subtly and not so subtly, that this was happening because patients wanted to get around waiting lists.
Let us examine for a moment the possibility that the patient wants to get around a waiting list. Is that a dreadful thing? Is that patient an awful person? Should they just bide their soul in patience and not be trying to jump the queue? Should they learn to be a good obedient, patient patient? I am sorry to have to tell the Minister that the re-education of patients has to take second place to the re-education of the Department of Health.
I was a teacher, as was the Minister. I was a good teacher. I suspect the Minister was a good teacher, too. And so I feel safe in suggesting that the Minister would agree with me when I say he cannot teach a student much when a student is frightened, or in pain, or nauseated, or in discomfort that falls short of pain but goes way beyond malaise. The people the Department of Health would like to re-educate are people who are sick, a small but important point. They are not looking for admission to hospital to have their appearance improved. They are sick. They have symptoms. They need action taken. Sometimes, their life is disrupted by whatever ails them. So they are not going to be really good students; they are not going to willingly learn to stand in line, accept queues or postpone solutions.
If someone is sick and anxious enough to submit themselves to the ‘Puck Fair' conditions of our accident and emergency departments in the major hospitals, knowing that they are likely to be left lying on a trolley for a night, or longer, then they must be pretty desperate. It is crazy for the Department, or anybody else, to send out the message that these bad patients are just trying to sneak around a perfectly good system.
It is not a perfectly good system and the Department, and the Minister, should be fixing it and doing so quickly. There are examples of the Department's failure in this matter. For instance, several Ministers for Health have made funds available to address bed shortages and reduce waiting lists. Both problems are interlinked and incapable of being resolved separately. However, the Department of Health appears to have failed to grasp this.
Now money is being provided to deal with one set of waiting lists. However, because of the crisis in accident and emergency departments, appointments and admissions are being cancelled, creating a new set of waiting lists or emergencies. One list is just being substituted for another.
More than 550 elective admissions to the Mater Hospital were cancelled during the first three months of this year because of pressures on the hospital's accident and emergency department. In January elective admissions for 266 patients were cancelled. In February 143 were cancelled and last month 146 were cancelled. Escalating admissions to accident and emergency departments at various hospitals throughout the country are disrupting normal services at the hospitals as the pressure on beds increases.
As pressures on the service began to mount, the Cork city hospitals, for example, used a service disruption score to measure the effects of the crisis. When it was introduced the score was 30 but it recently climbed to 70. The scoring system was introduced to measure the level of disruption caused by the numbers being admitted through accident and emergency departments against the numbers awaiting admission from the community and from GPs, the numbers of extra emergency cases in five-day beds and the number of extra beds being introduced to cope with the situation. Every option possible to reduce bed-stay and to improve co-ordination of tests was being tried.
A major increase in casualty admissions in the first quarter of this year and the lack of step-down bed facilities have contributed to many of the hospitals much publicised casualty crisis. There is pressure on the system to continually provide additional step-down arrangements for patients in acute beds to ensure rapid discharge. There is an increased demand in all hospitals for non-acute accommodation which needs to be met and which will require joint planning between the hospital managements, the Department of Health and the various health boards. Hospitals are being continually hampered by their inability to discharge acute patients to appropriate facilities at any given time, thus causing blockage of beds. There is clearly a need for additional non-acute beds and there is also a need for more short stay beds within hospitals to deal properly with the elective workload.
Any cancelling of elective admissions as a result of the large increase in accident and emergency admissions will clearly have long term effects on waiting lists if it continues. The Department of Health appears to be refusing to accept any responsibility for this. The Department is not participating in this week's summit on the crisis in accident and emergency departments. All the other parties will be there and the Department should be there too as it has an important role to play in solving this crisis and integrating health services.
This integration role for the Department has been set by the health strategy document which was produced by the Fianna Fáil - Labour Government. It proposed that the Department, the health boards and the hospitals should come together to tackle problems. Since the Minister for Health has not insisted on the Department's participation, does this mean he does not agree with the health strategy document? Does he also not agree with its proposals on action for acute hospitals which included an objective to ensure quality facilities for patient care? What happened to this objective as it has certainly not been to the fore in this current crisis?
I am very tempted to say the Department needs its head examined, because it does not seem to be able to learn from experience. If you go around the country and talk to the people in the health boards — I am delighted the Minister is in the process of doing that — they will say that what is happening this year has been happening for the past few years. It is a well established trend, this big curve of extra demand at the beginning of the year, but the Department seems determined to pretend that it is not real and it does not need to plan for it. That is roughly the equivalent of a leaving certificate student saying at this time of the year that there is no real need for him to revise his work in the next few weeks. Any mother would say to such a student: "you need your head examined." Any patient or relative of a patient who has got a free sample of accident and emergency departments in a major hospital in the past few months would say that the Department needs its head examined. I am not sure that is true. I think it needs its heart examined — if it has one, and I hope, with Deputy Noonan in charge, that it might have one. If the Department of Health had a heart, it would be observing the truth about the current situation which is that the people who go to accident and emergency departments are often the most vulnerable, are the people who do not have the money to go the private route for care and treatment. They are the people who do not know how to work the system. The patients who suffer most are those vulnerable people, the very young, the very old, particularly the very old. The people who have gone on strike this year are the last people you expect to go on strike. Nurses can and do take a great deal of punishment and an awfully big workload. Even when they went on strike this spring they did it in ways calculated to inconvenience patients as little as possible; they were obviously trying to draw the attention of the Department to the fact that here was a problem that was simply not being acknowledged or managed.
I am asking the Minister for Health to take action on this. The motion demands an increase in the level of funding to adequately address the problems. I would go further. I ask the Minister to stop his Department behaving as if this yearly crisis was a minor problem caused by patients. Plans must be developed to prevent this unacceptable hardship to patients and their families.
This Government has been in office for less than five months and it is unbelievable that in such a short period it has lost touch with reality. It is obsessed with looking after the privileged. Despite the presence of Labour and a Democratic Left Minister for Social Welfare it gave a 2.5 per cent increase to social welfare recipients and pensioners which will probably not even match inflation this year. Worse again, the rise only applies to a social welfare recipient's primary payment, not to dependant and supplementary allowances. At the same time a Labour Party Minister for Finance gave major tax breaks in the budget to the financial institutions which already make massive profits. The Government abolished the bank levy which resulted in a windfall of £12 million in 1995 for the financial institutions. Next year this windfall will be £24 million. The financial institutions will also make a killing from the 2 per cent cut in corporation tax.
The Government seems to know how to look after its banking friends but has no interest in the health services. When we came to Government seven years ago we immediately set about rebuilding the hospital and health care infrastructure. It took time and effort. It was done painstakingly and with attention to detail. While we were trying to solve the problems the then Opposition's only reaction was to criticise us. As is now clear the Opposition's words were hollow. In a debate on 3 November 1992 on the general medical services proposed by Deputy Owen, now Minister for Justice, she stated, as reported at column 1876 of the Official Report, that in all arguments about the health service and GMS "the most important individual is the patient". She appears to have forgotten this now that she is a Cabinet Member. If she has not, why does she not push for resources for the State's hospitals?
She is not the only one in the Fine Gael Party with amnesia. As reported at columns 1319-1323 of the Official Report, 30 March 1993, Deputy Flanagan complained bitterly about waiting lists. He wanted action and stressed that hundreds of beds had been taken out of use in all the Dublin hospitals. He wanted the Minister for Health to commit himself to action. That Government took effective action but it has been let slip by this Government. Where is Deputy Flanagan now that his party is in power and can take action? He is keeping his head down because instead of taking action this Government is adding to the problems by not recognising the crisis in the health services and providing adequate resources.
Deputy McManus, now Minister of State, was also a vocal contributor to the debate on the health charges in March 1993. As reported at column 1654 of the Official Report she considered there was a massive decline in spending on health care. She said she wanted our health services to be "better and more equitable and at the same time to provide jobs for more of our highly trained young people". She is now a member of Government but she and Democratic Left appear to have fallen under the spell of the financial institutions and have forgotten the crisis in hospitals and accident and emergency departments.
The breaks given to the banks in the budget are in sharp contrast to the provisions made for the health services. No allocation was made for the provision of extra step-down facilities which would free up acute beds in hospitals. The extra resources required could be found if the Government made health care a priority over tax breaks for banks. It is to be condemned for its failure to recognise the crisis and must immediately assess the level of funding required by the Department of Health and the health services and consider an increase so that the crisis in the health care service can be adequately assessed.