Dáil Éireann díospóireacht -
Wednesday, 24 Nov 2004

Vol. 593 No. 2

Adjournment Debate.

Hospital Services.

Mr. Deenihan

The accident and emergency department at Kerry General Hospital is without doubt the most under-staffed accident and emergency department in the country and is struggling to cope with massive increases in patient numbers coupled with an unacceptable lack of resources. The reason it manages to operate is the hard working commitment of the staff and the assistance they receive from colleagues in other specialities in the hospital. Kerry General Hospital offers its acute services to the population of Kerry, which is approximately 132,000. It also serves parts of north Cork and south Limerick.

When it was originally constructed, attendance at the accident and emergency department was 13,500 patients per year. This has now risen to 29,000 over the past two decades. To cope with this increase in numbers, one would expect that more staff, equipment and space should have been provided. However, in contrast with other acute hospitals around the country of similar size, this has not happened. The role of the accident and emergency department at Tralee has expanded over the years. The most significant change has been in the use of accident and emergency departments as a point of first contact with the hospital for all patients requiring emergency care and few patients who are ill are admitted directly to a ward, even when beds are available.

This change occurred for a number of reasons, but primarily because of patient safety. The accident and emergency department structure is specifically geared for patient management and is ideally located to access all other areas of the hospital such as the X-ray department. Some changes have been made in recent years. Five junior doctors at senior house officer grade were appointed to the accident and emergency department four years ago. These doctors have limited experience and must work under the supervision of more senior medical staff. In October 2003, Dr. Sean O'Rourke took up the post of consultant to the accident and emergency department and in addition some internal building works have been undertaken to maximise limited space and provide two X-ray examination cubicles.

The fundamental problem that affects the accident and emergency department is one of under-resourcing. For example, the Royal College of Surgeons in Ireland recommends that for each 3,500 patients there should be one SHO. The five SHOs at Tralee general hospital should see approximately 17,500 new patients annually. However, patient numbers are far above this level, at more than 29,000. There is approval for a further two SHO posts, but these remain unfilled. I understand there is an application to seek approval for an eighth post because of the increase in the number of patients. As I previously stated, SHOs are junior doctors with limited experience. When the accident and emergency consultant is not on call, the department has no registrars to turn to for advice in medical emergencies.

Nursing levels are also a concern. With only 24 wholetime equivalent nurses in the department, each night-shift is covered by only three nurses. During summer months an additional night-time nurse is provided, but he or she is removed at the end of September. Bearing in mind that patients frequently present at the accident and emergency department late in the evening, and given that they have to wait longer to be assessed, the night-time is often as busy, if not busier than day-time. Given the pressures this degree of cover is simply not adequate.

The hospital management submitted a brief to the Department of Health and Children in June 2002, outlining the facilities required to bring the accident and emergency department up to an acceptable standard. However, the hospital is still awaiting a response from the Department regarding these proposals. The majority of patients who attend the accident and emergency department have suffered injuries of varying severity. These patients are seen and treated by the accident and emergency doctor and nurse, with the majority being discharged. Patients presenting with conditions such as chest pain, stroke, pneumonia and asthma are the second largest group. Many of these patients are sicker and older and require speedy assessment and treatment. Their conditions need to be stabilised in accident and emergency departments prior to transfer to the wards. An acute medical unit is essential for this type of patient. This type of facility has been a resounding success in Kilkenny. However, it costs approximately €1 million per year to run such a facility. Such a unit in Kerry General Hospital, located next to an operating theatre and parallel with the accident and emergency department, would be of immense benefit to this important group of patients.

There is an urgent need to increase accident and emergency medical staff to an appropriate level. The appointment of three additional SHOs and three registrars would reflect medical staffing levels in similarly sized units around the country. There is also the need to increase nursing numbers to reflect the continuing demand on the accident and emergency department in the hospital. Funding for the establishment of a properly functioning and acute medical unit should be prioritised and this should include approval for an increase in medical nursing and non-nursing staff.

Approval from the Department of Health and Children for a new accident and emergency department in Tralee is essential and the funding to put this in place should be sanctioned immediately.

Minister of State at the Department of Health and Children (Mr. S. Power)

It is a difficult question to ask, but I wonder whether the Deputy, in his football playing days, sent a few fellows into the accident and emergency department himself.

Mr. Deenihan

This is a serious matter.

Mr. S. Power

I appreciate that. That is why it has been chosen. I thank the Deputy for raising this matter and I want to acknowledge the contribution made by the staff at the Kerry General Hospital, Tralee, in difficult circumstances.

The Department of Health and Children has been aware since 2002 of a proposal to develop new accident and emergency infrastructure at Kerry General Hospital. It has not been possible for the Department in the intervening period to commit to this proposal in the light of competing demands generally on the health capital programme and given the significant capital and non-capital funding implications involved in this case. The proposed development has, however, been included this year within the new health capital investment framework 2004-08.

The proposed scheme consists of renovation works at, and a new extension to, the existing accident and emergency department at the hospital. The Southern Health Board has prepared a draft brief. The issues at the hospital are being examined by the Department in the context of new capital commitments that can be progressed under the framework for 2005 or beyond, in line with overall funding resources available during the period 2004-08. The project team is expected to meet early next week to consider the draft brief submitted by the Southern Health Board.

With regard to the pressures on accident and emergency departments generally, the Tánaiste has identified the delivery of accident and emergency services as a priority area for attention. Many of the difficulties and delays experienced in accident and emergency departments reflect systems-wide issues. It is, therefore, necessary to take a whole-system approach, involving primary, acute, and sub-acute care as well as community care in tackling the problems in emergency medicine departments.

This Government has in recent years, introduced initiatives aimed at improving the delivery of acute services and alleviating the pressures on accident and emergency departments. Additional funding of €70 million has now been secured in new current expenditure in 2005 to implement a number of initiatives to improve the delivery of emergency services. These include improvements in the following areas: patient flows through accident and emergency departments by developing and expanding minor injury units, respiratory and chest pain clinics in hospitals; acute medical units for non-surgical patients; the physical environment for patients and staff, including cleaning and security measures; direct access for GPs to diagnostic services; the availability of acute beds for emergency patients by sourcing capacity in the private nursing home sector for those patients who have completed their acute phase of treatment; and expanded home care packages to support older people at home.

It is expected that a high level steering group will now be established made up of representatives from the Department of Health and Children and the Health Service Executive to implement the initiatives in 2005.

Ambulance Service.

Mr. Lowry

A new community hospital on the grounds of the old Hospital of the Assumption, Thurles, is currently under construction. I welcome the fact that the building programme is on schedule for completion and that the facility will be fully operational in spring 2006. The new hospital will provide a wide range of services such as respite, rehabilitation and long-term care. The old hospital contained an ambulance station that served a large part of Tipperary. This station was always an integral part of the hospital. Everyone assumed there would be a new ambulance base facility as part of the new overall hospital plan.

On making inquiries to the Mid-Western Health Board I was shocked and dismayed to discover that provision has not been made for an ambulance base. It is an astonishing omission that highlights the lack of forward planning and co-ordination on the part of the Department of Health and Children. A temporary ambulance base has been established in an old laundry building on the hospital campus. This building is dilapidated and totally unsuitable for staff and patients. The building has an asbestos roof, which raises serious health and safety issues. Male and female members of staff have to share one toilet. The present circumstances are totally inadequate and unacceptable. There are legitimate health and safety concerns for the emergency medical technicians and other staff.

The Thurles ambulance station provides pre-hospital emergency services and patient transport for a large section of north Tipperary. It also forms part of the health board's response to any major emergency. Depending on demand, this station also provides cover to other areas, such as Roscrea and Nenagh. The Thurles station provides 24 hour cover. Two-person crewing on all ambulance vehicles has been implemented. This year so far, the crew from the Thurles ambulance station answered almost 6,500 calls. This temporary shack houses in excess of 15 staff who are entitled to and deserve a safe and healthy working environment to enable them to continue their life-saving work.

According to the construction programme from the Department, demolition of the existing hospital, including the removal of asbestos will commence in early July 2005. As part of this demolition the current temporary accommodation will also be removed. Amazingly the Department of Health and Children has no provision within the scope of the hospital project for interim measures to accommodate the ambulance base.

The Mid-Western Health Board has recently submitted a detailed proposal for funding to the Department of Health and Children to build a new modern ambulance base on the campus, the estimated cost of which is approximately €1.6 million. It would be commonsense and cost effective to sanction the construction of a new base immediately. The builders are currently on site and can undertake the essential building work with a simple variation to their existing contract. The Department of Health and Children must provide the necessary funds for a modern ambulance station as a matter of urgency. The facts speak for themselves. Quick responses save lives. Many of the 6,500 patients carried by the Thurles ambulance would not have survived if an ambulance had to travel from Limerick or Nenagh. The reality is that if the ambulance base is closed or funds are not provided to build a modern base lives will be lost in the Thurles and mid-Tipperary area.

Without an ambulance base a person with a cardiac arrest in Thurles has almost zero chance of survival. A cardiac arrest patient must get immediate emergency medical attention to have a significant survival chance. This is only possible with a local ambulance base.

I ask the Minister of State to inform the House if his Department will take responsibility for the potential loss of life arising from the present bungling with the ambulance station in Thurles. When funding for the community hospital was sanctioned why was a modern ambulance base not included in those plans? What proposals does the Department intend to sanction to secure a permanent ambulance base in Thurles? When will the Mid-Western Health Board be notified that it can proceed with the planned development of a new ambulance station.

There has been a dramatic reduction in the level of health care delivery in north Tipperary. The status of Nenagh General Hospital is under threat from the implementation of the Hanly report. There is neither an accident and emergency or a cardiac care unit in Thurles. The provision of a proper ambulance facility is of vital importance to the delivery of adequate health care to the people of Thurles and mid-Tipperary.

Mr. S. Power

I thank Deputy Lowry for raising the issue. The report of the Strategic Review of the Ambulance Services 2001, forms the basis for the development of pre-hospital emergency medical services into the future. It identifies aspects of the current emergency ambulance service that need to be addressed to bring the service into line with best international practice to ensure effective and quality driven practices.

The report recommended that the service be developed at a number of levels. Principal among the developments being put in place arising from the report are the elimination of on-call arrangements as a means of providing emergency cover, improved fleet reliability; and the roll-out of the emergency medical technician-advanced programme.

The elimination of on-call arrangements is designed to facilitate further improvement in response times. Additional funding of more than €4 million was provided in the current year to facilitate the continuing phasing out of on-call arrangements in a number of regions. This is a programme the Tánaiste hopes to be in a position to extend.

In the area of the ambulance fleet and equipment, the Department provided additional capital funding of more than €8 million in the past 12 months to assist the boards-authority with their fleet and equipment replacement programmes which are essential prerequisites for enhanced speedy and appropriate care. The Mid-Western Health Board ambulance service was allocated approximately €1million of this funding.

In regard to the new Community Hospital of the Assumption in Thurles, a brief to replace existing institutional services for the elderly at the 150 year old Hospital of the Assumption was completed in recent years and construction commenced in April 2004.

The scope of the development is in keeping with the objectives laid down in the report, The Years Ahead, and comprises accommodation and ancillary services for 72 inpatients and a day hospital. The need to replace the ambulance station on the campus was recognised in the brief and space has been protected on the site for provision of a new base. The original base, housed in an old gate lodge, was inadequate and has been demolished. The service is currently housed in temporary accommodation on site.

The Mid-Western Health Board has reviewed its requirements for the new ambulance station and has recently clarified its proposals in this regard to my Department. These proposals take account of an option appraisal exercise and the implications of the current health reform programme. The current proposal recognises service development in terms of the elimination-reduction of on-call arrangements and the introduction of two-person crewing to all ambulances. The development as proposed is designed to provide the accommodation required to support the future development of the service. These proposals are currently being examined by my Department and will be considered in conjunction with the Mid-Western Health Board, in the context of overall capital priorities.

The Government is fully committed to the development of our emergency ambulance service. Much has been achieved in the development of the service and I recognise that much remains to be done. It is essential to maintain the progress made and to continue the process of service development, so that effective pre-hospital emergency care is accessible to those who need it most, when and where it is required.