Léim ar aghaidh chuig an bpríomhábhar

Dáil Éireann díospóireacht -
Tuesday, 10 Nov 2015

Vol. 895 No. 3

Hospital Emergency Departments: Motion [Private Members]

I move:

That Dáil Éireann:

agrees that:

— prolonged waiting times in emergency departments are associated with poorer outcomes for patients;

— the safety and quality of patient care must be a primary focus and timeliness is a crucial component of quality care;

— patients should receive a high standard of treatment irrespective of when or where they seek emergency care and they should not experience excessive waiting times in emergency departments;

— elderly patients, in particular, should not be waiting more than six hours; and

— consultants are obliged and entitled to highlight conditions that may jeopardise patient care;

recognises that:

— last month was the worst October on record with 7,971 admitted patients cared for on trolleys; and

— over the first 10 months of this year almost 80,000 admitted patients were on trolleys;

notes that:

— the April 2015 initiative, while reducing waiting times for the Fair Deal and the number of delayed discharges, has not reduced the overcrowding in emergency departments; and

— the introduction of a system of fines to penalise hospitals that do not meet non-emergency care targets could further aggravate the difficulties in emergency departments;

calls for the Government and the Health Service Executive to:

— ensure safe, adequate and consistently available staffing levels for all emergency departments;

— recruit additional designated staff to look after admitted patients who are on trolleys;

— ensure the total patient time spent in the emergency department is less than six hours;


further calls for:

— the recommendations of the 2012 Health Information and Quality Authority report (entitled Report of the investigation into the quality, safety and governance of the care provided by the Adelaide and Meath Hospital, Dublin incorporating the National Children’s Hospital [AMNCH] for patients who require acute admission) to be fully implemented; and

— the strategy to improve safety, quality, access and value as set out in the 2012 National Emergency Medicine Programme to be implemented.

The purpose of the motion is to highlight the continual overcrowding our emergency departments face nationally. Day in and day out, we see the Trolley Watch numbers and hear harrowing stories of patients lying for inordinate lengths of time in emergency departments. I would be failing in my duty if I did not raise this issue consistently. It is not something that happens every now and again. It is consistently a failure of determination by the Government to address the fundamental problem of lack of capacity across our hospital system. We had some very serious personal issues being brought to public attention recently having regard to the number of elderly people waiting on hospital trolleys in emergency departments. In that context, it is significant to acknowledge first and foremost the work of front-line emergency medicine consultants, nursing staff and all of the support staff required to ensure our hospitals are working. Unfortunately, they are expected to deliver more than the capacity will allow.

Issues were raised last week about overcrowding at Tallaght and comments were made by an emergency medicine consultant there. It was dealt with in a distasteful way. He was raising the plight of a patient under his care in the emergency department. I found it amazing that there was an attempt to damage the messenger. He said a patient was waiting for over 27 hours in an emergency department which was not appropriate. Unfortunately, the guns were turned on him notwithstanding the fact that he was a whistleblower. It is his duty to advocate for the patients in his care. It was very distasteful that the Minister would dismiss it summarily and try to undermine the message he was bringing. I found it incredible that, according to reports, the Minister decided to contact the particular patient. I find it almost unethical that a Minister of the day, regardless of whether he or she is a doctor, would contact a patient in the care of a doctor to ask whether or not he or she was satisfied with the treatment and service. It is wholly inappropriate. The Minister should reflect on that.

Commitments have been made time and again since 2011 to tackle head on the overcrowding in our hospital system and emergency departments and on our outpatient and inpatient waiting lists. We could go back and revisit the stewardship of Deputy James Reilly when he was Minister for Health. At the very least, it was inept in the handling. That was acknowledged by the Taoiseach himself who said at one stage on the floor of the House that he was taking a hands-on approach to the management of the health service because, obviously, he felt the Minister was not capable of doing it by himself. That was a sad indictment and undermining of the Minister of the day. However, a decision was made to shift him on. What has happened subsequently is that the story and how it is told has changed. That is all. The underlying circumstances for patients across our emergency departments has not changed. In fact, it has got progressively worse. We now have continuous incremental increases month on month of people waiting for inordinate lengths of time on hospital trolleys throughout our emergency departments. Some hospitals consistently breach the requirement for a timely throughput of patients. The idea that we can point fingers at or blame consultants because they speak out is distasteful to say the very least. The Minister should bear in mind that when he was Minister for Transport, Tourism and Sport, he lauded and applauded whistleblowers who stood up to champion the issue of the quashing of penalty points. He said they were very brave people. As Minister for Health, he was delivered the message by a whistleblower in an emergency department that people are waiting inordinate lengths of time, that their health is being put at risk and that basic human rights were not being afforded to them. His response was to undermine that person. He tried to attack the whistleblower and bring him into ridicule. That is something he should reflect on.

The broader issue in the motion is the requirement to recognise that last month was the worst October on record. It saw 7,971 admitted patients cared for on trolleys. Over the first ten months of 2015, almost 80,000 admitted patients were on trolleys. The Minister said he would tackle the issue. He set new targets to reduce the use of hospital trolleys and he established an emergency department task force last year. The task force eventually met just before Christmas and it then resurrected itself on 6 January when there were over 600 people waiting on trolleys in emergency departments nationally. The task force eventually published recommendations in April. In June, the Department sent a one line email to the HSE asking it how it was getting on with regard to the recommendations. All in all and on a continual basis, a very hands-off approach is being adopted by the Minister and the Department in respect of addressing the national crisis. It is a crisis of huge proportions. The continual glib commentary that things will get worse before they get better is not a sustainable position for any Minister for Health to hold. The Minister continually diminishes expectations and talks about things getting worse before he will have an opportunity to improve them. The Minister has been in place for well over a year and the Government has been in place for almost five years but the position has consistently and rapidly deteriorated.

The motion notes that while the April 2015 initiative reduced waiting times for the fair deal and reduced the number of delayed discharges, it has not reduced the overcrowding in emergency departments. That was a key tenet of the proposals brought forward by the emergency department task force. We were told that if we could reduce the waiting times for the fair deal, there would be a more efficient transfer of patients from acute hospital settings into step-down and nursing home facilities. Of course, it has not addressed the fundamental problems because there are more fundamental problems in our hospital service. The Minister and his predecessor consistently said that it was not all about resources and hospital beds. At times, the Minister has said the problem would not necessarily be solved by providing additional hospital beds. The bottom line, however, is that it is impossible for our emergency departments to cater for what is presenting itself on a continual daily basis throughout this country without an expansion of capacity. The idea that we can pretend on a continual basis that things will improve without actually addressing the fundamental, underlying nature of the problems is not a tenable position to be in. Dampening expectations continually and putting presentation, spin and PR on it is not acceptable.

The motion calls on the Government and the Health Service Executive to ensure safe, adequate and consistently available staffing levels for all emergency departments. The Minister should know and I am quite sure the emergency department task force has highlighted the fact that we do not have adequate staffing in our emergency departments. We have front-line staff who are worked to the bone and put to the pins of their collars on a continual basis. They work under inordinate pressure and give above and beyond what is considered normal duty. There seems to be no acknowledgement of that but when people speak out, there is an effort to quash any dissent and undermine their views and ability to express freely their concerns and advocate for patients. The Tallaght case is indicative of the view that is held by the Minister and the Department of front-line staff, particularly our emergency medicine consultants who are working under extraordinary pressure.

We could go through the Government's record on health and the funding of same. Today, I asked the Taoiseach about the amazing utopian announcement of universal health insurance, UHI, that was made in 2011. It was to transform fundamentally how we delivered and funded health care, but the opposite has been the case. There is a paralysis in the consideration of how to fund health care for the years ahead. For a long time we have been discussing the abolition of the HSE and how we are to establish hospital groups that will formally be transferred into trusts. However, we discovered that the Minister recently made a case for the potential privatisation of the management of some of those groups. He seems to be trying to absolve himself and the Government of responsibility for the health service, which is a public health system. He must examine this matter quickly, as the people should be informed of what the Government intends to do with that service if returned to office.

We cannot get a credible opinion from the Minister or the Taoiseach regarding UHI. The Minister consistently refers to universal health care. We all know what that is, and UHI is a different animal. Some Ministers with whom the Minister serves have consistently tried to undermine him. For example, the Minister for Public Expenditure and Reform has called UHI a non-runner in off-the-record briefings, given the costs that would be incurred by people who retained private health insurance and those who would be obliged to get some. A bit of honesty in the Minister's proposals for funding the health service would be important this side of an election. The commitment as regards the publication by the ESRI and others of a scoping exercise after many years of prevarication on the UHI project was also important.

If the Minister does not believe me that health services are in rag order, including our emergency departments and outpatient and inpatient waiting lists, he might observe that the members of the Irish Nurses and Midwives Organisation, INMO, have balloted for industrial action and highlighted the need for some acknowledgement of the crisis in hospitals. Front-line staff in emergency departments are warning the Minister that the crisis is jeopardising people's health. Across modern health systems, empirical evidence has shown that inordinate delays in assessing, triaging and treating a person result in adverse outcomes. People who are waiting inordinate lengths of time on trolleys in our emergency departments are dying because of delays in assessments. This is a fact. The Minister may not want to accept it, but people are dying on his watch because of his inability to deal with the crisis in our emergency departments. He should weigh on this heavily when responding to the motion.

The Government's amendment is self-congratulatory and restates what the Government will do, but it does not acknowledge the crisis in the health system. It lauds the Minister, stating: "supports the Minister for Health in his continued determination to bring about improvements in urgent and emergency care services."

It is signed by the Minister himself. This is more self-congratulation. He is commentating on the health services and putting a spin on them that has no relation to the reality of patients' daily experiences. The 91 year old who waited 29 hours on a trolley is not an unusual occurrence. It happens constantly. While Beaumont Hospital was nearly being shut down because of overcrowding in its emergency department, the Minister was at a public relations institute event to outline to PR professionals how good he was at PR, spin, press releases and presentations.

We have an obligation to highlight the Minister's failing to deal with overcrowding in emergency departments. We do not do this just to cause him embarrassment. If we do not do it, we will fail in our duty to the many people who are left languishing on trolleys because of the Government's inaction and inability to address a national crisis that has been worsening under its watch and the Minister's in particular. This is not just me saying this, as these are the statistical facts. Behind those statistics are patients who are not being treated in the fair or reasonable manner that they expect when presenting at public hospitals. I commend the motion to the House.

I thank the Leas-Cheann Comhairle for this speaking time. I acknowledge the dedication, commitment and, above all, actions of Deputy Kelleher in proposing such a comprehensive motion on emergency departments.

Eventually, one gets used to the Government's style of counter-motions that are tabled week after week. Tonight's is a half-hearted, sly acknowledgement of a problem, yet it is riddled with self-congratulation and guff. These are followed by an attempt to shift responsibility for the problems created by this Government onto someone else before finally disassociating itself from direct responsibility for resolving the issues at hand. As a parliamentary technique, designing an amendment like this is grand, but it is difficult to see how citizens on the receiving end might see any solution to their problems.

The Minister for Health refers in his amendment to the addition of 149 public nursing home beds. What he fails to mention are the 7,000 residents of the 119 public nursing homes that failed to meet HIQA's physical environment requirements. I wonder how these older citizens and their families feel about the Government parties' approach to self-congratulation in its amendment. Only last week, the Minister of State, Deputy Kathleen Lynch, announced that, rather than bring HIQA's opinions to the Cabinet to ensure that sufficient funding was provided, she and the Minister, Deputy Varadkar, would solve the non-compliance problem by extending the deadline for compliance by six years. Pretend and extend, as it were. As a way of getting around failing to hit key performance indicator targets, this works from a political point of view but abjectly fails from the point of view of the thousands of citizens who languish on trolleys and in corridors in accident and emergency units. They and other vulnerable citizens have been told to take their place in the queue and that the Government has prioritised rewarding people on twice the average industrial wage with tax cuts. Those people must come first. The sick, the vulnerable and the senior citizens must wait.

This approach of shifting targets in order not to miss performance indicators is an admission of failure. It is an approach that the recent Ministers for Health, Deputy Leo Varadkar and, before him, Deputy James Reilly, have practised like an art form. What is the solution to failing to hit the average waiting times target? Double the target. The solution to failing to bring nursing homes up to HIQA standard is to extend the deadline.

After failing to address the accident and emergency crisis, however, the Minister changed his approach. In response to the recent case of a 91 year old man who was left on a hospital trolley for 29 hours, the Minister deployed his patented approach, that of the disinterested observer. He calmly and nonchalantly informed the nation that he was not surprised by what had occurred and that he expected more such instances to arise in the coming months. It was almost as if he believed that the deficiencies in the health service were an act of God, some kind of natural disaster, and that there was nothing to be done but shrug one's shoulders because we could expect these situations to happen.

While asserting that no one was to blame for the difficulties in accident and emergency departments around the country and carefully ignoring his own responsibilities as Minister for Health, he then opined that the health service would benefit from having sections of it privatised.

Here we get to what I believe lies at the heart of the matter. Fine Gael and, whether wittingly or unwittingly but as a patsy, the Labour Party have in health and in others areas of the public service engaged in a deliberate policy of degrading services and diminishing the expectations of the public, the members of which have a right to an acceptable service. Having stood over the degradation of public services, the Government uses the poor state of those services as an excuse to privatise them. Of course, they will be sold to the favoured few or perhaps the favoured one. I should not go any further with this line because someone is likely to make an accusation against the House in order to have the record redacted.

This Government has consistently failed to demonstrate the kind of urgent political will required to deal with the crisis in our health service. Instead, every year there has been a scramble for funds and an urgent requirement at the end of each year to address what is clearly a case of underfunding. The evidence of that is that there is no plan beyond the plan to fire-fight.

The question of whether there is political will in the Cabinet to face up to the future costs of the health service must be asked here tonight. Of late, the Minister's main rival for the leadership of Fine Gael seems more committed to buying F-15 fighter jets for the chaps in the Defence Forces than he is to funding public services. For some in Cabinet, the allure of NATO seems stronger than building the kind of state whose legacy we can celebrate in years to come. Before the current Minister took on the health portfolio, he successfully won plaudits and political capital for backing whistleblowers in An Garda Síochána. He did this against the interests and even the will of some of his Cabinet colleagues who sat with him at the table on the day. He rightly won praise, including from me, in the corridors of Leinster House generally and across the floor of this Chamber. However, his actions in the recent past contrast starkly with his silence in response to a HSE internal inquiry being launched against a whistleblower from within that organisation. I acknowledge the work of Dr. James Gray, who deserves the support of this House and the Minister. The Minister supported the Garda whistleblowers but he has refused to listen to those in both the health service and the mental health service. He and the Minister of State, Deputy Kathleen Lynch, have refused to listen to Deputies and to testimonies in the print media, in local media and on radio stations, including my local radio station, Galway Bay FM, a presenter on which, Keith Finnegan, deserves credit for his work in respect of waiting lists at University Hospital Galway. The Minister and Minister of State have not listened because they do not want to do so; they do not want to know the truth. To listen would mean they would have to face the consequences of the decisions they make within Cabinet in respect of the health portfolio.

During the recent debate on the Financial Emergency Measures in the Public Interest Bill 2015, I made what I believed to be a reasonable and uncontroversial statement:

The challenge for the next Dáil should not be primarily around a language of taxation and the economy. We do not live in an economy; we are citizens of a society. There must be a discussion about the fabric of our social structures.

I also said:

We need to start talking about delivering the social wage. We live in a society, not an economy. We can have the debate[s] side by side.

One can work with the other. Those comments are uncontroversial to me and I believe they apply to this debate. When responding to my comments, Deputy John Paul Phelan of Fine Gael, a Deputy for whom I have great respect, expressed something close to outrage and said the next general election should not be held on anything other than the economy, as if we do not have a society and as if the economy and society do not go side by side. For the Deputy, it is a question of the economy and the economy only. He said:

Fianna Fáil has learned nothing if it believes the primary debate in the next Dáil should not be about the economy and taxation. The economy should always be part of the primary discussion that takes place here and [elsewhere and across the constituencies].

In saying that, Deputy John Paul Phelan drew attention to the key difference between his policies and those of Fianna Fáil. He and Fine Gael believe that a government exists to serve the economy, while I believe a republic exists for the people and the good of society and that the economy ought to serve society rather than rule it. We are not a society of statistics. A statistical rise in GDP does not feed or clothe people. It does not respect the dignity of an elderly person in an accident and emergency unit, and it does not provide a disabled person with the dignity of his or her own citizenship within a republic. The solution requires political will and belief, and a value system should exist at Cabinet level.

Our accident and emergency units have become ground zero in the fight that must take place. As one of the highest-paid Ministers for health in Europe, Deputy Varadkar must roll up his sleeves and resolve the problem. We need to ensure a fairer society as we approach the next general election. Our communities require and expect that the most vulnerable people, some 350 of whom are to languish on trolleys in acute hospitals tonight, require this. What is occurring is completely unacceptable. It is not as if we did not know this set of circumstances was coming down the track like a train. The Minister knew and we were forewarned. Clearly, stronger political will is required. The Government does not have as part of the fabric of its politics the will to protect the most vulnerable.

I welcome the discussion initiated by Deputy Kelleher on the emergency departments and the need to have a frank, open discussion in this House on how we can resolve the problem. Like the Leas-Cheann Comhairle, I am a long time in this House. I have noted that the health services have used up a lot of debating time and energy down through the years. Despite the efforts of many Ministers, the brains of the country and top-class management, we never seem to be able to come to grips with the problems in the health service throughout the country. The ongoing crisis we are facing in our emergency departments is simply not acceptable and must be tackled without delay.

The Government has failed to keep its election promise to end dangerous overcrowding. It is estimated that 350 patients per year die as a consequence of the latter. The failure of the Minister to take definitive action on the real and serious risks to patients from overcrowding continues to threaten the lives of vulnerable and elderly patients attending accident and emergency departments. We receive e-mails from him stating heads must roll. I do not know whose heads he suggested should roll. Is it the management in the HSE, the management in the hospitals or that in the accident and emergency departments? The Minister has never really spelled out whose heads should roll. At times, he is inclined to blame others rather than tackle the problem head-on himself. This is symptomatic of the overwhelming failure of Fine Gael and the Labour Party to deliver on the programme for Government commitment on health. The problems in the emergency departments are symptomatic of a system-wide problem in the acute hospitals. The capacity issues must be addressed, which requires a system-wide response. What we really need to see is immediate enforcement of the six-hour target for the 1 million patients attending emergency departments every year, with an absolute ban on any patient staying over six hours in an emergency department.

The news that overcrowding in emergency departments increased by 14% during the year to October is yet another indictment of the Minister, Deputy Varadkar, during his tenure in the Department of Health. Last month was the worst October on record, with nearly 8,000 patients cared for on trolleys. I noticed this week that one of the hospitals in Dublin has tendered for the purchase of new trolleys. The Minister might explain who gives approval to buy new trolleys. Obviously, if the hospital is buying new trolleys, patients will be on them for the remainder of this year, next year and for years to come. I doubt that the hospital would invest in new trolleys unless there was a plan for their use.

In the first ten months of this year almost 80,000 admitted patients were on trolleys, which is the highest figure for the first ten months of any year since the INMO's Trolley Watch began. This comes despite the publication of the emergency task force report seven months ago. I do not know what happened to that report or if any action is planned following it, but it certainly does not seem to have any relevance in the Dublin hospitals at present.

As a Wexford Deputy I have a direct interest in the Dublin hospitals because County Wexford is now aligned with them. It is important that patients coming from Wexford do not have to spend their time on trolleys in accident and emergency units for more than 24 hours, as they do in some cases. Very little thought was put into that alignment because it does not seem as if the Dublin hospitals are able to cater for Dublin patients let alone those coming from rural areas.

The situation has been highlighted of elderly people spending 24 hours on trolleys while awaiting admission for urgent treatment. We had a 93 year old and a 91 year old in this position but those are only the ones whose cases were highlighted. I am sure there are many other elderly people whose cases were not reported in the newspapers. I do not think the Minister would accept that people of such an age should have to spend 24 hours or more on a trolley. Why would hospital management allow such a situation to occur and continue over 24 hours? Some people tend to blame nurses, but nurses in accident and emergency departments are worked to the bone. In many cases not enough nurses are on duty at night so they are not in a position to provide one-to-one support to elderly people.

Last week, the INMO suggested that a specific person should be designated to deal directly with people on trolleys. The designated person could ascertain the age of a patient and therefore try to fast-track elderly people into a hospital bed or at least have them treated without having to wait for 24 hours. It is a good suggestion and one the Minister should ensure hospitals act upon immediately, thus providing a designated person to deal with such a situation.

The six-hour target for 1 million patients attending emergency departments every year was a recommendation of HIQA which should be implemented without delay. I understand it is a four-hour target in the UK, so we should try to reach that target rather than going in the opposite direction with people waiting for up to 24 hours on hospital trolleys.

Dangerous overcrowding persists because it is tolerated and accepted as an unfortunate but normal side-effect of corporate governance failure from the top of the HSE down. I see it in Wexford and other hospitals, although I must compliment the management of Wexford General Hospital because it only had ten people on trolleys last month when every other hospital had huge numbers. That compares with 270 or 280 on trolleys in October 2014. Wexford General Hospital has a strong manager and management committee who have taken action to deal with the trolley situation. Other hospitals should do the same.

During the week, Beaumont Hospital had a ward with 30 beds closed due to renovations. With a bit of common sense, management would not have renovations going on in October, November and December when hospitals tend to be busy and overcrowded. Surely the management could have arranged to have renovations carried out in the wards at a less busy period in the year rather than waiting until now. I put that down to bad management and bad decision-making. That matter should certainly be taken up with the management of Beaumont Hospital. However, I must compliment the hospital because my daughter attends there regularly as she suffers from spina bifida. It is a very good hospital providing a very good service. However, decisions such as closing a 30-bed ward at this time of year do not make sense.

The lack of doctors in rural areas seriously impinges on overcrowding in accident and emergency departments. People tend to go directly to hospital rather than their local GP because in certain areas there is no local GP anymore. That is due to decisions taken by the HSE to withdraw funding they had in the past. That situation needs to be re-examined by the Minister. I wrote to him recently concerning a doctor in Adamstown, County Wexford, who finds it difficult to provide a service based on her current income given that many supports have been withdrawn. She introduced small charges for those attending her clinic to try to survive in that rural area of the county. However, she was reprimanded by the HSE because it was a breach of contract. She could not do that despite the fact that patients in that area were only too happy to pay a small fee to ensure the GP remained in the area rather than emigrating to Australia, Canada or elsewhere. That situation also needs to be dealt with.

I welcome that 64 new ambulances are being purchased. However, one ambulance person said to me recently in Wexford that despite the new ambulances, there is no one to operate them due to a lack of drivers. That service should be provided 24 hours, seven days a week throughout the country, but that is not happening. I had a case last week in my town where a woman unfortunately passed away. They rang for an ambulance to be told the ambulance was there but there was no driver. It did not make any difference in that case because the person had passed away. However, it makes no sense to have a state-of-the-art ambulance with no driver. These issues need to be dealt with.

The CareDoc system came in some years ago to keep people out of accident and emergency departments. If a person rings CareDoc now, however, they are usually answered by a nurse or someone else on duty. They will say to go to Wexford hospital, Kilkenny hospital or whichever hospital is nearest to the caller. They no longer provide the type of service that is needed.

Fire brigade action is required to deal with the problem of people on trolleys in accident and emergency departments. The nurses' union says there has been a complete failure of management to address identified areas of concern such as staffing, including recruitment and retention, the maintenance of a safe work environment for staff to enable them to care for their patients to the highest standard, consistent use of agreed escalation planning, enhanced senior clinical decision-making presence throughout the seven-day cycle, and improved access for triage nurses to order diagnostics to aid patient flow.

The INMO is making these requests of management but the buck stops with the Minister to ensure management will introduce such services. The INMO is also demanding safe, adequate and consistently available staffing levels and additional separate staff to look after admitted patients who are on trolleys. That is the point I made earlier, that there should be designated staff to deal with those on trolleys, to keep an eye on them and to ensure that they are not left on trolleys for one or two days but are seen to as quickly as possible.

Emergency departments should be designated as a specific place of employment under the Safety Health and Welfare at Work Act, thus requiring regular inspections to ensure staff health and well-being.

The motion serves to put pressure on the Minister and prompt him to deal with the problems now common and more or less taken for granted in accident and emergency departments throughout the country. Good management can deal with some of the problems but other problems remain, including lack of staff, reduction of staff numbers, difficulties recruiting staff, ambulance problems and doctors in rural Ireland leaving in droves - there is no longer a sufficient service in rural Ireland and this is leading to overcrowding in accident and emergency units.

I call on the Minister to take his responsibilities seriously. As I stated at the outset, there have been many debates in the House during my time here and I have been here a long time - some 32 or 33 years - the same as the Acting Chairman. No one seems to be able to get to grips with the health service despite the fact that so much money has been pumped in. The money is not being spent or used wisely. Despite promises from the top in the HSE and from the Minister, Deputy Varadkar, there seems to be a serious lack of proper management in the accident and emergency departments in all our hospitals throughout the country, but especially in Dublin. There seems to be serious problems in Dublin in respect of accident and emergency departments. I know there is a significant population in Dublin and that large numbers of people attend accident and emergency departments in Dublin. However, it should still be possible to manage the services to ensure that if trolleys are used, at least people are not lying on them for 24 hours plus, which seems to be the case at the moment.

The Minister for Health, Deputy Leo Varadkar, is sharing time with Deputies John Deasy, Michelle Mulherin and Dan Neville. You have 30 minutes in total.

I move amendment No. 1:

To delete all words after “Dáil Éireann” and substitute the following:


— that improving waiting times in Emergency Departments (EDs) is a key priority for Government;

— the wide-ranging set of actions which are being put in place by the Health Service Executive (HSE) to achieve improvements in the delivery of care in EDs;

— the difficulties which overcrowding in EDs cause for patients, their families and the staff who are doing their utmost to provide safe, quality care in very challenging circumstances; and

— that optimum patient care and patient safety at all times remain a Government priority;

notes in particular that:

— the Minister for Health convened the ED Taskforce last year and the publication, in April 2015 of the ED Taskforce action plan, with a range of time defined actions to (i) optimise existing hospital and community capacity; (ii) develop internal capability and process improvement and (iii) improve leadership, governance, planning and oversight;

— the Director General of the HSE is co-chairing the ED Taskforce Implementation Group from now until March 2016. This is to ensure that all relevant parts of the health service, including acute, social and primary care, are optimising resources to deal with the particular challenges associated with the winter months;

— the significant progress made to date on the ED Taskforce plan is as follows:

— delayed discharges are reducing steadily from 830 in December last year to 567 on 3 November and the average number of patients waiting greater than nine hours on a trolley in October was 115, down from 173 in February;

— waiting times for Nursing Home Support Scheme (NHSS) funding have reduced from 11 weeks at the beginning of the year to three to four weeks;

— transitional care funding has continued to support 3,000 approvals, which is significantly above the original target of 500;

— over 1,200 additional home care packages will have been provided by the end of 2015;

— 149 additional public nursing home beds and 24 additional private contracted beds are now open;

— in addition, 65 short-stay beds opened in Mount Carmel Community Hospital in September;

— 270 of 300 additional beds funded under the winter capacity initiative will open by the end of November. The remaining 30 will open in February 2016; and

— 129 hospital beds which had been closed for refurbishment or for infection control purposes during 2015 will be reopened by the end of November;

— the HSE has provided over 1,400,000 inpatient and day case treatments and over 2,400,000 outpatient appointments up to the end of September this year – an increase of 8% inpatient and day case treatments and 2.3% outpatient appointments compared to the same period in 2014;

— the provision of additional funding in 2015 to relieve pressures on acute hospitals is as follows:

— €74 million in April 2015 which has supported significant progress to date on reducing delayed discharges and lowering the waiting time for Fair Deal funding, as well as providing additional transitional care beds and home care packages to provide viable supports for those no longer needing acute hospital care; and

— €69 million in July 2015 – €18 million to support the acute hospital system over the winter period by providing additional bed capacity and other initiatives to support access to care and €51 million to ensure achievement of the maximum permissible waiting times for scheduled care;

— this additional funding came on top of measures already taken in budget 2015, when the Government provided €25 million to support services that provide alternatives to acute hospitals;

— all of the funding referred to above is additional to the welcome increase in the total financial resources made available to the HSE by the Government in 2015; and

— a series of campaigns are ongoing to attract frontline staff in order to meet patient care requirements;

— in the past 12 months there are over 500 more nurses working in the health service;

— since September 2011, over 300 additional consultants have been appointed to acute hospitals around the country, including 78 consultant appointments this year;

— the number of Non-Consultant Hospital Doctors employed in the health service has increased by 338 since last year; and

— ED consultants have increased by 30 since 2007; and

supports the Minister for Health in his continued determination to bring about improvements in urgent and emergency care services.”

I welcome the opportunity to update the House on what is being done to improve access to services in our acute hospitals. I acknowledge that too many patients throughout Ireland are still spending far too long in our emergency departments waiting to be seen, moved to a hospital bed or sent home. This causes difficulties and distress for patients and their families and makes working conditions more difficult for staff. That is why dealing with this problem is a key objective for the Government.

The events of last week, when a number of individual cases were highlighted in the media, were met with the familiar cries for more beds, money and staff. We have heard much the same from Deputy Kelleher and others tonight. However, this is already happening. The problem is more complicated with multiple causes and they all need to be addressed. Any efforts undertaken must be sustained.

I reconvened the emergency department taskforce in 2014 to provide focus and momentum to deal with the challenges presented by hospital overcrowding. Progress is being made on implementing the plan. The Government has allocated more than €117 million in additional funding this year to reduce overcrowding. We have got the fair deal scheme waiting time down to between three and four weeks, from 15 weeks this time last year. This has freed up 225 hospital beds every day and is supporting hospitals to re-open closed beds as well as add more beds. Over 500 more nurses are in place compared to 12 months ago and we have more registered doctors than ever, with a further 338 non-consultant hospital doctors and 78 consultants appointed this year.

As I mentioned there are a number of different causes that can give rise to hospital overcrowding and it is worth setting them out. First, there are demographic pressures. The growing and ageing population is causing a small but relentless increase in demand year-on-year. Second, the level of attendances can increase or decrease for all manner of reasons, including general practitioner referrals, influenza, weather or accidents. Third, admission rates vary widely from hospital to hospital. In some hospitals, patients are twice as likely to be admitted than in others. This can be cultural or down to the fact that a particular doctor will admit more patients than necessary. Less experienced doctors and locums have a lower threshold for admissions than experienced or more senior doctors, who are more confident in sending a patient home. There is also the issue of elective admissions. This involves patients being brought straight in for surgery or from a clinic and into a hospital bed rather than through an emergency department. Some hospitals manage this better than others by taking more people in when trollies are low and restricting the number when numbers on trollies are high. Others manage it less effectively. There is also the question of length of stay. Some hospitals can sort out the average patient in four days. Others might take a week, thereby using twice as many beds to do the same amount of work. This is often linked to getting tests and scans done, skeletal services at weekends or slow decision-making due to infrequent senior clinician-led ward rounds or board rounds. Other factors include care provided on an outpatient basis and the operation of acute medical assessment units.

Some hospitals can complete investigations in a single day and therefore the patient need not be admitted. Others must admit a patient. This requires a bed to be allocated simply to get investigations carried out. Then there is the question of bed capacity. Some hospitals may simply not have enough beds. Another area where capacity can be a problem relates to the delayed discharge of patients from hospitals. Some areas do not have enough nursing home capacity or home care packages and this means patients can be delayed leaving hospital. I was keen to explain this point to Deputy Keaveney, although he has left us. That was why the decision was made to spend more time meeting the HIQA standards. The alternative was to start closing down or blocking admissions to district hospitals and community hospitals throughout the country, something neither the Minister of State, Deputy Lynch, nor I could stand over. It does not make sense to say that a four-bed or six-bed ward is not up to standard while we allow other services to have 40 people on trolleys in an emergency department. That is why we made the decision. It was for practical reasons. More important, we now have the type of budget that was not available in the past six years because of the economic crisis. It will allow us to refurbish and replace these old nursing units, some of which are over 200 years old. I welcome the support of the Irish Nurses and Midwives Organisation for that decision.

There are many other issues related to efficiency or lack of efficiency in the operation of a hospital. Hours can be lost getting the discharge paperwork for a patient done, getting prescriptions written or getting the bed cleaned for the next patient. This could be done in an hour but sometimes it can take as long as five hours, thus leaving someone else on a trolley during that time even though a bed is available. I visit hospitals all the time on either an announced or unannounced basis. Often I see overcrowding in the emergency department and then empty beds on the wards. That is most frustrating and simply not acceptable.

Another cause is bed closures. This can occur for a number of reasons, including staff shortages, renovations or infection control. There is also the interaction with primary care provision in a given area. Where community intervention teams are in place patients can avoid admission or be sent home early since the nurses in the community intervention team can administer intravenous drips at home or in a nursing home. They can also check wounds or monitor blood levels. When these services are not in place, patients have to stay in the hospital until everything is sorted out, thus lengthening the average length of stay. There is no simple or quick-fix solution to the problems in our emergency departments. I note Deputy Kelleher brought the matter back to the time of my predecessor, the former Minister for Health, Deputy Reilly. Of course he could have brought it back further to the time when he served in Government alongside the former Minister, Mary Harney, or when his party leader and now candidate for Taoiseach, Deputy Micheál Martin, was Minister for Health and Children.

Our approach to tackling this issue is to address the challenges throughout the health service. We must ensure all relevant parts of the health service, including acute, social and primary care, are working together to make the best use of resources. Experience has taught us two key lessons. First, additional hospital beds alone will not resolve the difficulty. Services and capacity in primary and community care are equally essential. They support people outside of hospital enabling them to access care in a primary or community setting or assisting them in the move out of hospitals to home or residential care. Second, today's cancelled operations are potentially tomorrow's emergency presentations. Therefore, it is equally important for us to balance planned and emergency care needs to prevent delays in diagnosing or treating illness that could result in greater needs for emergency intervention next week, next month or next year.

The real answer is to continue to implement the tailored solutions we are already working on, in particular the 88 actions identified through the emergency taskforce. The actions are a combination of immediate measures to target the pressure areas - fire brigade action, as someone else referred to it - as well as long-term sustainable solutions, which of course will take time to implement. These are designed to address emergency department overcrowding, provide specific care pathways for frailer patients, specifically elderly patients, and facilitate early discharge planning, beginning when patients first come into the hospitals with community and primary care services closely involved. The solutions also envisage more efficient discharge processes, including weekend discharges in order that patients can be discharged as soon as they are medically fit and better access to home-care and care in the community. Other plans include making the best use of all the non-emergency department facilities available, such as medical assessment units, minor injury units and urgent care centres as well as reducing delayed discharges.

Delayed discharges refer to patients who have been medically discharged and are waiting to go to a nursing home or home with supports. They are now steadily reducing. The latest figure is 567, the lowest in many years, compared to a high of 830 last December. This means we have freed up approximately 265 beds every day to be used by patients, which is a capacity increase equivalent to a medium-sized hospital. In addition, by the end of 2015 we will have provided over 1,200 additional home care packages, 149 additional public nursing home beds, including a new community hospital in Mount Carmel and another to open the next few weeks, 24 additional private contracted beds to support Drogheda and 65 short-stay community beds. All of these have been open since the summer.

These very significant increases in capacity are beginning to be reflected in emergency department performance. While it is still extremely challenging, the number of people waiting for nine hours or more on a trolley fell to an average of 115 in October, compared with 127 in June and 173 in February. We know the hospitals which are most affected, and these have been the subject of a particular focus in supporting them to implement solutions.

We also know the hospitals that have demonstrated specific improvements in areas such as length of stay, trolley waits, delayed discharges and helping patients and their families negotiate the fair deal applications process. These include Mullingar, St. Vincent's, Connolly Hospital Blanchardstown, St. James's, Portiuncula and Mercy University Hospital. I could have mentioned Wexford, as Deputy Browne did, favourably as well. Common to all of these sites is strong executive and clinical leadership, and integrated working across the community and social care services and national clinical programmes.

We also need to provide more alternative models for pre-hospital care so that ambulances do not necessarily have to transport every patient to a busy emergency department. I have asked the National Ambulance Service to review protocols and I expect some progress on this matter in 2016.

We have a very high volume of activity in our acute hospitals. On average, 250,000 outpatient appointments and between 120,000 and 130,000 inpatient or day case procedures are carried out every month. The HSE has provided over 1.1 million inpatient and day case treatments and over 2.4 million outpatient appointments up to the end of September this year, an increase of 8% in inpatient and day case treatments and a 2.3% increase in outpatient appointments compared to the same period in 2014. The health service is expanding and doing more, rather than being cut back, and the facts show that.

As I said, we must also address access to hospitals for elective work. Additional funding of €51.4 million provided by the Government in 2015 has allowed the HSE to maximise capacity across public and voluntary hospitals, as well as outsourcing activity where the capacity is not available to meet patient needs within the maximum allowable waiting time. The latest NTPF figures published last Friday show reductions in total inpatient and day case waiting lists, in the numbers of patients waiting between 15 and 18 months and those waiting over 18 months. Similarly, there have been reductions in the total number of people waiting for outpatient appointments, which has fallen below 400,000 for the first time this year. At the current time, 85% of patients wait less in a year.

The HSE is working with hospital groups towards a new maximum waiting time of 15 months by the end of the year. As part of this work, the HSE is applying fines to hospitals which breach the maximum waiting time in order to incentivise improved performance for the longest waiters. The Opposition talks about accountability a lot, but seems to express absolute outrage at the notion that any hospital be held to account for its performance. Where hospitals fail to meet performance targets which others can meet, and where those reasons are internal as distinct from other causes, then that needs to be tackled. When additional resources are invested, patients and taxpayers have a legitimate expectation that questions should be asked if improvements are not secured and actions taken. What is the Opposition’s alternative? Its solution is to throw good money after bad, as it did in the past. That is not a solution or an alternative.

Primary care services are also helping by providing alternatives to hospital emergency departments, such as GP out-of-hours services and primary care teams, reducing emergency department attendances through avoidance measures such as access to primary diagnostics and the provision of chronic disease and minor injury care in primary care settings and also enabling earlier discharge from hospitals. GP out-of-hours activity has increased by 10,000 patients in 2015 and community intervention team, CIT, activity, which is particularly focused on relieving pressures in emergency departments in hospitals, has increased by 30% compared to last year, with some CITs now actively working in nursing homes. Where equipment, aids and appliances are required to facilitate hospital discharges, community teams are given priority to acquire these, and palliative care and end-of-life services in the community are also being enhanced, such as additional beds in Galway and nurse specialist appointments which are now under way.

The difficulties in the health service have been exacerbated by recruitment challenges, which is well known. Less well known is the progress being made. According to the HSE, the number of staff employed in the public health service has increased by over 4,700 full-time equivalents over the past 12 months, with a focus on medical and nursing recruitment. Government policy is to move to a consultant-delivered service and the number of consultants has grown significantly in recent years to 2,700 full-time equivalents. Between 1 January 2015 and the end of September, the HSE has offered 82 consultant posts, 78 of which have been appointed and 69 have taken up duty. The number of non-consultant doctors has increased by over 1,000 in the past five years and now stands at 5,500, the highest ever. There are 500 more nurses on the health service payroll than 12 months ago.

We are now facing into what is very likely to be a challenging winter period. It is imperative that we sustain the momentum of the various initiatives I have already outlined. To that end, additional funding of €18 million has been provided for winter initiatives which will increase the capacity in our acute hospitals. Some 301 additional beds are being opened and 129 beds which had been closed are being reopened, subject to staffing. I appreciate the positive comments of Deputy Brown on the spina bifida services in Beaumont Hospital, which are very good. I understand what he said about the wisdom of closing St. Damien's ward at this time of year. It is never a good time to close down or renovate a ward, in particular in a hospital as busy as Beaumont, but it needed to be done and it is a specialty kidney and renal ward. It had to be done for patient safety and outcome reasons. I am assured by the management in Beaumont that the ward will reopen this month.

Work is ongoing on other specific initiatives, and some have already commenced. For example, a new eight-bed clinical decision unit and four-bay surgical assessment unit are now open in Our Lady of Lourdes Hospital, with further beds to open later this month. The day hospital service in Beaumont has increased from two to three days and will become a five day service in the course of this month, giving elderly patients, in particular, an alternative way into the hospital rather than having to go through the emergency department. A similar system exists in the Mater through Smithfield.

Additional beds have been provided at Connolly Hospital Blanchardstown for overflow capacity and to take some benign surgical work from Beaumont, alleviating the situation there. The new Leben building in Limerick has been opened, providing an additional 24 beds in the stroke and cystic fibrosis units. At long last the cystic fibrosis and respiratory unit has opened in Cork University Hospital.

I have heard much talk from the Opposition about the need for additional resources to address the problems in our emergency departments, but unfortunately all it has been is talk. Sinn Féin and Fianna Fáil in their alternative budgets for 2015 provided nothing at all to address emergency department pressures. In contrast, we have provided €117 million and a further €51 million to address waiting lists. It is fair to acknowledge that they recognised the issue in their alternative budgets for 2016, promising to provide €86 million in the case of Sinn Féin and €90 million in the case of Fianna Fáil, but that is still less than the €117 million we provided in 2015 and the further significant funding we will provide in 2016.

Both parties talk a lot about the need to hire more staff, but Sinn Féin’s plans are to cut consultant and management pay and increase their taxes, in a move that would be guaranteed to make recruitment more difficult. Fianna Fáil, in its alternative budget, made no provision for the Lansdowne Road pay restoration for nurses, young doctors, ambulance drivers, paramedics and therapists. I do not see how we could possibly recruit more staff if we were not to fund or reneged on the commitments made in the Lansdowne Road agreement.

It is little surprise that in the case of Fianna Fáil joined-up thinking is so absent. After all, it ran away from the health ministry in 2004 after Deputy Martin’s period as Minister for Health. During this time, the Fianna Fáil-led Government, supported by Independents, promised to end waiting lists permanently within two years and ensure sufficient bed capacity in hospitals. Instead, it set up the HSE. Thereafter, so scarred by the experience it was happy to leave the ministry to Mary Harney even after the demise of the Progressive Democrats in 2007. Nobody in Fianna Fáil wanted the job, so it left it to an Independent. I expect it is the same old Fianna Fáil, and it does not want the job now and will not want it after the election.

Fianna Fáil's record in health speaks for itself. It set up the HSE and now wants to get into power to stop Fine Gael dismantling it. It spent more than €100 million on the IT systems known as PPARS, which did not work. It took free GP care from the over-70s, but the current Government has restored it not only to the over-70s but to all those under six years of age. Let us not forget Deputy Micheál Martin's famous response to the emergency department overcrowding that occurred when he was Minister, which was to complain that the hospitals had not ordered enough trolleys.

My focus is on patient outcomes, not on rhetoric, which is all we hear from the benches opposite. I am focused on making sure that patients receive the care they need when they need it. This is a substantial challenge for the health services, which were seriously damaged as a result of the economic crisis, caused in no small part by the actions and inaction of the last Government.

In any debate about health care, whether it is in this House or in the media, numbers are thrown around like confetti. The House should be assured that we are making some progress, and this is borne out by a reduction of 13,000 in the number of people on trolleys, which equates to a 16.7% reduction compared with 2011, the year in which we took office, and the fact that 85% of people who require an outpatient appointment or surgery are seen in less than 12 months.

The initiatives I have outlined this evening are slowly but surely gaining traction and are beginning to make a difference not in all places but in some places and not for all patients but for some patients. It is too simplistic and, indeed, wrong to suggest that it is just a question of increasing funding or staff or capacity in our hospitals. On any given weekday the number of people on trolleys peaks at around 300; it rarely exceeds 500. One would think, therefore, that putting an extra 600 hospital beds into the system would resolve the problem. I hope I have explained the reasons it will not be that simple. I ask the Members opposite, any of whom could be in the next Government, to be careful about the comments they may make because they may live to regret them in only a few months' time. Sustained investment, sustained reform and performance improvement are needed. Short-term solutions will only work in the short term, if at all. I can assure the House of my ongoing commitment and that of the Government.

The motion mentions poorer outcomes for patients, safety and quality of patient care, standards of treatment, elderly patients and conditions that may jeopardise patient care. If one just arrived from a different country, walked into this Parliament and picked up the motion and read it, one would probably consider it to be quite reasonable if one did not know who was running the health system between 2000 and 2011 and what those people did when it came to health care budgets, particularly as it relates to directing money towards the patient. They are the same people who drafted the motion. Within our system, if one excludes general practitioners and other primary care services, the average figure for pay in all operating environments or units is between 70% and 90% of total costs. In acute hospitals pay accounts for more than 70%, and in disability services it is about 90%, making a rough average of 80% in those operating units. I dealt with pay in the Committee of Public Accounts a couple of years ago. Let us look at pay trends from 2002 onwards. The 2002 outturn pay figure for the health boards was €3.5 billion. By 2012 it had increased to €4.71 billion, a 35% increase. In voluntary hospitals, pay accounted for €1.13 billion in 2002, and by 2012 that figure had increased to €1.55 billion, a 37% increase. The collective trend is approximately 36%. That gives an idea of the increases during that ten-year period.

The HSE's annual financial statement shows that its basic pay increased by 24% between 2005 and 2011. The increases grew in the past six years, and in the last decade allowances increased by 22%; for example, night duty pay increased by 18%. Generally speaking, there were very substantial pay increases across the board. In the HSE's pay costs for management and administration, there was an increase of approximately 24% between 2005 and 2011. Those are the figures in the financial statements and the accrual accounts. Given that about 80% of the spend in the operating units goes towards pay and salaries, one comes to the conclusion that when the party that drafted this motion had control over the health system the directing of increases in the health budget towards the patient was not a priority. That statement is backed up by hard figures and facts. As everyone knows, when people get used to increases in their pay it is very difficult to reverse them; it is almost impossible. Health care workers deserve to be well paid. I am trying to point out that most of the new money injected into health care between 2002 and 2011 was not channelled towards essential services or to the front line or directly to the patient. When I read this motion, knowing that by 9 o'clock tomorrow evening the voices opposite will get louder and more accusatory and a little angrier, it is worth pointing out when the party opposite was in power it spent most of the extra money in health on pay, not on the patient. The facts prove that.

With regard to the issue of people on trolleys in emergency departments, I compliment the Minister, who has not been ducking and diving. In December 2014 he convened an emergency department task force. The reality is that there has been a serious conversation and a serious analysis of the issues leading to the overuse of trolleys, and a serious effort has been made to address it. Sometimes that is forgotten in the very hard cases that we hear of, and without doubt it is serious when people, especially the elderly, end up on trolleys. When the top people in the HSE work with the Minister, there is a concerted effort to find a solution. It is not a simple solution. A multifaceted approach is required to address delayed discharges, including improving access to diagnostic procedures. It is a question of ensuring that people go through the system more quickly and that those who need to leave have an appropriate bed to go to, whether in a step-down or a nursing home facility, or, if going back to their own home, that they have a home care package or something of that sort. It is quite complex. In the case of Mayo General Hospital, there has been an increasing demand. From the beginning of the year to date, aside from the surges, we have seen a 1% increase in demand. The much-talked-about issue of an ageing population is not in the future; it is now. We see more elderly people presenting with chronic illness who are in our hospitals in medical beds.

In the brief time available to me, I compliment the Minister, whom I have approached with many health issues. The investment in Ballina District Hospital means that all step-down beds are open; this has also happened in Swinford District Hospital and, to a certain extent in Belmullet Community Hospital. This all helps the situation. Ten extra full-time permanent staff are employed. The hospital and staff do a great job. Prior to the establishment of the task force, Mayo General Hospital achieved a substantial reduction in the number of people on trolleys simply by implementing a change of approach to bed management and addressing the issues of delayed discharges and so on. Ultimately, however, there is an increase in demand across the board, which has undone some of the good work done.

In respect of the fair deal scheme, this time last year there were 79 people in Mayo waiting to be approved and validated. Today, there are four people waiting for approval. That means more people can get into nursing homes. The focus on home help, home care packages and so on has helped people to remain in their homes.

There has been increased investment in primary care centres and services. Much good work has been done but until we eradicate the trolley issue or bring it to a position of minimal effect, the work will not be completed.

I pay tribute to the management and staff of Mayo General Hospital and particularly those who work in the accident and emergency department there. They demonstrate out and out commitment to providing the best possible care for patients. They are very pragmatic and, especially when we see so many people in the accident and emergency department and on trolleys, it can be very trying for patients and staff. We must continue to work towards a solution and I know that is what the Minister is about. He has my support in that regard. It is worthwhile to show all the efforts that have been made as it is a complex issue.

I welcome the opportunity to discuss the motion. I will deal with one element, namely, that the safety and quality of patient care must be a primary focus, with timeliness being a crucial component of quality care. I fully agree with that. In the short time available, I will discuss regulating the area of psychotherapy and counselling. As the Minister knows, I spoke with him about this matter at the health committee meeting on 20 October. Earlier today, I spent a full hour with a person who has had serious difficulties with a psychotherapist. We regularly hear from people like Bodywhys, the eating disorders association of Ireland, that there are serious difficulties in this area. It is ten years since the then Minister promised there would be regulation of the sector as quickly as possible under the Health and Social Care Professionals Act 2005. I know the Minister obtained a report from CORU, the regulating advisers, about this in March this year. There will be further soundings and we will hear more at the end of this year or early next year. There is disagreement among bodies in some respects.

Patient care is a key issue. It is not acceptable that somebody may achieve an advanced diploma on suicide in the course of six weekends or that someone else may obtain a diploma on eating disorders, which is a highly complex area both in psychiatric and physical terms, over eight weekends. I take this opportunity to highlight the urgency required after ten years to bring about regulation.

Deputies Ó Caoláin, Tóibín and Stanley are sharing time.

The Minister did his best to talk down the crisis in our health services but he will now have to hear some of the reality of the impact on service users and those dependent on it. Reports last week of a 91-year-old man spending 29 hours on a trolley in Dublin’s Tallaght hospital, while his wife was also on a trolley for nine hours, depict a health service that is on its knees. This news emerged following a letter from Dr. James Gray, an accident and emergency department consultant, to the chief executive of Tallaght hospital, in which he claimed that there were "grave and dangerous governance failures". The position in which this elderly man found himself was absolutely appalling and a clear violation of his basic human rights. Last week, there were also horrific newspaper reports of an elderly woman placed in an all-male ward due to overcrowding in South Tipperary General Hospital and who was allegedly subjected to a horrific sexual assault. Another report is that of Mr. Dualtagh Donnelly, the father of two who bled to death while waiting 40 minutes for an ambulance to arrive, despite his family home being only five minutes from the Dundalk ambulance station. He lived close to Louth County Hospital, where the accident and emergency department has been closed. This litany of horrendous events stretches way back. In December 2014, an 87-year-old woman spent 57 hours on a trolley and a chair in a hall in University Hospital Limerick. In June 2015, two elderly ladies, both over 100 years old, had to suffer the indignity of spending more than 24 hours on trolleys while awaiting hospital beds. In September 2015, an elderly cancer patient spent five days on a trolley at Our Lady of Lourdes Hospital in Drogheda.

These are not isolated incidents and I am sure there are many more of which we have not heard. Our health service is a shambles. Overcrowding continues to increase and all measures taken to date have failed to address the critical issues of bed capacity and staffing. Last month was the worst October on record, with 7,971 admitted patients cared for on trolleys. In the first ten months of this year almost 80,000 admitted patients were on trolleys, which is the highest ever figure for the first ten months of any year since Trolley Watch began. According to the Irish Nurses and Midwives Organisation, INMO, in October, for the 15th month in a row, there was an increase in the level of overcrowding in accident and emergency departments. The latest monthly figures also confirm that 25 of the 29 accident and emergency departments have endured an increase in overcrowding in 2015 compared with the same ten-month period in 2014.

Beaumont Hospital's accident and emergency department recently had to go off call as a result of severe overcrowding. It is unbelievable that in 2015 patients and workers alike have to deal with conditions like this. As a result of these intolerable workloads, the INMO has begun balloting its members working in accident and emergency departments in respect of possible industrial action. This Government, faced with the enormity of the challenge of dealing with this crisis, has utterly failed in its obligation to alleviate the suffering caused by a health system in tatters. Efforts by the Government to date have amounted to little more than a stand-still response, holding things as they have been rather than investing and resourcing the identified needs of our health service.

The latest fanciful notion from this Government and the Minister's mouth is that hospitals that consistently underperform will see their management passed over to a private operator. I am aghast to think of how this would affect patients, particularly as they would then be at the mercy of a profit margin. The Minister also wished to incentivise hospitals to do more work. This would suggest that the overstretched men and women in our hospitals - in whatever role they play - could be induced to do more for our health service. This is simply not true, as the nurses in St. Vincent's Hospital have been forced to take industrial action to highlight.

Last week, the Minister, Deputy Varadkar, stated that it was "indefensible" that any patient was forced to spend more than 24 hours in an accident and emergency department. I remind him that he also stated a number of months ago that there would be "zero tolerance" of patients requiring hospital admission waiting in accident and emergency departments for more than 24 hours. So much for zero tolerance. He continually states that there is a plan in place but this plan is not working. The crisis is escalating at a ferocious rate.

A severe shortage of nurses is a major contributory factor in the current crisis. Nurses are choosing to go abroad because of poor working conditions and the lack of career prospects here. A Health Service Executive recruitment scheme to encourage Irish nurses working abroad to return home and take positions in the health service here has been extended after it managed to attract just 77 people. The aim behind the nursing in Ireland initiative, announced on 23 July, was to recruit 500 Irish nurses and midwives within three months. At least 4,000 additional nurses are required as a matter of urgency in our health service. The Government must engage in a massive recruitment campaign to bring nurses back home and encourage more nurses training in Ireland to stay in service in their own country. This must be combined with a drastic improvement in working conditions at home or else all will be for naught.

This is not about money, although the Government has made matters worse through its savage cuts under the financial emergency measures in the public interest legislation in recent years. Our public health service is severely under-resourced and requires a commitment not only to new investment but also to the public ownership model itself. This seems not to be forthcoming from Fine Gael and, even more disgracefully, from the so-called Labour Party. The Government has provided €18 million euro in additional funding for health in 2016 when demographic pressures and the Lansdowne Road agreement are stripped out. That is what the budget 2016 document says and that is what the Minister, Deputy Howlin, placed on the record in this House not many weeks ago, and yet the Minister still provides multiples of that with his colleagues in government - nearly ten times that amount - in tax relief to those who earn in excess of €70,000. This is a damning indictment of the Government's approach to the health crisis.

The health service has gone through five years of sustained vandalism. The current and previous Governments have gouged €3.3 billion and 9,000 staff out of the health service. As a result, the points of access for citizens into the health service have been severely restricted. In my constituency we have Navan hospital and we have a hospital in Drogheda. So far this year, 7,700 people have been forced onto trolleys by the Government. That is the whole population of the town of Trim, every man, woman and child. The equivalent of that population has been forced onto trolleys in those two hospitals in our region. Being put on a trolley means delayed diagnosis, delayed treatment and poorer outcomes. It can mean significantly deteriorating health or death, yet the small framework document, which is the official policy document of the Government, seeks to close the emergency department in Navan hospital. Will the Minister ensure this document is no longer the policy document for the Government?

Access to hospitals via ambulances has also become more difficult. I know of 40 separate cases where ambulances took at least one hour to come to emergencies in my county in recent years. There were fatalities in seven of those cases. In the past week we heard of the tragic case of a young father, Dualtagh Donnelly.

Access to hospitals via waiting lists has also become more difficult, with 69,000 people on inpatient and day case waiting lists, 401,000 people waiting on outpatient lists, children on painkillers waiting more than six months to access dental treatment, and 3,000 children on waiting lists for mental health services. The backdrop to this is a high and increasing youth suicide rate. At the same time, the Government seeks to close the 24-hour psychiatric unit in Navan. It was supposed to be closed at the beginning of last month but has been pushed out until after the general election. This is despite reduced bed capacity and people being turned away. This is a false economy. If diagnosis and treatment are delayed, hundreds of thousands of people will see their health deteriorate. It will necessitate more crisis interventions, which cost money and clog up acute emergency services.

Under the stewardship of the Minister, the unacceptable has become the normal in this State. I wish to raise with the Minister a petition that has gone before the petitions committee from a constituent of mine in County Meath who believes strongly that water is being contaminated in houses throughout the State. This water is being pushed from pressurised heating systems into the household water and then, through shower units, is leading to respiratory disease among a large section of the population. Will the Minister draw this to the attention of the HSE and have it investigated? Prevention is better than cure.

I welcome the opportunity to speak on this motion. No one can deny we have a crisis in emergency departments throughout the State. The facts are there. While we have a crisis throughout the State, the Portlaoise emergency department is fighting for its very survival. A report was commissioned under the stewardship of Dr. Susan O'Reilly and we were supposed to have its conclusion and outcome in September. However, we now find it is delayed and, two months on, we still do not have it. I am raising the question of whether it is being delayed until after the general election. I hope not because the people of Laois and beyond want to know what is happening to their emergency department.

Portlaoise is one of the busiest emergency departments outside of Dublin. An average of 40,000 patients go through that unit. The number of patients on trolleys has increased by 60% on last year. They are the facts and the figures are there to show that. There are a number of problems, the main one being that there is only one temporary consultant and some out-of-hours cover by a visiting consultant. There is no emergency department on call outside of 9 a.m. to 5 p.m. That is not acceptable and we know the damage it is causing to the viability of the unit. We also have a shortage of nursing staff in the unit, which needs to be improved. There are only 39 medical beds in Portlaoise hospital and I am told by staff in the hospital that this is causing a bottleneck in the emergency department because beds are not available to move the patients off trolleys, through the emergency department and into the medical wards. There are only 39 beds and ten more are needed. Other hospitals are having difficulties but they have more staff available per patient. The budget in Portlaoise at one stage was in the region of €52 million per annum. At the moment it is in the region of €47 million. That is a real problem because it costs money to employ nurses, consultants and other staff. The hospital needs to be funded as a busy regional hospital, not just as a small local hospital.

Obviously we want emergency departments improved throughout the State and we have a crisis. We need the report into the situation of the emergency department in Portlaoise to be published. We were supposed to have it in September. Will the Minister bring that forward to provide the 24-7 on-call consultant coverage we need in the hospital and to provide the nurses who are needed? About eight extra beds are needed in the medical wards. Those extra beds would transform things in Portlaoise. Will the Minister for Health provide those? The INMO members are not threatening to go on strike for their own gain. They stated very clearly that they are going to do so because they are concerned about emergency departments and the risks to patients. They want to ensure the health, safety and well-being of their staff on the front line. That is what they said. We must listen to these people who are at the coalface. We must provide the supports, the finance and the resources to staff these emergency departments properly. Portlaoise urgently needs the three actions I outlined.

We can all agree that health care should be based on need. With the health care budget we have, which is massive, we should have a state-of-the-art health service. We have excellent care for people once they get into the system, but getting in is the problem. That is the thrust of the motion. Tá sé uafásach éisteacht leis na fadhbanna atá ag daoine, go háirithe seandaoine, le déanaí. Cad ba cheart dúinn a dhéanamh?

I acknowledge the work of the doctors in local areas who are doing their best to keep people out of emergency departments. We must remember that they are just for accidents and emergencies. These doctors, with additional equipment and facilities, could stay open much later and prevent more people going to emergency departments when they could go to their local doctor. We need to look at emergency departments in terms of the demands on the service. Those presenting with addiction issues need a separate facility which should not to be imposed on the general population, because that is not fair to either group.

To break the cycle of addiction, we need staff who are trained in addiction and we need a service where those who present drunk or drugged in accident and emergency have an opportunity to sleep it off, get the medical care they need but, more importantly, be linked in to detox, community programmes or whatever because at present the emergency department is a revolving door for those in addiction. According to the statistics from the HSE for August 2015, some 8,000 plus were returning attendees. I wonder if there is a breakdown of those and how many of them were presenting in addiction.

Another group who have significant difficulties at accident and emergency departments are those who present with mental health issues, autism and Asperger's syndrome. Accident and emergency is a nightmare for them. Designated intellectual disability nurses would ease that situation for such people. I ask that the Minister look at a separation of services.

Regarding the waiting time for knee and hip replacements, I thought patients were making progress in this area but the calls are coming in again. I am hearing of delays with hip and knee replacements. If the replacements were done speedily, these patients would not have to give up their jobs, which is what they tell me they have to do. It is worth considering that they could be back in work paying their taxes rather than in a situation where they are a cost to the State. There is a role here for the treatment abroad scheme. It would be interesting to conduct a cost-benefit analysis on what it costs the State to have someone out of work as opposed to utilising the treatment abroad scheme. If the private health care system can be run efficiently and promptly, why can that not be replicated in the public health service?

Great work is being done by our doctors and nurses, and they are in demand abroad. While the salaries that those abroad would get here might bring them back, one aspect they will not come back for is the working conditions here because they have better working conditions abroad.

I thank the Acting Chairman, Deputy Durkan, for the opportunity to participate in this urgent debate on the health service and the lack of supports in accident and emergency departments. It is a national scandal that the Government still has not fixed the health service and provided safe and quality service for all of the people. Elderly patients and persons with disabilities are being left lying around and, in some cases, with no services.

Today, in my constituency office in Donnycarney, a mother of a 28 year old severely disabled young man told me of her recent experience in Beaumont Hospital. Her son, who has severe cerebral palsy, is PEG-fed, non-verbal and five stone in weight. His mother made the following points. His feeding system has a balloon attached to bring the food, fluid and medication to his colon and when this bursts, which can happen at any time, it cannot be replaced in the accident and emergency department but must be done through the radiology department in Beaumont that he has attended for the past ten years.

On Saturday, 31 October at 6 p.m., his mother took him to Beaumont as the PEG had burst. There was nobody in radiology to deal with this, as it was only open for stroke victims but if it had been an emergency, the team would be called in and they would see him. His mother was very concerned that her son would receive no food, fluid or medication if this was not rectified, but the doctor in accident and emergency told her to take him home and just feed him as normal, which is what his mother and her husband did after receiving this advice from a trained doctor. On Sunday, 1 November, they returned to Beaumont to the same experience, with nobody in radiology to see their son. They went back on Monday, and when they got to see the doctor in radiology, he said it was not okay to feed their son through the broken tube as their son cannot vomit if there is something wrong so they queried the authority of the doctor on the previous visit.

Normally, the procedure takes ten to 15 minutes to perform, but this day it took over an hour. They could not get the tube in and her son was very agitated, which was upsetting for herself and her husband. The doctor took them both aside and explained how dangerous this procedure had become and that this was due to the mother feeding him through the broken tube. Their son's temperature was now reading 38.5°C and the doctor told them to take him back to accident and emergency. At this stage, the mother was quite worried about her husband, as it was taking its toll on him. Her husband is 70 and the mother is in her 60s. They took their son home, as they had had enough of Beaumont over the weekend.

The mother and her husband have never been away from their son's side since he was born and would like to know what are his rights. He is being discriminated against because he has no voice. This has to stop in Beaumont. Nobody seems to be in charge. This family is suffering. I ask the Minister what are the rights of this person with a disability? Does he and his family deserve a quality health service? The Minister needs to act, and act now.

Debate adjourned.
The Dáil adjourned at 9.05 p.m. until 9.30 a.m. on Wednesday, 11 November 2015.