JOINT COMMITTEE ON HEALTH AND CHILDREN díospóireacht

Irish Hospital Consultants Association: Presentation.

Vice Chairman (Deputy Devins)

The purpose of this meeting is a discussion with the Irish Hospital Consultants Association, IHCA, regarding public hospital services. I welcome Dr. Josh Keaveny, president of the IHCA and consultant anaesthetist at Beaumont Hospital, Dr. James Binchy, consultant in emergency medicine at University College Hospital Galway, Dr. Gerard Lane, consultant in emergency medicine at Letterkenny Hospital, Dr. Gerard McCarthy, consultant in emergency medicine at Cork University Hospital, Dr. Paul Browne, consultant haematologist at St. James's Hospital, and Mr. Finbarr Fitzpatrick, secretary general of the IHCA.

I draw attention to the fact that while members of the committee have absolute privilege, this privilege does not apply to witnesses appearing before it. Members are also reminded of long-standing parliamentary practice to the effect that they should not comment on, criticise or make charges against a person outside the House or an official by name or in such a way as to make him or her identifiable.

Dr. Josh Keaveny

We propose to discuss the bed capacity problem that exists in the Irish health service, manifested as constant difficulty in accident and emergency departments and long waiting periods for beds in the main hospitals. The number of beds available in acute and other hospitals poses a problem. There is a shortage of long-stay beds for elderly people and patients requiring rehabilitation. There is a lack of capacity in the acute sector to deal with the current health care demands of an increasing population. Dr. James Binchy, secretary of the Irish Association of Emergency Medicine, will expand on the emergency medicine problem.

Dr. James Binchy

I will give an overview of the role of accident and emergency departments, the perceived overcrowding and the accident and emergency crisis over the past ten years. The primary role of the accident and emergency department is resuscitation and stabilisation of acutely ill or injured patients. Another role is the management and assessment of less seriously ill or injured patients. The department should not be used as the main route by which general practitioners can gain access to hospital services. In recent years, the workload of the departments has increased in terms of complexity and interventions, particularly those of a time-critical nature involving the use of clot-busting drugs to manage heart attacks, and they are filled with inpatients lying on trolleys waiting for hospital beds.

I wish to recount the history of how this problem arose. The first recorded incident occurred on 21 October 1991 in the Adelaide and Meath Hospital, when the consultant, Mr. Keye, received a letter from three members of staff complaining about a patient who should have been in a hospital bed but who remained in the accident and emergency department overnight. The problem initially occurred in Dublin during the winter months before spreading to peripheral hospitals and becoming a year-round phenomenon. This mirrors what happened in all other countries, particularly Australia. In Ireland and other countries, closure of hospital beds preceded this trend.

While attendances at the accident and emergency department at University College Hospital Galway have not increased in the past year — between 2004 and 2005 there was a slight reduction in attendances and a 4.5% reduction in the number of emergency admissions — there was, however, a 45% increase in the number of patients lying on trolleys in the department waiting to gain access to beds. This is reflected in other departments throughout the country, particularly that in Limerick, which was cited by Professor Drumm and the Minister for Justice, Equality and Law Reform, Deputy McDowell, as not having a bed problem. To date this year, Limerick hospital has had 727 patients on trolleys overnight in the accident and emergency department. On the worst evening there were 32 such patients.

I wish to refer to the effects of this on the functioning of accident and emergency departments. Patients expect appropriate treatment in a timely fashion. People are frightened to go to accident and emergency departments because they believe they will be obliged to wait for hours. It has been shown that the length of time patients, including those discharged, spend in accident and emergency departments is directly related to the occupancy level of the hospital. When there are no beds available in a hospital, waiting times in the accident and emergency department, even for patients discharged, increase.

We have suspected for many years that this has an adverse effect on patient outcomes. Recently published papers have confirmed this. If a patient is admitted to an accident and emergency department when the hospital is overcrowded and its bed occupancy rate is greater than 90%, there is a 20% to 30% excess patient mortality rate. This study was conducted in the greater Perth area and has been circulated to members. The study considered an area with a population of 1.4 million people, equating to 120 excess deaths per year in an area the size of the greater Dublin area.

The media recently referred to contagious diseases. A paper from Canada addressed the recent outbreak of the sudden acute respiratory syndrome, SARS. In one Canadian hospital, 78 patients were infected and five died. All of those individuals were contaminated by one patient who should have been admitted to an appropriate isolation facility but who stayed overnight in an emergency department. We see this as a significant public health problem. It is no longer a crisis, it is an emergency that must be dealt with quickly.

I wish to briefly address some misconceptions, one of which is that this is an accident and emergency department crisis. It is not an accident and emergency department crisis. The causes and most of the solutions lie outside the accident and emergency departments. The workload coming through such departments in terms of emergency admissions is largely predictable, except where a major incident occurs. The problem is that when a patient has completed his or her episode of emergency care, a bed is not available in the hospital. This is called "exit-block" or "hospital access block" in some countries.

It is interesting that we do not have such a trolley problem during holiday periods when elective work slows down. Over the Easter period, there was not as serious a trolley problem as there had been in previous weeks. Some people attribute this to the announcement of the accident and emergency task force. However, it was predictable and came about because work relating to elective procedures had slowed down and more beds to which patients could be admitted were available.

Other misconceptions I wish to address include the recent discussion in respect of the hours during which patients attend emergency departments and that fact that most of them do so outside normal working hours. In fact, 75% of attendances occur between 8 a.m. and 8 p.m. Only 30% of attendances occur between 5 p.m. and 1 a.m. The point was raised that working practices are inefficient and that patients must be seen by five doctors before they are admitted. Certain small groups of seriously ill patients are seen by five or more doctors and this is perfectly appropriate. However, it is not the normal practice for the vast majority of patients who attend emergency departments.When patients are brought to hospitals following major traumas, the services of intensive care, orthopaedic and general surgical specialists and, perhaps, plastic surgeons will be necessary.

There has been much discussion in the media to the effect that the problem is due to inappropriate attendances, such as those involving people who are drunk attending accident and emergency departments. Those who are drunk still require care if they have a medical problem. They account for a small percentage of attendances. If we removed all of the drunks and patients with supposedly inappropriate conditions — most of whom are ambulatory — who come to emergency departments, we would still have large numbers of elderly patients waiting on trolleys for admission to hospital beds.

The other misconception is that the trolley problem is due to outbreaks of flu or the vomiting bug. The latter place extra strains on the system but the problem with bed capacity is year round in nature. It is not related to significant seasonal variations, other than during holiday periods when elective surgery slows down and more beds become available.

I re-emphasise that overcrowding is not due to the number of attendances at accident and emergency departments. The number of attendances per 1,000 of population in Ireland is similar to that in the UK. During the past five years, the UK spent a large amount of money on developing minor injury units, walk-in centres, out-of-hours GP co-operatives and NHS Direct. None of these has been shown to have made a significant impact on emergency department workloads. The recent Tribal Secta report confirmed that in Galway, where I work, the establishment of the Westdoc GP co-operative two years ago had no significant impact on accident and emergency department attendances.

The problem involves a lack of acute inpatient beds. There are three acute beds per 1,000 of population in Ireland. The UK figure is 3.5 beds and the OECD average is 4.1. To match the UK figure, we require 2,000 extra beds. To meet the OECD average, 4,000 new beds will be needed. In her report on acute hospital bed capacity in 2002, Dr. Mary Codd recommended the creation of 3,000 new beds. She stated that even if we increased efficiencies by 30%, we would still need 3,000 new beds. Internationally, it has been shown that the problem is based on bed occupancy. Once bed occupancy rates exceed 85% — the hospital in which I work runs at a 94% rate — there will regularly be days when there will not be enough beds for emergency admissions.

What is the solution? The first part of the solution is to accept that the cause of the problem is that there are not enough beds in the acute system. Everybody seems to be shying away from that. One can tinker around the edges and try to divert people from hospitals, but the vast majority of these patients required admission. On Tuesday morning, 28 patients were on trolleys in the accident and emergency department at UCHG. After the post-take ward round by two consultant physicians, which was completed by 10 a.m., no patients were fit for discharge and the vast majority required acute hospital beds.

We must accept the cause of the problem and apply a policy of zero tolerance in respect of trolley waits in emergency departments. We accepted one person on a trolley, then two and then three. The general manager of a hospital must be responsible and accountable for trolley waits. Resources must be allocated towards solving this problem. Fundamentally, we need an increase in beds and relative capacity to reduce our occupancy rate to below the accepted international norm of 85%.

Much debate has taken place on whether we have a total or relative lack of hospital beds. If an 85 year old lady needs admission to a hospital bed, it is irrelevant whether that lack is total or relative. Not having a bed available for her at that time means we, as a society, have failed her. I thank the committee.

Dr. Keaveny

I will ask Dr. Lane to make some further comments. He, along with his colleague, Dr. McCarthy, has been asked to join the accident and emergency task force.

Dr. Gerard Lane

I have been working in Letterkenny General Hospital for approximately four years. On my return to Ireland, I inherited a significant trolley problem. I am a member of the task force, which is one of the more public groups in this area. It is one of the five groups of which I am aware that are struggling to deal with this issue and its causes and that are seeking to develop responses to it.

As a consultant in emergency medicine, I and my 47 colleagues are part of the solution, not part of the problem. The underlying problem is self-evident. The hospitals in this country do not have adequate bed capacity to deal with the activity created by an expanding population. I am not here on foot of a personal issue, I am present because I am convinced by the evidence, freely available in the literature, that putting people on trolleys in accident and emergency departments for prolonged periods causes additional mortality. Put simply, having patients in an overcrowded accident and emergency department for prolonged periods results in additional deaths. It is not because we do anything nasty to them in accident and emergency departments. International experience and research from Australia, which members will find between pages 23 and 33 of the submission document, clearly show that patients brought into a hospital on a day when it is overcrowded have up to 30% additional mortality over those who go through more rapidly on a day when it is not overcrowded.

My colleague alluded to Perth. The paper from Perth is extremely precise. It states that an association between mortality and overcrowding of the magnitude of 100 additional deaths in a population of 1.4 million has been identified. The subsequent paper in the submission document was compiled by Dr. Drew Richardson in Canberra. The final page of his paper contains a scary paragraph which states that the additional mortality associated with being delayed in emergency departments is 13 deaths per year in the ACT area. The figure of 13 deaths means very little until it is put into context, namely, that it is the same as the figure for road deaths in the area to which I refer.

When I read those two papers, it solidified what I had suspected but could never prove. It also frightened me. I do not know whether these figures are transferable to Ireland because our road death figures are much higher than those in Australia. However, even if one tenth of those additional deaths are happening in our hospitals because of overcrowding in accident and emergency departments, then we all have a duty to address the causes, namely, excessive occupancy and a lack of bed capacity. We must remedy the situation at the earliest opportunity because each day of each year, lives are being lost. I thank members for their attention.

Dr. Keaveny

Dr. Paul Browne, who is chairman of the medical board of St. James's Hospital, will now make some comments.

Vice Chairman

I ask Dr. Browne to be brief because many members wish to ask questions.

Dr. Paul Browne

As chairman of the medical board of St. James's Hospital, a major teaching hospital in Dublin, I have recognised in recent years the need for all staff at the hospital to work together to deal with the problem of overcrowding. The medical consultants, senior nursing staff, senior hospital managers and the hospital board have established an internal task force and have examined all of the proposed solutions to the difficulties in the hospital system. We piloted the medical admissions unit concept, which is being brought forward. We explored models of team working, within and across disciplines. We also examined potential alterations to processes within the hospital that have an impact on waiting times in the accident and emergency department.

Nevertheless, even with these changes the hospital board has recently concluded that three core issues must be addressed. In the context of many of the Dublin teaching hospitals, there is a need to commission additional off site, long-term care beds, which must be available on a recurring basis and not as a one-off measure in response to a perceived short-term emergency. Additional in-hospital bed capacity is also required and between 100 and 200 beds in large teaching hospitals must be run differently from standard hospital beds. They must be protected to allow surgeons and other specialists to provide treatment to patients with, for example, cancer, who currently cannot be admitted to have necessary operations. One of our concerns is that, with the focus on the accident and emergency departments, pressure is falling on other critical areas within the hospital. Additional medical staff must also be appointed to provide the required services. These core requirements must be delivered together, in parallel.

Vice Chairman

I propose to take groups of three questioners at a time. I ask members to be brief and to ask questions rather than make speeches.

Deputy Twomey

It is generally accepted that more beds are needed in the hospital system. If we have at least 100% occupancy of our hospital beds, it is inevitable that problems will arise. In that context, accident and emergency departments are the bottleneck in the system. However, Professor Drumm and the Tánaiste and Minister for Health and Children, Deputy Harney, seem to have a totally different interpretation of the situation. They do not see bed numbers as being the problem at all.

It was asserted earlier that the out-of-hours co-operatives have no effect on the accident and emergency crisis, but it was never envisaged that they would do so. British literature on the subject, dating back ten years, indicates that it was never suggested that out-of-hours clinics would solve problems in accident and emergency departments. While they may be raised in arguments involving accident and emergency services, those involved are aware that such co-operatives are designed to provide primary care or out-of-hours general practitioner services. They do not operate as a substitute for accident and emergency departments.

The Tánaiste and Minister for Health and Children, Deputy Harney, made comments in the Dáil yesterday to the effect that patients in Dublin hospitals are not discharged on Saturdays and Sundays. She also said that 2,800 bed days were lost at Cork University Hospital last year as a result of delays in discharging patients. This information was contained in the Tribal Secta report. She also pointed out that Finland has fewer beds in its hospital system than Ireland but that its system functions much better than ours. According to the Tánaiste, the United Kingdom has the same number of acute hospital beds, has a much larger elderly population than Ireland and its problems are equivalent to Ireland's. The patient journey through our acute hospitals is being used to argue that work practices in our hospital system are bad and are contributing to the problem. I ask the delegation to comment on these issues.

It is obvious that emergency medical units and minor injury units are not going to solve the problem. The Tribal Secta report made it clear that the emergency medical unit in Wexford General Hospital is experiencing enormous problems because patients cannot be moved into acute beds in the hospital. The acute hospital in Kilkenny has been used as an example of one where the emergency medical unit works very well. There is no doubt, with the consultants working closely together in Kilkenny, the emergency medical unit functions very well. However, many people seem to have forgotten that Kilkenny was given a large number of additional acute beds in 1997 and 1998. That is why the problems there are not as great as those in Wexford.

Professor Drumm has used Waterford as an example of a hospital where patients waiting on trolleys is not a problem. However, the ear, nose and throat, ENT, beds are used in Waterford to take the overload from the accident and emergency department. As a result, it is almost impossible to carry out ENT procedures in the south east. Four ENT consultants are arriving at the hospital every morning to find that most of their day-case beds are occupied by patients from the accident and emergency department. On some days, only one or two ENT procedures are carried out at the hospital. The use of such beds is not a long-term solution.

Perhaps members of the delegation can contradict some of the comments made by Professor Drumm and the Tánaiste and Minister for Health and Children, Deputy Harney. I also have a number of questions for the delegation, since its members are the people——

Vice Chairman

Deputy Twomey should be aware that many other committee members wish to ask questions.

Deputy Twomey

Yes, but this is important. The European working time directive has effectively stalled but it will have to be introduced and adhered to. Does the delegation wish to comment on the consultants' contract and the European working time directive?

This committee discussed the issue of consultant contracts. The length of the working day for consultants must be increased to reduce the number of non-consultant hospital doctors. However, if we are to abide by the working time directive and the recommendations of the national task force on medical manpower, as well as provide a consultant-led service, we will need a radically new contract for consultants. These issues are just as important as acute beds.

Comhairle na nOspidéal is responsible for approving and appointing consultants. That body has a considerable input from hospital consultants but there are enormous regional variations in consultant numbers that have, in some respects, got worse over the last decade. Does the delegation believe that consultants could have had a greater impact on reducing the inequalities between different regions? Why were such inequalities allowed to develop?

Deputy Connolly

This meeting is timely, given that these issues were debated in the House in full yesterday. Different people proffered different solutions to the problem. There appears to be a major difference of opinion between members of the delegation and Professor Drumm in terms of how to solve the problem. Professor Drumm states that it does not relate to acute hospital beds. His focus is on resources for community care and step-down or nursing home beds. The delegation, on the other hand, placed great emphasis on the fact that 3,000 acute hospital beds are needed. I cannot possibly disagree with that but what is the likelihood of obtaining those beds? It appears this problem will remain until those beds are provided. I have spoken with nurses and junior staff in accident and emergency units and heard what they had to say. They made reference to the fact that many patients present at accident and emergency units even though they are not strictly accident and emergency patients. They said their wards have been used by gardaí as a section 12 area as a place of safety for children. There is a lack of social workers from 9 a.m. to 5 p.m. and at weekends when there are more social problems. To obtain the best service for their patients, general practitioners send them to accident and emergency units to wait until their results arrive because GPs do not have the same speed of access to diagnostic reporting. Issues like this effectively block off accident and emergency units.

Deputy Twomey talked about regional variations which suggest that a section of the country does not operate effectively and another can be held up as an example to which to aspire. Is this a myth? People regularly ask us why there are no patients on trolleys in certain hospitals. We recently listened to a presentation from the Nenagh hospital group and it indicated that part of its admission procedures involved GPs liaising directly with an admissions officer and sometimes agreeing to care for the patient for an extra night, thereby giving the patient a more comfortable time and taking pressure off the accident and emergency unit. I would like to hear the consultants' views on whether there is any other way the admission of a patient can be organised.

It would be remiss of me not to ask the consultants their views on the Hanly report. The report proposed closing two of the accident and emergency departments in the mid-western area, in Ennis and Nenagh hospitals. I think I know their views but I ask them to say whether they think this is a good proposal. What effect do they feel it would have on accident and emergency services in Limerick?

We talked about minor injury units. Must every patient be seen by a consultant in an accident and emergency unit, as we are told? Junior doctors can do much of the work. Deputy Twomey mentioned weekend discharges by consultants. It is often pointed out as a problem that consultants, such as those present today, do not cover at weekends in order to discharge patients and free up beds. Will they comment on that?

I would have thought the introduction of minor injury units or wet rooms would have brought about a reduction in the numbers in accident and emergency units and was disappointed by the consultants' response. Deputy Twomey asked about the progress of the European working time directive. Has it been parked?

Deputy F. O’Malley

I welcome the delegation. Has the state of the population's health improved in the past ten years? Professor Drumm said recently that capacity is not the only issue. If that were the case things would be much better, given the increase in resources that has been allocated to the health services. It is about changing the structures. What role do the consultants see themselves playing in the solution? Dr. Lane said they were part of the solution and I was glad to hear it, because all too often they are seen as part of the problem. It is multi-faceted and complex but I would like to hear how they specifically envisage delivering a solution.

Discharge policies are not fair. We are all responsible for getting value for the money allocated to the health services. If we are paying for a service we are entitled to expect value for money, including a 24-hour service, seven days a week. What is the consultants' attitude to the rostering of consultants on a 24-hour basis, seven days a week? It is not satisfactory that our acute beds are blocked by people who may not need them but cannot be discharged at the weekend. Weekend opening is widely thought to have the potential to alleviate the problem.

Who has responsibility for the management of beds in various hospitals? Some are better than others. Kilkenny hospital is always cited as somewhere where it is done well. People involved there in the front-line provision of services came together and identified the problem and there is now a far swifter throughput of patients and more efficient use of resources. I asked Professor Drumm at a meeting of this joint committee why that good example was not followed in other areas. He wants such practices adopted but who is preventing it? For a chief executive to fail to adopt best practice and allow delays to accident and emergency services — I am sure the consultants will agree the priority must be to provide medical services to patients — is disgraceful. We are all good at apportioning blame but we need to ask where responsibility lies.

As Deputy Connolly asked, is it necessary to force a patient presenting at accident and emergency units to be seen by so many experts, as happens at present? There must be major changes in our medical services and the delays in accident and emergency services are evidence of that. At the Progressive Democrats' conference the question was whether the unions were up for change. Are workers in the health service up for change, in the form of putting patients first?

Both the Tánaiste and Professor Drumm accept the need for increased capacity but before that we need to make sure we get maximum efficiency in the management of the current number of beds. There is no point providing more if the system is not working. The system must be fixed and then we should move quickly to increase capacity.

Neither the Tánaiste and the Department of Health and Children nor Professor Drumm and the Health Service Executive will solve the problem but the people who work in the health services will. That is accepted and changes need to take place in the consultants' contracts to establish their areas of responsibility.

Deputy McManus

I will be very brief. Why have the consultants been unable to convince the Minister for Health and Children or Professor Drumm of the need for acute beds? Are the consultants aware that the numbers of long-term community beds have been consistently dropping since 1997? The sub-consultant grade, which I thought was dead, was raised again at the IMO conference. Can they comment on that? What are the consultants views on funding being diverted into private hospitals being built on public lands?

Dr. Keaveny

There are a number of issues. I am sick and tired of comments that people in my profession do not go to work, do not care about their patients and do not attempt to discharge them. These are scurrilous and unfounded remarks but are constantly being made by politicians and some people in the health services.

Deputy McManus

Some politicians. Consultants are guilty of the same thing.

Come on, Deputy Fiona O'Malley.

Dr. Keaveny

No hospital in the world provides every service on site. The York study in the UK showed that the vast majority of work is done between 8 a.m. and 8 p.m. and there was absolutely no need for 24 hour cover within the hospital sector. Some people do not appear to have read the report or to be aware of it.

With regard to bed capacity, a number of studies have been done which indicated that we are short of beds. Professor Drumm has come into his job and he has a personal view on the matter. Professor Drumm is a paediatric gastroenterologist who has worked in Crumlin hospital. I have worked in adult hospitals all my life. I work in Beaumont Hospital, which is in one of the fastest expanding conurbations in Europe. There is probably in excess of 400,000 or 500,000 immigrants in this country, all of whom demand a health service. The health service cannot cope any more.

Within the health service there are approximately 2,500 consultants. Over 100,000 people work in the health service. There will not be an increase in service without bringing everybody on board. There has been no negotiation with the other unions to get other people working more flexible hours or 24 hours a day, seven days a week. Consultants cannot carry out elective work on Saturday and Sunday without radiographers, porters, secretaries etc. We use the facilities the best we can.

At one stage last year in Beaumont Hospital the most common operation was no-bed people being cancelled. The idea that we are not in there trying to make the system work better is wrong. We are all trying, and why else are we here today? Everybody here sits on committees in hospitals and is constantly looking at ways to get patients through quicker, expand the service and get more use out of beds. We are interested in this because we are interested in patient care. That is why we went into the medical field. It is a bit cheap for people to constantly refer to the work practices of consultants as the cause of the problem. There must be a sea change in the way everybody in the health service works. That may require hospital managers and CEOs working at the weekends.

I sat down with Mr. Finbarr Fitzpatrick to meet with the then Minister, Deputy Martin, and senior officials in the Department of Health and Children four years ago. In discussing flexibility, we stated that if they outlined what they wanted in this regard we would see what we could do to deliver it. The flexibility of other people must also be increased. The then Secretary General of the Department of Health and Children made it quite clear that it would be extremely difficult to get the other unions to change their work practices because the way in which it was structured was very lucrative for key members.

Deputy Twomey

Is Dr. Keaveny stating that his group discussed the extended working day with the Department of Health and Children at some stage in the past five years?

Dr. Keaveny

In the past five years we offered that we would talk about changing the way the health service was run, that we would look at different factors which would make the day a bit longer and more efficient. It was conceded by senior officials in the Department of Health and Children that there would be difficulties in bringing other people on board. We have never stated that we would not look at increased flexibility in changes to work practices. We have made it clear to everyone that we will consider all these issues.

Deputy Twomey

We have all been misled on this. The indication was that Dr. Keaveny's group was not up for this extended working day and flexibility within the system. Dr. Keaveny is saying that it was the Secretary General of the Department of Health and Children who at some stage in the negotiations stated the extended working day was a non-runner.

Dr. Keaveny

When the accident and emergency crisis first became apparent and people were talking about it, we stated we could of course consider the issues. When the new contract comes in all of this will be up for discussion. We stated this a long time ago, but the reality is that nothing has happened. It must be understood that the doctors are the drivers of the health service, but other people must be brought along also. If it is not accepted that negotiations must take place with everybody else in the health service to get them to move forward, the process will go nowhere. Most doctors who I know in Dublin arrive in work before 8 a.m. and remain until 6 p.m. or 7 p.m. I do not know anyone who arrives at work at 10 a.m. We all must be in early. We have to beat the traffic.

With regard to contracts and the negotiation of a new contract, the current proposal for a public only contract would be a disaster for the country. Anyone who feels that such a contract is workable in the current environment and the way we deliver health care is absolutely misguided. I was at a meeting in the UK earlier in the week and people asked me about it. They were astounded that anyone would consider bringing in a public only contract. The UK does not have it, and most countries now employ consultants who work in both the public and private sectors. In that way expertise is kept in the public and private sectors.

Another interesting point is that consultants do much work which is outside their contract. I fear we will go down the line taken in the UK, and when all factors are brought on board there will be a problem with the location of clinical work. There are different areas for teaching, governance, audit etc. People should understand that the vast majority of consultants in this country work extremely hard and give very good value for money.

People believe I am highly paid. My salary in Beaumont Hospital is €130,000 per year — I do not get paid €160,000 or €170,000. I do not think I am highly paid for my expertise. People may smile at this but I am not highly paid for my expertise. The health service gets very good value from people like me. When I am on call I am at work. If I am on call at the weekend I am in the hospital at 9 a.m. on Saturday to do all the required work, as are all my colleagues.

Deputy F. O’Malley

Dr. Keaveny seems to think I was only referring to consultants with regard to the need to change. I did not make that reference. I said that all hospital workers need to change and I wish to clarify the remark.

Dr. Keaveny

I wish to be quite clear. Perhaps some of my colleagues would like to comment at this stage.

Dr. Browne

I agree. In my brief presentation and using our hospital as an example, I was trying to convey the way to go forward with regard to the problems of admissions and bed capacity, which is manifesting in the accident and emergency department and leads to difficulties for patients and staff morale at all grades. The committee members have made these points. One of the joint committee members mentioned that in talking to people on the ground, one gets a sense of it.

All the relevant people have a responsibility to work together, and we have heard the model of the Kilkenny hospital and elsewhere cited. The medics, nurses, senior management and the HSE, as the current external manager of the health service, should sit down to put together a plan which has three essential points. One of the essential points is additional bed capacity, as I have outlined. The second is the provision of adequate beds off the hospital campus, which may include community beds, beds for dependent people or the elderly. In other parts of Ireland a different type of need may exist. The need is regional.

The third point is an increase in appropriate staffing in appropriate ways. Without getting into anecdotes about how procedures work in our major teaching hospital or contractual issues, with the existing position, many doctors discharge patients. I have an anecdote of my own. I am a cancer doctor and I was on duty this past Easter weekend. I was at work on Friday, Saturday, Sunday and Monday, and I discharged many patients. During that time I saw a large number of other consultants in the hospital doing the same within the framework of the existing contract.

There is an absolute willingness, as we have a responsibility to do the best we can despite the difficulties we deal with. We must realise we need progress on all three elements. In St. James's Hospital, the people on the ground feel that, from the hospice perspective, we are not getting progress on the bed capacity issue. The issues are correctly being cited and addressed, but there is a nervousness because there is no tangible progress with regard to bed capacity. That is essential. Progress cannot be made without all the elements I have outlined.

Mr. Finbarr Fitzpatrick

I refer committee members to page 4 of the presentation. One of the important points is the length of stay. What is contained on page 4 is based on the Department of Health and Children's acute bed survey, published in January to February 2002. The average length of stay then was 6.5 days, which is one of the shortest of the OECD countries. It emphasised the fact that people are discharged as quickly as possible, and the pressure coming from the accident and emergency departments to discharge patients, which has been mentioned. A matter arose in the negotiations with the HSEA where a survey was carried out on the records of consultants who worked out-of-hours in the evening, overnight and at weekends. The evidence is clear from the claims, notes and patients records that visits are being made out-of-hours and at weekends and that they result in discharges.

I refer the joint committee to page 14 of the documentation supplied, under the heading "flexibility" 1999. The written documentation is within the Department of Health and Children. That was at the time when the Medical Manpower Forum, established by the then Minister for Health and Children, Deputy Cowen, was in existence. We made a submission in September 1999 on flexibility across the board not only for consultants but for all who work in the hospital services. It was based on a point made in one of the earlier presentations, that 75% to 80% of attendances at accident and emergency units occur between 8 a.m. and 8 p.m. and that, therefore, much more of the hospital working day should be reflected in that pattern. That submission has been in existence since 1999. We are prepared to reflect that in the contract negotiations from the consultants' point of view.

Life expectancy has improved. Unfortunately one of the problems is that people are living longer and everyone expects every treatment. As people get older they want joint replacements, cataract operations, heart surgery and so on. Very few, irrespective of age, are turned down for treatment. That creates a huge burden on the health service, a burden that will increase.

Deputy McManus

Did the Tánaiste say she would create 1,000 private beds within three to five years? The policy is to expend the money on private beds. That is what she is doing. What is Dr. Keaveny's view?

Dr. Keaveny

Private health care in the UK is growing rapidly and is one of the biggest areas for private equity investment. To some extent that may reflect an international trend. If private beds are to be located on public sites one must ensure one is employing people who can look after them. Our concern, which is unusual, is that there appears to be a view that the new consultant contracts would be public only and consultants would not see private patients. It is difficult to know how that will marry with the development. The reality is that people have much disposable income and if they want to spend it on private health care, to some extent that is their own business.

The hospitals get a good income from private practice. If we get rid of that private practice the hospitals will have to be supplemented to the tune of hundreds of millions of euro each year. It may be a way forward. The way in which consultants are employed will have to reflect that because it is inconceivable that people would be on different types of contracts trying to work together, look after patients and run group practices. It would be a disaster and Dublin would not attract the quality of people it now attracts to work in this city on public-only contracts.

Dr. Gerard McCarthy

The discussion reflects what is a complex, multifaceted problem. We continually try to be flexible. On whether a consultant must see every patient, certainly not in the emergency department but they like to know as much as possible about every patient. Our twin tension is a timely service and a quality service. However, we are introducing advanced nurse practitioners throughout the country. Cork University Hospital has just been credited as a training site for that. I have been involved in the local implementation of the primary care strategy for a number of years in Cork. We have had some successes. We have identified all the issues we all talk about — direct access to diagnostics and community care beds. Sometimes they are successful but sometimes they are not. It appears to me that the goal posts shift on occasion in terms of whether funding is available or redirected. I cannot see through the opacity of that but I turn up for every meeting and make suggestions. We put a good deal of time into it. Undoubtedly, there has been an increase in resources in the health care service but it does not appear to have resulted in an increase in capacity, which appears to be what we are speaking about.

Let me come back to our original point, which is the use of the emergency department as a pressure release valve for the inadequacies in the system. Apart from the personal cost to us and the frustration — we will leave that aside for the moment — it is not good for the patients. It has been going on for years. The attitude appears to be that while we are trying to figure out all the other changes, we can always let the patient numbers build up in the emergency department. We must focus on that and sort it out. We know it is unpleasant. It is bad for the patients and their families and we also know it is associated with increased mortality. In terms of all the other solutions, several will work and some will not.

Deputy Twomey

My questions on Comhairle na nOspidéal and the European working time directive were not answered. Mr. Fitzpatrick said the task force was set up in 1999 and that he and his colleagues offered the Government an extended working day at that time. The European working time directive was due to be implemented on 1 August 2004. I agree with Mr. Fizpatrick on the bed stock review. We reviewed bed stock in 2001 with the per capita report. We will review it again in 2006. We have more reviews on bed capacity yet we have no beds. It is obvious that is a load of nonsense.

Regarding the European working time directive, we are hearing there is a total paralysis in regard to changing work practices in the health services over the past seven years. There is no new contract that is applicable to today's work practices, even though the consultants are doing their job. There is no move on the European working time directive even though that is seven years old. Where does that leave the Tánaiste who talked about taking on 2,500 consultants over the next ten years? Are those consultants available or is that another pie in the sky figure? I agree with Mr. Fitzpatrick on the bed capacity issue but his basic point is that there has not been any change and there is no obvious sign of change in the foreseeable future.

Dr. Keaveny

I will make one comment and then ask Mr. Fitzpatrick to talk about the European working time directive. There is constant change in the hospital in terms of the treatment of patients. We constantly change the way we treat patients. There may not be an outward appearance of change but people are constantly changing the structures and the way they work internally, as we do, to provide the best possible service. There may not be a contractual change but we are all making an effort to do it, regardless of whether our contracts have changed but changing our contract on its own may have a limited effect unless the way the hospital operates is changed. On the European working time directive, we have not been governed by that so far but I will let Mr. Fitzpatrick speak on that issue.

Mr. Fitzpatrick

The European working time directive, as Deputy Twomey correctly stated, was to have been introduced for the NCHDs on 1 August 2004. We were in the Department in April 2002, approximately 16 months beforehand, inquiring about the position because we envisaged that if NCHD hours were to be reduced we would have to compensate for that either by extra NCHDs, which people were not recommending, or the appointment of extra consultants. As we know, neither happened and therefore it is outside our remit.

In fairness to the other members, they should be given an opportunity to contribute. We will take questions from Deputy Gormley, Senator Henry, Senator Feeney and Deputy Cooper-Flynn.

Deputy Gormley

I welcome the delegation. I agree that bed capacity is a fundamental problem and I said as much during yesterday's debate. However, I have a number of specific questions. The first relates to the decrease in the number of beds. According to the delegates' figures, the number of acute hospital beds decreased by approximately 6,000 from 1980 to 2000. However, the delegates said that the problem was first manifest in 1991. Can they explain why it took that length of time to become manifest?

My second question is for Dr. Josh Keaveny. He described the public-only contract as a disaster. Can he expand on that and explain why it would be such a disaster? I did not hear all Dr. Lane had to say but I believe he mentioned Finland. Finland was repeatedly used as an example by the Tánaiste yesterday. Did Dr. Lane tell the committee that he is not familiar with the Finnish experience? It appears that the Finns have greater efficiency. That is what the Tánaiste tells us.

The problem of people arriving drunk at accident and emergency departments has been played down this morning. However, according to the figures we have received, approximately 25% of people who arrive in emergency departments at the weekend are inebriated. That must play some part in the crisis being experienced in accident and emergency departments. Will Dr. Lane discuss this?

Dr. Lane referred to the part played by social services. Sometimes it is not only necessary to see the consultant over the weekend but also the social worker. However, the social worker is not present until the Monday. Is this a problem as well? Is it delaying discharges at the weekend? The anecdotal evidence I have received indicates that there is a problem at weekends. Dr. Lane said that he is on site. However, something is happening to prevent people being discharged. Will he comment on that?

Senator Henry

I thank the consultants for attending this meeting. It has been most useful. It is interesting that there were complaints about people on trolleys in the Meath Hospital within a couple of years of Dr. Steeven's Hospital being closed. It took a huge amount of the trauma from the city. It is important to note that. Another issue is working day flexibility. It would be useful if things happened from 8 a.m. to 8 p.m. but it is impossible to concentrate on the medical profession only. When I was working in hospital medicine the secretarial staff left at 4 p.m. because they started work at 8 a.m. giving appointments in the outpatient department. After that, it was a case of me and a nurse trying to work out appointments. This is not efficient. That must be addressed and it involves porters, radiographers and others. If there have not been talks with those unions representing those grades already, we are looking to something that is ten years down the line. That is most disappointing.

In the good old days, when there was 85% occupancy and beds could be washed, which helped keep infection down, I recall that experienced, well qualified general practitioners always sent acute admissions straight to the wards. Having visited the accident and emergency departments of three hospitals in which the delegates work, these people now seem to be going to accident and emergency departments. This is ridiculous and must be stopped now. These people should not be in those departments given that experienced general practitioners have made their diagnoses. They should not be in that position.

One matter that worries me enormously, and perhaps the delegates have figures for it, is the cancelling of elective operations. Within the last few days I was contacted by a woman who was supposed to go into one of the delegates' hospitals. Monday appears to be a bad day for elective operations being cancelled. She had an ovarian tumour but the operation has been cancelled several times in the last couple of months. I am aware of another case involving breast cancer where the operation was cancelled several times. This woman has now been put on two waiting lists by her consultant because he works in two hospitals and is trying to get her in somewhere. What is this practice doing to the waiting lists?

Discharge policies have been mentioned. The Vice Chairman and I visited a hospital in Barcelona. There was a really tough guy in charge of it. Looking at discharge policy, he insisted that readmission was noted to check if patients who were being discharged early were being readmitted. Are these people being counted as new admissions or is it acknowledged that they are readmissions, perhaps because they were discharged too early?

My last question is about the private beds. There is incredible confusion about private hospitals on public sites. It is being said that they will be looked after by the people who work in them but unless it is an entirely separate hospital with its own intensive care unit and so forth, if patients need to be transferred to the public hospital who will look after them there? In the public hospitals public patients are put into private beds if they are empty and the public patient needs a bed.

Senator Feeney

I welcome the delegation. Much of what I wished to discuss has been covered. I wish to refer to something Dr. Keaveny mentioned. The Tánaiste, Deputy Harney, and Professor Drumm attended a committee meeting a few weeks ago. They talked about the back-up from, say, pathology, X-ray and so on, the fact the hospital cannot work without that and that we would have to look out-of-hours for that type of discipline and back-up. It was said that what is needed is a sea change among all involved taking in the other disciplines also. The hours of a consultant were outlined. I smiled and said "My God, they are nearly as long as the hours we, as politicians, work." We rise early and go to bed very late. We work 24 hours per day, seven days per week.

A meeting five years ago was mentioned at which the then Secretary General of the Department said there would be a problem bringing in other personnel to work out-of-hours. What happened in regard to that? Did the consultants take his word for it, did they try to tease it out with some of the people who work alongside them in the hospital, did their union, the IHCA, do anything about it or was it simply left?

For the past five or six years there has been much talk about a consultant-led or consultant delivered service. Approximately how many consultants — I am not only talking about accident and emergency consultants — in the IHCA serve the public and the private sectors? How do their hours break down per week vis-à-vis the public and the private sectors?

I turn to the issue of a private hospital being located on the grounds of a public hospital. We heard this morning that the most important factor in all of this is extra beds. Joe and Josephine Soap do not care whether those extra beds are delivered publicly or privately as long as they are provided. If one introduces 1,000 beds into a private system, is one not freeing up the beds ringfenced in the public system for private patients?

I would have thought the Blackrock Clinic and the new Galway Clinic and, in particular, the Mater Private Hospital and St. Vincent's Private Hospital were operating very well and that there was no problem with them. I fail to see the argument that people are not in favour of more private hospitals, whether on private land or adjacent to a public hospital. In fact, it would probably be better if they were adjacent to public hospitals.

I am not only focusing on what Dr. Keaveny said but he said things on which I would like him to develop. He said Dublin would not attract the type of doctor there at present with a public contract only. Will he elaborate on that? Does he believe what is in place, in terms of the public-private mix, is working and is manageable? It seems everybody fears change. We will get nowhere if we block things because we are afraid to move on or are afraid of change.

What are the views on the new accident and emergency unit being run by the VHI? I do not know much about it but I have heard people who have used it say they are happy with it because they can go somewhere, be treated and do not have to wait in a hospital waiting room.

Deputy Cooper-Flynn

I welcome the consultants and thank them for their presentation. To start on a positive note, I, too, would like to welcome the statement by Dr. Keaveny in regard to consultants showing flexibility and a willingness to extend the working day. The impression this committee had was that the stumbling block was the consultants. If one positive message comes from this meeting, that must be it. I hope Dr. Keaveny does not get into trouble for that but, in any event, that is critical.

I come from the west so I know Dr. Lane would have similar problems in Donegal to those I experience in the west where we have one accident and emergency consultant. I understand the consultant contract is for a 33 hour week and that the hours are worked at the discretion of the consultant. If that is not the case, I would like to be enlightened. That would tie in with what Dr. Browne said that they worked over Easter which I appreciate is an anti-social time. However, if there is only one consultant working in accident and emergency, how can a hospital manager manage a situation where a consultant only works 33 hours per week? I appreciate the accident and emergency consultant has a team of people around him or her. I asked my local hospital manager if we would benefit from an additional accident and emergency consultant but the reality is that we probably would not under the existing contract. I would like to hear the doctors' comments on that.

I was delighted to hear Dr. McCarthy say this was a multifaceted problem. Listening to the presentation, I did not get that impression. The need for more hospital beds seemed to be the message coming across strongly. I was critical of the Tánaiste's ten point plan to deal with accident and emergency because it did not deal with the accident and emergency problem in the west. I went through it point by point at the time and said it would not work and, as it turns out, it has not worked.

Dr. Lane is on the task force and when Professor Drumm was before the committee, he said there is a new approach, that is, this pilot scheme where 15 accident and emergency units are being looked at. Out of the 15, thankfully, one is Mayo General Hospital, the hospital with which I am most familiar. The hospitals were asked to put forward local solutions to the accident and emergency problem because the problem is different in each accident and emergency unit. In some hospitals more than others, it is a question of capacity. As it happens, we have a capacity issue in Mayo General Hospital, so it is one part of the problem. However, it is by no means the entire problem.

A person from Mayo might have to stay in hospital for three or fours days because he or she is having tests carried out in Galway which could easily be done in Mayo General Hospital. While I accept the figures at face value that our hospital stays are better than those in other European countries, a person's hospital stay could be reduced by three or perhaps fours days if some of these tests were carried out in the local hospital.

In regard to contract beds, I have spoken in the past about subvention rates, improving access to step down facilities and better management of existing hospital beds. The capacity of my local hospital was increased by 100 beds five years ago but public step down facilities in the local community were reduced by 140 beds. That is a problem also.

Dr. Keaveny or Dr. Binchy made the point that 30% of people come to accident and emergency in the evenings, although the majority come within the working day. However, even 30% attendance after hours is significant. That a junior doctor makes a decision whether to discharge or admit a patient is a problem. The consultant is the person best trained to decide whether a person should be admitted or discharged. Having a junior doctor make a decision on someone who a consultant might have seen a number of hours earlier might mean that he or she may err on the side of caution and admit a person who could be discharged or, unfortunately, discharge someone who should be admitted, as has happened. I mentioned a case recently in the Dáil in which an elderly man was discharged in his pyjamas at 2 a.m. and sent home in a taxi to the most rural part of County Mayo. This happens and it is hard to understand why.

To me, it comes down to management. If the best trained people, our accident and emergency consultants, played a decision-making role for as long as possible during the day that would be a positive step in dealing with accident and emergency cases.

While I have never been admitted to accident and emergency and therefore I am not one of the 1.25 million to which Dr. Lane referred I, like everybody, acknowledge that doctors work hard but it is just about trying to manage the business as best we can and getting the most out of them so hospital managers can manage hospitals effectively.

Deputy Neville

I also welcome the delegation. One lesson, in particular, we have learnt here is that there was certain unfair demonising of consultants. Consultants have always been put in front of us as the big stumbling block. While there has been the view that anything can be done in the health services if one can shift the consultants from their position, seven years ago consultants made it quite clear they were prepared to look at their contract, increase their flexibility and develop the service.

Is what we are getting from the Tánaiste and Minister for Health and Children, Deputy Harney, about privatising hospitals merely spin? Her proposal for private hospital developments is the issue today. Last week, after years discussing it, the issue was that there was an emergency crisis in accident and emergency. Is there a reluctance to really get in there and deal holistically with the problem? From listening over almost two hours, that is the impression I am getting. My impression is that there is piecemeal dealing with various issues, where they keep debating it, keep the issue live, change the emphasis but do not get in there to deal with it. I ask the delegation to expand on that because many of us are quite amazed at the little return for the amount of money going into the health services.

The IHCA is at the coalface and obviously it has an opinion on how the health services have been developing in recent decades, and especially recent years. Despite the vast increased funding that has gone into the health service, why are there such levels of what we believe is inefficiency in the delivery of it? Many of us believe the inefficiency is in the area of administration, management and all sorts of other areas of perhaps unnecessary activity which is being funded. When we query these issues in the Dáil, the first response we receive is a list of the increased expenditure over the years in the health services. If we raise in the Dáil anything the IHCA states today, the first reply we will get is a list of the increased funding that has gone into the health services. One sits there mindful of accident and emergency, waiting lists, the psychiatric services etc. All this money is going in to the health service but there is no return.

Perhaps the IHCA would comment variation in the numbers of consultants per 100,000 in the regions.

Vice Chairman

As there are many questions, I ask the delegation to be as brief and succinct as possible.

Deputy Gormley

I asked five specific questions at the outset.

Dr. Keaveny

I will make a general comment first. The Irish health service is quite good. It provides excellent care to a great many patients. While we are sitting here, there may be 300 people on trolleys around the country but there are probably 3,000 undergoing operations and receiving treatments and thousands attending outpatient services. Generally, the health service provides a good level of service for most people. I have worked in the UK, America and Ireland. The standard of the Irish health care service is very good. We have a problem, which is one of capacity and which is manifested by this constant trolley watch, but let us not forget the position of the vast majority of people who come into hospitals. The key matter in Ireland is to get into the hospital because once one is in, one gets a very high level of care. We should never forget that.

Billions of euro are spent on the health service, the majority on salaries. If one sets benchmarking at 8% and increases health service funding by 9%, then 8% goes on salaries and 1% goes on expanding the service. By the time the hospitals pay salaries, they are constantly short of money to expand services.

Consultants have generally driven all these services over the years. It is consultants, not management, who have been the drivers to expand clinical units, whether they be cancer units, heart surgery units, liver transplant units or whatever. It is consultants who come in with the idea, who come forward with the plan and who drive it, and it is very difficult to get anything done.

One of the matters Deputy Gormley raised was the contract. The way the health service has been structured over the years, we have had a mix of public and private health care. That is how the service has developed and evolved over the years. Each sector has relied on the other. When one speaks about the future, it is crucial that the expertise currently available to all patients continues to be available. If we split the public from the private practice, we will split that expertise. The person with money will still be able to avail of all the expertise but the person without money will not.

The country is not big enough to employ many experts in everything. There are complicated, difficult medical problems where there are a small key number of people who can deliver that service well and I fear that some of these people will leave to work in the private sector in future. The man with money can go and see such a person in the Blackrock Clinic or the Mater Private Hospital or he can use the public service, but the man with no money must be stuck in the public service. It would be a fundamental error.

People ask if it would be attractive. It would be unattractive because the very best people in medicine are driven. They have been high achievers at schools, high achievers at university and have worked hard, in Ireland and abroad. They are driven people who expect to be rewarded for it in the society in which we live. If one wants to attract the guy to come back from Vancouver, Seattle, Perth or London, one must make it attractive to him because one is in a competitive market. All around the world there is a shortage of high-class doctors. We must be careful that we do not create a situation that prevents people coming back to this country. I have no difficulty in looking at how to resolve the public and private mix within hospitals etc., but we would be making a big mistake if we tried to drive a wedge between public and private practice and between the people who work in each sector. I will get my colleagues to answer one or two of the other points Deputy Gormley made.

Dr. Binchy

An interesting tension is developing between Deputy Connolly's question and that of Deputy Cooper-Flynn. Patients want their service providers to operate as locally as possible and I subscribe to trying to do that as much as possible. There is also a duty to provide the best possible service. These are the tensions involved. When we talk about consultant providers and numbers, we should decide where we are going.

I wish to comment on the reality of practice for the majority of consultants. The time of 33 hours is notional. The majority of consultants hold a contract known as "Category 1". This means they are committed to the single public hospital in which they work. There may be some private practice in that hospital, but that is where they work. In my hospital, approximately 50% of consultants, including myself, hold such a contract.

On average the time per week worked directly in patient care and related matters is way over 33 hours. The weekend worked by me was done in addition to that, to a 50 hour week, which is quite common. I assure the committee that our CEO has a detailed plan of what we do. It is interesting when one sits down and maps it out as described earlier. In many professions, including the professions mentioned here today, people often work in excess of what the contract notionally specifies. The reality is that I am not on a roster system whereby if I worked over the Easter weekend, for example, I could take Monday, Tuesday and Wednesday off. It does not work like that. In fact, it is added to the standard working week in terms of an emergency service or an extra service provision. There are variations depending on the type of specialty or practice, location and hospital set-up, but they are local variations. There is generally an understanding and an agreement, and very often a plan in place. It was required when I took up my post under the current contract in 1997-98. I had to discuss it in detail with the manager.

Three questions related to the geographic and regional spread. This may get back in part to the question of how to reconcile providing an excellent service locally while saying to people that they should travel to Dublin, Cork or Galway to get all the services. While it is difficult to provide an excellent service in-hours and out-of-hours, we must work towards it. The only solution to this issue is significant additional investment throughout the country. Someone asked about the Comhairle function. This is the body that up to recently recommended the number and distribution of consultant posts, to which there was a substantial input from consultants. There is a large number of Comhairle reports available on the website, many of which were published recently. When one reads the reports on all specialties, including rheumatology, medicine, endocrinology, diabetes services and emergency medicine, they make clear recommendations about providing a substantial additional increase in consultant numbers in every region. Regionalisation is the theme. When one examines the priorities assigned to these reports, this is what is being stated. The frustrating aspect is that, given the changes in the health service structure, the Comhairle structure as it previously operated does not currently exist. We are in a period of transition and it is not clear how the recommendations will apply in future.

The second frustrating aspect, which has been articulated by the former secretary of Comhairle and by various outgoing chairs of Comhairle over the years, is that the reports are put together in a collective way but are not implemented. There is a large number of Comhairle reports, such as in the case of rheumatology, where there is a critical shortage of services throughout the country. A report was published a decade ago which mapped out clearly how these services should be rolled out in the Deputy's region, for example, but it has not happened. A second report was published this year, which was one of the last acts of Comhairle in the same area, reiterating what was said ten years ago. The perception sometimes is that consultants somehow are trying to keep the numbers of consultants down. When the consultants who had an input into Comhairle were involved in this, they made these very clear and detailed reports publicly available through that process. The difficulty is that they were not resourced and implemented when they should have been. It gets back to the issues that were highlighted earlier. We must accept that additional investment is required.

I would like to answer a specific question that was raised about how to square the perception in the Dáil and among the public that there is a substantial additional investment in health care and yet there appears to be a crisis. There has been a huge investment and improvement in many areas of cancer services over the past ten years, which is my area. There has been a big increase in the complexity of treatments and the number of treatments a person may have to go through. This is a good thing because it means that more people are living longer. However, it costs people time and money. Every individual with cancer requires more time, assessment, care and support, and rightly so. What is also important in this area is the rolling-out of the regionalisation of cancer services. We have gone some of the way but not a sufficient way in that area. This is an example of where there has been additional investment. However, it does not mean extra beds. It means investment in terms of people to provide the services. Many of these people are not doctors, they are nurses, support staff and others who work behind the scenes.

Vice Chairman

I ask Dr. Lane to be brief because we are under severe time constraints.

Dr. Lane

The issue of finances arose earlier. While a large amount of money is being invested in the health service, it is mostly going on salaries. Current OECD figures indicate that we are spending 7.3% of GDP on health, which is just 1.3% behind the OECD average. Because of the growth in the economy, the amount of money pumped in up to 2002 only reflected a 1% move upwards, up to 7.3%. While the money being invested in real terms is large, the economy has moved also. Based on 2002 figures released recently, which is a 1% increase of GDP, we are still 1.3% behind the OECD average.

Vice Chairman

Are these the 2002 figures?

Dr. Lane

Yes. These are the 2002 figures released recently.

On Deputy Cooper-Flynn's query regarding what I did this week, I began work at 8 a.m. on Monday and got home at 9.45 p.m. This was 13.5 hours, and boy was I in trouble when I got home.

Vice Chairman

In all fairness, we do not need a blow by blow account. I ask Dr. Lane to confine himself to answering the questions as briefly as possible.

Deputy Cooper-Flynn

I must apologise. I was not questioning Dr. Lane's work. I was just trying to understand how the contract is managed given that one can work at one's discretion. I was trying to get my head around that point.

Dr. Lane

On the issue of private beds, there is a huge amount of suppressed demand within the service both in the public and private side. Private beds being pumped into the system will only work to relieve the current emergency within the emergency departments of our hospitals if the freed up beds in the public sector are ringfenced and preserved for elderly and infirm people on trolleys in emergency departments. There is a huge danger that we will have an appearance of a suppressed demand and that the freed beds will disappear for real demand, and the private beds will also disappear. Private beds will be useful to me in Letterkenny when I can take someone with a fractured hip and wheel him and get him into the bed.

On insurance issues and so on within emergency departments, it is frequently said there are no atheists in foxholes. I frequently feel I am in a foxhole at work, but there are no insurance issues within my emergency department. I do not know what anyone's status is and I really do not care. This is also the attitude adopted by my colleagues. I do not know what is the patient's status. That information is gathered later.

I applaud the point made earlier with regard to direct referrals. It is an absurdity of our system that a general practitioner of 12 or 20 years experience must send his patient, whom he knows to have appendicitis, a subarachnoid haemorrhage or whatever, to see a junior doctor or a senior house officer, SHO. If there is a bed in the ward for the patient with an attendant specialist, it is appropriate the patient should go directly to that bed. Currently, we do not have this type of bed occupancy and, perforce, these patients must go to the emergency department to get the best care.

I do not mean to run down family practitioners. I am on the register of general practitioners in the UK and Ireland as well as being on the register for specialists in Ireland and the UK. I am married to a general practitioner and I know the hours general practitioners put in and the amount of soul-searching involved before sending patients to accident and emergency units. They do not do it lightly. I applaud general practitioners and welcome their support in trying to make improvements.

Senator Feeney made the point that we need a sea change of the entire hospital system. We have a system which evolved on a nine-to-five basis. However, as a result of demand, we now need the hospital and the support services which help it and allow us decant patients to their homes or step-down facilities to be extended, if not to a 24-hour seven-days-a-week basis, which is the ideal, to longer hours and for weekends. It is not enough to approach a single group and ask it to move. We must ask for a whole system move.

We return to the old wobbly three-legged stool. The only way we will get our health service back on balance is by addressing the process issues, which have been spoken about at length. We also need to address capacity issues, particularly acute capacity. We need more beds and smarter beds and need to address the issue of decanting patients and the provision of additional community beds. The problem that will face me when I return to Letterkenny in the morning and see 14 people on trolleys for whom I do not have a bed is that there will be no bed available. The reason I and my colleagues are here is to speak for those patients.

With regard to consultant numbers, we visited Boston earlier and visited a hospital providing a high standard of care. That is the direction I would like to take. However, we must appreciate that there are significant revenue costs if we are to have consultants and a hospital that works like that. We will not be able to achieve that——

Senator Feeney

On that point, is it realistic for the Tánaiste to say we need to double the number of consultants in the system? Can we achieve that? When we consider what is spent on overtime for junior hospital or non-consultant doctors — approximately €2 million last year — is it realistic to expect we can double the number of posts? Are the medical personnel available to take those positions?

Dr. Keaveny

We need to double the numbers, but it will not be easy to fill the positions quickly because the number of medical students in recent years has been pitiful. Filling the positions will be a slow process, but we need to start and to get the best people possible into those jobs.

Senator Feeney

Are there enough Irish people abroad? It was mentioned this morning that many of your colleagues working abroad would be happy to return if the right package was offered and made attractive to them. Could we get non-Irish people to fill the positions?

Dr. Keaveny

To be honest, I am not sure there are thousands of Irish people waiting to come home. People's circumstances are all different. If people are away for five or six years in North America, their children are American and the family gets comfortable where it is and there is no longer a great rush on it to return. Urban areas here have become too expensive for families to return to and maintain their lifestyle. We have a problem therefore in that regard. We must address the problem and start recruiting. The quicker we get on with it the better. It may not be that easy to recruit these people quickly. Medicine is no different to other professions. Whether we are trying to recruit accountants, engineers or medical professionals, we are in a competitive market in the effort to get the best people in the world to come here to work. We must move on and try to do it. We will not know how difficult it will be until we start the process.

Deputy Twomey

We must be honest. The medical professionals are not there. Many of the consultants appointed to the large hospitals in Dublin have been taken from our regional hospitals. From my direct experience I know of two consultants who were appointed to Wexford hospital who returned to America and of two others who returned to Dublin. We must be honest that the consultants are not available.

Senator Henry

I support Deputy Twomey on that.

Deputy Twomey

There has been a total failure to regionalise services and to deal with the European working time directive. There has also been a failure to move on to a consultant-provided service. Deputies Connolly and Cooper-Flynn have asked about this and the facts should be stated clearly. We will deliver the Hanly report by default, purely because of the paralysis in not making the necessary changes in the European working time directive and in the consultant-provided service. We must state this clearly so that people do not take a mixed message from this committee.

Vice Chairman

On behalf of the committee I thank the witnesses for their comprehensive presentation. Many issues were raised apart from the original brief. I am sure we will invite the group here again. I wish all those who came a safe journey back to their hospitals.

The joint committee adjourned at 12 p.m. until Thursday, 11 May 2006.

JOINT COMMITTEE ON HEALTH AND CHILDREN díospóireacht - Thursday, 27 Apr 2006

Irish Hospital Consultants Association: Presentation.

Dr. Josh Keaveny

Dr. James Binchy

Dr. Keaveny

Dr. Gerard Lane

Dr. Keaveny

Dr. Paul Browne

Dr. Keaveny

Dr. Keaveny

Dr. Keaveny

Dr. Keaveny

Dr. Keaveny

Dr. Keaveny

Dr. Keaveny

Dr. Keaveny

Dr. Keaveny

Dr. Keaveny

Dr. Browne

Mr. Finbarr Fitzpatrick

Mr. Fitzpatrick

Dr. Binchy

Dr. Binchy

Dr. Keaveny

Dr. Keaveny

Dr. Keaveny

Mr. Fitzpatrick

Dr. Keaveny

Dr. Lane

Dr. Lane

Dr. Keaveny

Dr. Binchy

Dr. Binchy

Dr. Binchy

Dr. Binchy

Dr. Binchy

Dr. Binchy

Dr. Binchy

Dr. Binchy

Dr. Keaveny

Dr. Keaveny

Dr. Keaveny

Dr. Keaveny

Dr. Keaveny

Dr. Keaveny

Dr. Keaveny

Dr. Keaveny

Dr. Keaveny

Dr. Browne

Dr. Lane

Dr. Lane

Dr. Lane

Dr. Keaveny

Dr. Keaveny

JOINT COMMITTEE ON HEALTH AND CHILDREN díospóireacht -
Thursday, 27 Apr 2006