09 May 2006
Minister of State at the Department of Health and Children (Mr. B. Lenihan): The Tánaiste cannot come to the Seanad today and I convey her apologies to Senators. I am pleased on her behalf to set out for the record of the House...
Dr. Henry: I welcome the Minister of State to the House. There was a letter in The Irish Times of Wednesday, 26 April this year from a Mr. Frank Bannister of Morehampton Terrace, Dublin 4, on solving the accident and emergency crisis. In my view he got a good grip on the situation. The letter states:
Madam,
Let me see if I have this right. The problems in hospital A&E units can be solved if there are more hospital beds or consultants stop blocking hospital beds or elderly patients stop blocking hospital beds or there are more step-down care facilities or there are more A&E consultants or consultants work more flexible hours or consultants work longer hours or procedures in A&E units are improved or more people go to their GPs first or more GPs are available at anti-social hours or there is less alcohol abuse on weekend nights or the Government pumps more money into the health service.
He had a good grasp of the issue. He finishes by stating:
That seems straightforward enough. Should be sorted out in no time.
The good aspect of this debate is that we have stopped saying that the crisis is solely in accident and emergency departments because it is not. That is where it is erupting. We have a serious crisis in many parts of the health service and it is erupting in accident and emergency departments, particularly in regard to the long-term use of trolleys as beds for patients who require admission.
Some of our accident and emergency units have been improved greatly in recent years but many of them are over 30 years old and have had bits added to them from time to time and portacabins put in place. As the two previous speakers said, the population has increased by hundreds of thousands, both native and immigrant, the population has also got much older and, in addition, far more medical and surgical procedures are being carried out. Very rarely do I now hear anyone saying that a particular procedure should not be carried out on someone because of his or her age. It just does not happen anymore. People expect to get treatment regardless of their age and, in general, they have a very good outcome.
I welcome the fact that various improvements are to be made in those hospitals where action has yet to be taken but I am disappointed by some of the points in the Minister of State's contribution. I have been looking at the accident and emergency unit in Wexford hospital for some time. It was decided several years ago that the outpatients department would be taken into the accident and emergency unit, which is tiny - I think it has four beds - and that a new outpatients facility would be built on the very adequate amount of land nearby. Why is a transit ward being built and why not go ahead with speed with the outpatients department?
There has been a great improvement in both St. Vincent's and St. James's hospitals since their new units have been built. However, the Mater and Tallaght hospitals will only be given admission wards which, apparently, will give more comfort and dignity to patients but will not allow them receive the sort of treatment they would get if they had a bed in a ward, which is what they need.
The Minister of State rightly emphasised, and Senator Glynn referred to it also, that there has been a major improvement in the number and training of staff in accident and emergency units but they can only deal with what is available to them. Senators Glynn and Browne were present when the accident and emergency doctors came before the Joint Committee on Health and Children and said that the problem with having people on trolleys is that they require admission but they have nowhere to send them. They produced one very interesting fact that I thought we should note. The first time there was a complaint about patients being on trolleys overnight, inappropriately kept in an accident and emergency department, was in 1991 in the Meath Hospital. Some of the staff working in the department wrote to the consultant in charge of the department to say that the way those people were being kept overnight was unsuitable.
It is worthwhile remembering that Dr. Steevens Hospital, which did an enormous amount of accident and emergency work for this city, had been closed down just two years previously. It said it could not cope with the budget it had been given by the Department of Health and had been told that if it could not cope, it could close down.
The manner in which the situation in this particular hospital was dealt with was a precipitating or tipping point in the beginning of the accident and emergency crisis in this city. Accommodating people on trolleys is a disgraceful practice which increases the mortality rate of these people when they are eventually admitted to hospital.
Our population has aged considerably. Those of us who are 65 and over occupy 46% of all bed days in acute hospitals. The older people become, the longer they must remain in hospital because they take longer to recover and because of the difficulty involved in obtaining step-down facilities for them.
Senator Glynn spoke about the difficulty of ensuring that people are brought home by relatives. When the population contained a very large number of married women who did not work outside the home, there were carers available to whom such patients could be discharged. However, we now have a much higher rate of employment outside the home among women who might have been in a position to care for people, and we will not see the resurgence in the number of such carers unless the economy changes considerably.
The number of community beds has decreased over the years, a situation which I was delighted to learn was to be addressed. I was also pleased to see that the situation regarding home helps is to be improved. Very many people want to go home after they recover and do not wish to occupy a community bed or enter a nursing home. If one can obtain home help services for them, this is often sufficient to meet the needs of such people. I recall attempting to obtain a reasonable answer as to why a woman in her 80s who had considerable physical disabilities but whose mental faculties were intact and who was happy to remain at home, was eventually forced to go to hospital. There was no one to replace the home help when they took the holidays to which they were rightly entitled.
I asked the HSE whether people were entitled to a locum home help when their general home help took holidays. I was informed that they were entitled to a locum home help if one is available. What sort of reply is this? It is utterly useless. Either the system is set up in such a way that people can be kept at home or it is abandoned. The answer I received was Jesuitical in that it appeared to ask me what type of question I was asking and insinuate that I might not have asked the right question. This type of response is extremely disappointing.
The Minister of State's speech refers to the introduction of a rigorous admission and discharge planning process. I would like to see the introduction of a rigorous admission process because it is certainly not happening at the moment. The discharge process is interesting in that people frequently may not be medically fit for discharge. How will one obtain beds in such a scenario where one is already working at over 100% capacity? A total of 85% bed capacity is considered safe and appropriate in an acute hospital because one must allow proper time for the cleaning of beds and the preparation of the surrounding area for the receipt of another patient. One does not wish to see patients getting into beds that are still warm from previous occupants but this is happening at the moment.
Senator Glynn spoke about examining general hospitals on a visit to Paris. I visited Barcelona at the same time where I visited a hospital where staff told us that when they examined discharge rates and the time people with similar conditions or complaints were kept in hospital by different consultants, they were very careful to examine the re-admission rate of these patients. We should examine this issue very carefully. If one has high re-admission rates, the situation is even worse than before because the person has spent time in hospital and must now occupy another acute bed.
I am glad to see that the situation regarding general practitioners is being addressed. The fact that experienced GPs must send patients they know require hospital admission, for example, a person with acute appendicitis or who has had a stroke, to accident and emergency departments is ridiculous. These people, who should be admitted to hospital straight away, form part of the group lying on trolleys in accident and emergency departments. Such a scenario wastes GPs' time.
It is clear from the Minister of State's speech that people who come into accident and emergency departments with a letter from their GP are sometimes seen by five people before they are admitted to hospital, representing a waste of five more people's time. In what I would describe as the good old days, if an experienced GP telephoned a hospital and told staff there that he or she was sending a patient with acute appendicitis there, hospital staff began to organise the operating theatre so the person was operated on at the earliest opportunity.
I am also pleased to see that GPs will have greater access to diagnostic facilities. It is utterly ridiculous that they have so little access to facilities like skeletal X-rays but the number of GPs who have access to skeletal and chest x-rays has decreased in the past seven years. This surely cannot be considered a positive development.
The broadening of access to diagnostic facilities will be welcome. However, can the Minister of State clarify whether negotiations have taken place with staff such as radiographers, physiotherapists or the porters who run various departments and their unions regarding the increased hours of access? If such negotiations have already started, it would be a welcome development.
Negotiating hours of access is one of the first matters that must be decided because increased access to any facility can be provided. People could easily work on in the evening until 8 p.m. but one cannot expect hospital staff, be they admission clerks, consultants or radiographers, to work from 8 a.m. to 8 p.m or 10 p.m. The Minister of State surely agrees that such staff must have a sensible working day and that this must be negotiated before any other progress can be made. To my knowledge, no negotiations have taken place so far.
Much has been made of the fact that it is impossible to contact a GP during what are described as anti-social hours. However, 75% of attendances at accident and emergency departments take place between 8 a.m. and 8 p.m. when it is possible to contact a GP. The assertion that people cannot contact GPs is a red herring.
I am delighted that there will be an enhancement and development of primary and community care services. I remember how the general practitioners and primary care services were offered tax initiatives if the quality of their primary care facilities improved. However, these initiatives have all gone to private hospitals.
There is considerable concern among many of us about the establishment of private hospitals. Will we end up running two parallel systems of health care in this country? Running two systems would be extraordinarily wasteful because approximately 70% of people are admitted to acute hospitals from accident and emergency departments. If myself, the Minister of State or the Leas-Chathaoirleach were ever involved in a car accident, we would want to be taken to an accident and emergency department in an acute hospital. We would not want to be taken to some unit which might be incapable of dealing with our injuries.
The situation regarding alcohol abuse and accident and emergency departments is interesting because accident and emergency consultants who appeared before the Oireachtas Joint Committee on Health and Children did not appear to think it was as grave a problem as has been made out. I acknowledge that alcohol abuse is a dreadful problem in some hospitals. The accident and emergency department in the Mater Misericordiae Hospital suffers considerably as a result of alcohol abuse because the hospital is situated at the top of O'Connell Street and any problems caused by people carousing in the city will affect the hospital.
Unfortunately, a considerable number of people who end up at the Mater have medical problems. Nothing is more of a nightmare than trying to keep an eye on inebriated people who appear to have head or abdominal injuries. One does not know whether they fall asleep because of the head injury or because of the alcohol they have consumed or whether they are vomiting because of abdominal problems or alcohol. Therefore, inebriated people present major problems and it is wishful thinking to suggest such problems will be easily solved.
Some hospitals are described as coping better with the accident and emergency situation than others. How are they coping? Is it by cancelling elective operations? This is a serious issue because some hospitals have admitted they do it in this way. Recently, a constituent wrote to me to tell me that her operation for a possible ovarian tumour had been cancelled for the fourth time. She may have been operated on by now because her gynaecologist, who works at two hospitals, put her on their waiting lists. I asked her to let me know once she has been operated on. Operations for someone like her should not be cancelled.
At one time a surgeon in Beaumont Hospital used to telephone me every Monday if his theatre list had been cancelled because of people in the accident and emergency department who needed to be dealt with over the weekend. In the Minister of State's speech, he referred to ring-fencing beds for people admitted through accident and emergency units. It would be better and fairer to ring-fence beds for elective admissions. Hospitals such as the Bon Secours can be very organised because they do not have accident and emergency units and can keep working on their elective admissions. These admissions were not given enough consideration by the Minister of State in his speech.
Palliative care was mentioned. It is disturbing that the Tánaiste did not seem to know how thinly spread palliative care is in the country. Some units are marvellous. For example, Our Lady's Hospice at Harold's Cross and the new unit at Blackrock Hospice were mentioned. Regarding the latter, someone told me that the food is wonderful and the chef is great. Is it not marvellous that someone is taking such care of food for people who may be in their last days? I was pleased to hear of this. We should also expand the palliative care home care service. Many people would prefer to stay in their homes. The number of people who say that one of their greatest wishes is to die in their own beds is amazing. However, it will not happen unless we manage to help our public health and palliative care nurses. It is important we give the home care teams our support.
A matter raised by the accident and emergency consultants when they appeared before the committee related to the association between hospital overcrowding and mortality among patients. They quoted from a paper on three Western Australian emergency departments published in The Medical Journal of Australia on 6 March 2006, which showed a direct link between the mortality rates of people admitted from accident and emergency units and overcrowding in hospitals. The link could be as high as a 20% to 30% increase in mortality rates, which is significant. How many people admitted to wards would have survived if they had not needed to wait in our accident and emergency departments?
We have a considerable problem. While I welcome the Minister of State's comment that it is being tackled in a multifaceted way, I am anxious about the jargon used in respect of performance targets. If financial rewards are given, it will be difficult to ensure that people are not discharged too early and readmitted. At one hospital, readmissions were counted as new admissions. What type of figures are such places getting? Different figures will come from different places. People will become demoralised because some of our major hospitals will need to take tertiary referrals from other hospitals. How will their performances be balanced, as we will describe it, against the performance of smaller and more localised units? How will the situation of cancelled elective operations be factored in? How will we allow for the fact that there are more senior consultants in a number of accident and emergency departments than in others? For example, Senator Glynn said that there was one senior consultant in Mullingar General Hospital and two in Tullamore General Hospital.
These factors make a considerable difference and it would be better to encourage rather than financially penalise people if they do not reach a certain standard in respect of discharges or the number of people on trolleys in wards. I am a great believer in "mol an leanbh agus tiocfaidh sí". It would be better to encourage people in this way, namely, that we understand what they are doing in terms of getting people out of accident and emergency units.
Bringing people in is not a large problem. Many people are treated every year in accident and emergency units and do not cause much of a problem. The real problem is that of people who need to be admitted to hospital but for whom there are no beds. If beds are not there, what can hospitals do except keep people on trolleys? Something must be done to encourage the whole health service to progress matters instead of having assessments, which will involve penalising people.
I wish the Minister of State well in what he hopes to do, as the issue is serious. Examining figures such as those from Western Australia should make us realise that not only is there dreadful discomfort for patients, there is also increased mortality. We cannot allow this to continue for any longer.
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