A Chathaoirligh,
I welcome the opportunity to update the House on what is being done to improve access to services in our acute hospitals.
At the outset I want to acknowledge that too many patients across Ireland are still spending far too long in our Emergency Departments, waiting to be seen, to be moved to a hospital bed, or to be sent home.
This causes difficulties and distress for patients and their families and makes working conditions more difficult for staff. That is why dealing with this problem is a key objective for the Government.
The disquieting events of last week, when a number of individual cases were highlighted in the media, were met with the familiar cries for more beds, more money and more staff. However this is already happening. The problem is more complicated with multiple causes and they all need to be addressed and any efforts and actions must be sustained.
I convened the Emergency Department Taskforce in 2014 to provide focus and momentum in dealing with the challenges presented by ED overcrowding. Progress is being made on implementing the Plan.
The Government has allocated more than €117m in additional funding this year to reduce overcrowding, it has got the Fair Deal waiting time down to between 3 and 4 weeks, thus freeing up over 225 hospital beds every day, it is supporting hospitals to re-open closed beds and to add more beds. There are over 500 more nurses in place than 12 months ago and more registered doctors than ever with a further 338 Non Consultant Hospital Doctors and 78 Consultants appointed this year.
Causes of ED overcrowding
As I mentioned there are a number of different causes which can give rise to hospital overcrowding and it is worth setting these out.
Firstly there are demographic pressures. The growing and ageing population is causing a small but relentless increase in demand year on year.
Secondly is the level of attendances which can increase or decrease for all sorts of reasons - GP referrals, flu, weather.
Third, admission rates vary widely from hospital to hospital. In some you are twice as like to be admitted to hospital than in others.
This can be cultural or can be down to the fact that a particular doctor will admit more patients than is necessary. Less experienced doctors and locums have a lower threshold for admissions than experienced and more senior ones.
There is also the issue of elective admissions – this involves patients being brought straight in for surgery, or from a clinic, into a hospital bed rather than through ED. Some hospitals manage this better than others by taking more people in when trollies are low and restricting them when trollies are high. Others manage things less effectively.
There is length of stay - some hospitals can sort the average patient out in four days. Others might take a week, thereby using twice as many beds to do the same work. This is often linked to delays in getting tests and scans done or skeletal services at weekends, or slow decision-making due to infrequent senior clinician-led ward rounds or board rounds
Also, there is the care provided on an outpatient basis and the operation of acute medical assessment units. Some hospitals are able to complete tests in a single day, so the patient does not need to be admitted. Others have to admit a patient which then requires a bed to be allocated.
Then there is simple bed capacity - some hospitals may just not have enough beds. Another area where capacity can be a problem is in the delayed discharge of patients from hospitals.
Some areas don't have enough nursing home capacity or home care packages which means that patients are delayed leaving hospital. Some are more active than others in getting patients to go home or on to stepdown.
There can be issues to do with the efficiency, or lack thereof, in the operation of a hospital. Hours can be lost getting a patient's discharge paperwork done, prescriptions written and the bed cleaned for the next patient. This could be done in an hour. But sometimes it can take as long as five hours, leaving someone else on a trolley during that time.
Another cause is bed closures which can occur for a number of reasons - staff shortages, renovations, or infection control.
There is also the interaction with primary care provision in an area. Where community intervention teams are in place, patients can avoid admission or be sent home early as the nurses in the community intervention team can administer IV, or drips, at home, check wounds, or monitor bloods. Where it isn't, they have to stay in the hospital until everything is sorted.
There is no simple or quick fix solution to the problems in EDs.
Our approach to tacking this issue is to address the challenges across the whole of the health service - to ensure that all relevant parts of the health service, including acute, social and primary care, are working together to make the best use of resources.
Experience has taught us two key lessons:
- Additional hospital beds alone will not fix this: Services and capacity in primary and community care which support people to stay out of hospital by accessing care in a primary or community setting, or assist them to move out of hospital to home or residential care, are equally essential;
- Today’s cancelled operations are potentially tomorrow’s Emergency presentations: therefore it is equally important for us to balance both planned and emergency care needs to prevent delays in diagnosing or treating illness which could result in greater needs for emergency intervention next week, next month or next year.
The real answer is to continue to implement the tailored solutions that we are already working on: the 88 actions identified through the Emergency Taskforce. The actions are a combination of immediate measures to target the pressure areas and also long-term sustainable solutions to address:
· Emergency Department overcrowding;
· Provide specific care pathways for older, frailer patients;
· Early discharge planning - starting when patients first come into hospitals with community and primary care services closely involved;
· More efficient discharge processes, including weekend discharges so that they can be discharged as soon as they are medically fit;
· Better access to homecare and care in the community;
· Making the best use of all the non-ED facilities available, such as medical assessment units, minor injury units and urgent care centres;
· Reducing Delayed discharges;
· Increased bed capacity in the hospitals for the winter months;
· Reducing the length of stay for patients who have been admitted;
· Recruitment of more medical and nursing staff into the health service.
Delayed Discharges
Delayed discharges are reducing steadily. The latest figure is 567, as compared with a high of 830 last December. That means we’ve freed up approximately 265 beds to be used by acutely ill patients every day.
In addition by the end of 2015 we will have provided over 1,200 additional home care packages, 149 additional public nursing home beds, 24 additional private contracted beds and 65 short stay community beds.
Emergency Care
These very significant increases in capacity are beginning to be reflected in Emergency Department performance. While it is still extremely challenging, the number of people waiting for nine hours or more on a trolley has fallen to, on average, 115 in October. This compares with 127 on average in June, and 173 in February.
Focus hospitals and improvers
We know the hospitals which are the most affected. These have been the subject of particular focus in supporting them to implement solutions.
We also know the hospitals that have demonstrated specific improvements in areas such as length of stay, trolley waits, delayed discharges and in helping patients and their families negotiate the complex ‘Fair Deal’ process. These include Mullingar, St Vincent’s, Connolly, St James’s, Portiuncula and the Mercy Hospital. Common to these sites has been strong executive and clinical leadership and integrated working across the community and social care services and the clinical programmes.
We also need to provide more alternative models for pre hospital care such that ambulances do not necessarily transport every patient to a busy ED. I have asked the National Ambulance Service to look at this issue and I expect to see some progress in this matter in 2016.
Scheduled care
We have a very high volume of activity in our acute hospitals, an average of a quarter of a million outpatient appointments and between 120,000 and 130,000 inpatient or daycase procedures each month. Our health services are expanding and activity is increasing.
The HSE has provided over 1.1m inpatient and day case treatments and over 2. 4m outpatient appointments up to the end of September this year – an increase of 8% inpatient and daycase treatments and 2.3% outpatient appointments compared to the same period in 2014;
As I said earlier we must also address the access to hospitals for elective work. Additional funding of €51.4m provided by the Government in 2015 has allowed the HSE to maximise capacity across public and voluntary hospitals as well as outsourcing activity where the capacity is not available to meet patient needs within the maximum allowable waiting time.
The latest NTPF figures, published last Friday, show reductions in the total Inpatient / Daycase (IPDC) waiting list, and in the numbers of patients waiting between 15 – 18 months and waiting over 18 months. Similarly, there are reductions in the total number of people waiting for outpatient appointments, which has fallen below 400,000. For the first time this year 85% of patients wait less than a year.
The HSE is working with Hospital Groups towards the new maximum waiting time of 15 months by year end. As part of this work, the HSE is applying fines to hospitals which breach the maximum waiting time in order to incentivise improved performance in relation to the longest waiters.
The Opposition talks about accountability but expresses outrage at the notion that hospitals be held to account for their performance. Where hospitals fail to meet performance targets which others can and where the reasons are internal, as distinct from other causes, then this needs to be tackled. When additional resources are invested, patients have a legitimate expectation that questions will be asked if improvements are not secured and actions taken. What is the Opposition’s alternative? Their solution is to throw good money after bad, just as they did in the past.
Primary Care
Primary Care Services are helping by:-
- Providing alternatives to hospital emergency departments, such as GP Out-of-hours services and primary care teams;
- Reducing ED attendances through avoidance measures such as access to primary diagnostic tests and provision of chronic disease and minor injury care in primary care settings; and
- Enabling earlier discharge from hospitals.
GP Out-of-Hours activity has increased by 10,000 patients in 2015 and Community Intervention Team (CIT) activity, which is particularly focused on relieving pressure in Emergency Departments, has increased by 30% compared to last year, with some CITs actively working in nursing homes also.
Where equipment / aids and appliances are required to facilitate hospital discharges, community teams are given priority to acquire these, and palliative care and end of life services in the community are also being enhanced, with additional beds and nurse specialist appointments underway.
Recruitment
The difficulties in the health service have been exacerbated by recruitment challenges. That is well known. Less well known is the progress being made.
- According to the HSE, the number of staff employed in the public health service has increased by over 4,700 full time equivalents over the past 12 months, with a focus on medical and nursing recruitment;
- Government policy is to move to a consultant delivered service and the number of consultants has grown significantly in recent years to 2,700 full time equivalents. Since the 1st January 2015 to the end of September the HSE has offered 82 consultant posts; 78 of those 82 have been appointed and 69 have already taken up duty;
- The number of Non Consultant Hospital Doctors has increased by over 1,000 in the last five years and now stands at 5,500, the highest ever;
- 500 more nurses are working in the health service than 12 months ago.
Future Actions - Winter planning
We are now facing into what is likely to be a challenging winter period. It is imperative that we sustain the momentum of the various initiatives I have already outlined. To that end additional funding of €18 million has been provided for winter initiatives which will increase the capacity in our Acute Hospitals. 301 additional beds are being opened and 129 beds which had been closed are being reopened.
Work is ongoing on specific initiatives, and some have already commenced – for example, a new 8 bed Clinical Decision Unit and 4 bay Surgical Assessment Unit are now open in Our Lady of Lourdes Drogheda, with further beds to open later this month. The day hospital service in Beaumont has gone from two days to three days and will be a five day service in the course of this month. Additional beds have been provided at Connolly for overflow capacity and to take some benign surgical work services from Beaumont. The Leben Building in Limerick has been opened providing an additional 24 beds.
Alternatives
I have heard much talk from the Opposition about the need for additional resources to address the problems in our Emergency Departments but unfortunately that is all it has been - talk.
Sinn Fein and Fianna Fáil in their alternative budgets for 2015 provided nothing to address Emergency Department pressures. In contrast we have provided €117m and a further €51m to address waiting lists.
It is only fair to acknowledge that they have recognised the issue in their alternative budgets for 2016 promising to provide €86m in the case of Sinn Fein and €90m in the case of Fianna Fail. Still less than the €117m we provided in 2015 and the further significant funding we will provide in 2016.
Both parties talk about the need to hire more staff but Sinn Fein’s plan to cut consultant and manager salaries and increase their taxes is a move guaranted to make recruitment more difficult. Fianna Fáíl’s alternative budget makes no provision for Lansdowne Road pay restoration for nurses, young doctors, ambulance drivers, paramedics and therapists.
It is little surprise that in the case of Fianna Fáil, joined up thinking is absent. They ran away from the Health Ministry in 2004 after Deputy Martin’s period as Health Minister.
During his time the Fianna Fáil-led Government, supported by Independents, promised to end waiting lists permanently within two years and ensure sufficient bed capacity in hospitals. Instead, they set up the HSE.
Thereafter, they were happy to leave the Ministry to Mary Harney even after the demise of the PDs in 2007. Nobody in Fianna Fáil wanted the job, so they left it to an Independent.
Fianna Fáil’s record in health speaks for itself:
· Set up the HSE and now want to get back into power to stop Fine Gael dismantling it;
· Spent over €100m on the PPARs IT system which didn’t work;
· Took free GP care away from the over 70s, while the current Government has restored it and also provided to all under 6;
And, let’s not forget Michael Martin’s only response to ED overcrowding, when he was Minister, was to complain that hospitals had not ordered more trollies.
Conclusion
My focus is on patient outcomes not rhetoric, which is all we hear from the Opposition benches.
I’m focused on making sure that patients receive the care that they need, when and where they need it. This is a substantial challenge for health services which were seriously damaged as a result of the economic crisis caused by the last Government.
In any debate about health care, whether within this House or in the media, numbers are thrown around like confetti. But the House should be assured that we are making progress and this is borne out by a reduction of 16.7%, or almost 13,000 people on trolleys since 2011. 85% of people who require an outpatient appointment or surgery are seen in less than 12 months.
The initiatives that I have outlined this evening are slowly but surely gaining traction and are making a difference for lots of patients. It is too simplistic and indeed wrong to suggest that it is just a question of increasing capacity in our hospitals.
On any given week day, the number of people on trollies peaks at around 300. It very rarely exceeds 500. You would think that putting another 600 hospital beds into the system would resolve the problem. I hope I have explained why it's not going to be that simple.
Sustained investment and sustained reform and performance improvement are needed. Short-term solutions will only work in the short-term, if at all.
I can assure the House of my ongoing commitment and that of the Government.