A Chathaoirligh,
Introduction
I welcome the opportunity to speak to the House on what is being done to improve access to our acute hospitals and in particular, initiatives to alleviate pressures in our Emergency Departments.
At the outset I want to acknowledge the distress for patients and their families caused by cramped and overcrowded conditions in some of our hospital emergency departments. I am also very cognisant that these crowded conditions make emergency departments a very challenging work environment for nurses, doctors and other hospital staff.
In recent weeks I have taken the opportunity to visit emergency departments, many for the second or third time. These visits enabled me to meet patients and families attending EDs. It also allowed me to see first-hand the challenges for healthcare staff who are endeavouring to provide high quality care in these circumstances.
I do welcome the fact that for the first time since I became Minister for Health Sinn Fein has chosen to use its Private Members time to debate the issue of health. However, the fact that it is only doing so in the dying days of this Dáil is clear evidence that health is not a priority for Sinn Féin and the party offers little more than soundbites at Leaders Questions. Unlike the water charges and property tax, improving health is not a red-line issue for Sinn Féin in entering coalition with Fianna Fail, should they have to.
In contrast this Government is committed to improving the health services and we have adopted a four-pronged approach to address the causes and challenges of ED overcrowding:
Measures to reduce numbers coming into hospital;
Measures to expand capacity and changes to work practices in hospitals; and
Measures to get people out of hospital sooner
As well as supporting major recruitment campaigns for doctors and nurses, the Government allocated more than €117m in additional funding during 2015. This funding was provided to enable the HSE and voluntary hospitals to implement a range of actions to reduce ED overcrowding, such as increasing bed capacity, reducing waiting times for Fair Deal funding and increasing access to alternatives to services.
From the Opposition benches I have heard, and will again no doubt today hear much talk about the need for additional resources to solve the problems in our emergency departments, but unfortunately that is all it has been - talk.
The Dream Team of Sinn Féin and Fianna Fáil in their alternative budgets for 2015 provided nothing at all to address emergency department pressures. In contrast, we have provided €117 million and a further €51 million to reduce waiting lists. It is only fair to acknowledge that they recognised the issue in their alternative budgets for 2016, promising to provide €86 million in the case of Sinn Féin and €90 million in the case of Fianna Fáil, but that is still less than the €117 million we provided in 2015 and the further significant funding we are providing this year. They call for more resources but their own policy paper s promise less. I look forward to hearing speakers opposite explain this contradiction in their contributions.
Both parties talk a lot about the need to hire more staff, but Sinn Féin’s plans are to cap consultant and management pay and increase their taxes, in a move that would be guaranteed to make recruitment more difficult. They also propose to pay GPs €120 a year per patient for unlimited visits, something that would surely render many practices unviable.
Fianna Fáil, in its alternative budget, made no provision for the Lansdowne Road pay restoration for nurses, young doctors, ambulance drivers, paramedics and therapists. I do not see how we could possibly recruit more staff if we were not to fund or reneged on the commitments made in the Lansdowne Road agreement.
It is little surprise that in the case of Fianna Fáil joined-up thinking is so absent. After all, it ran away from the health ministry in 2004 after Deputy Martin’s period as Minister for Health. During this time, the Fianna Fáil-led Government, supported by Independents, promised to end waiting lists permanently within two years and ensure sufficient bed capacity in hospitals.
Instead, it set up the HSE. Thereafter, so scarred by the experience it was happy to leave the Ministry to Mary Harney even after the demise of the Progressive Democrats in 2007.
As part of the Health Strategy developed during Michael Martin’s period as Health Minister 3,000 additional hospital beds were to be provided. In fact in the period that followed, 2005 to 2011, the number of acute beds was reduced by 1,245 (10.3%).
Trolleys remained a persistent problem. Yesterday the number of patients on trolleys according to the Irish Nurses and Midwifes Organisation’s trolleywatch figures was 356, this is 27% down on the same day in 2011 when after 14 years of Fianna Fail rule the figure was 492. 14 years, much it, boom.
As for Sinn Fein we have seen in Northern Ireland their health policy in action. Like Fianna Fail, they have done everything possible to avoid taking direct responsibility for health except for their disastrous tenure of the portfolio from 1999 to 2002. The Sinn Féin minister during this time, Bairbre de Brún, became famous for setting up enquires and review groups during her four years in office – perhaps she was taking lessons from Micheal Martin who was Minister for Health at the time in this jurisdiction.
In medical circles, her unwillingness to make decisions was soon called ‘paralysis by analysis’. It was even wondered whether she would reach the point where she would have to order a review of the reviews because so many had been commissioned. Under Sinn Féin’s watch in Northern Ireland waiting lists hit a record high, with the longest treatment queues in the whole of the European Union.
The recently published Sinn Féin health policy ‘Better for Health’ gives us an insight into their current plans. It is a strange combination of old ideas which were tried and failed elsewhere, and good ideas that would require a level of investment that is just not realistic. Sinn Féin’s approach to policy is almost childlike. Their approach to finite resources is to want to have it all anyway, so they will put €5 billion into health, billions into education and housing, indeed billions into everything. I’m not even sure they could fund everything if they raised taxes to the highest they’ve ever been in this country. Even if you robbed a bank you’d never pay for it all!
In contrast the Government has developed plans recognising the range of difficulties confronting our health services and the reality that it will take a number of years, resources, commitment and long- term thinking to achieve fundamental improvement.
Current Trolley Situation and Specific Challenges during this winter period
We know from experience that the winter period, and particularly the New Year, is a peak activity period for Emergency Departments throughout the country.
Nonetheless, from mid-November up to this week, there have been improvements in the numbers of patients on trolleys. This week trolley numbers are somewhat higher, however, an analysis of recent performance through a 30 day moving average shows a 10% improvement on the overall numbers on trolleys against the same period last year.
There is some variation with hospitals like Letterkenny, PHB, Mullingar, St James, The Mater, Tallaght, Connolly, showing significant improvements. Others have fared less well and some have disimproved.
In the first couple of weeks of 2016, EDs are seeing up to a 7% increase in the numbers of patients attending, with some sites showing more than a 17% increase in numbers attending. Putting that in context, there are on average, up to 3,000 patients presenting to Emergency Departments on a daily basis with nearly 200 patients presenting at larger Emergency Departments each day.
In order to manage this particular winter peak period, the ED Taskforce Implementation Group has been overseeing hospitals’ winter resilience plans. Also at the moment, my Department and key members of the Implementation Group are engaging in a weekly meeting to monitor ED performance and patient waiting times on trolleys.
Initiatives to address Emergency Department Overcrowding
When we look at the factors which contribute to overcrowding in Emergency Departments, it is clear that the response needs to be at a number of levels. All relevant parts of the health service, namely Acute Hospitals, Social Care and Primary Care have to work collaboratively, so the Government has been driving a response by all elements of the health service.
a) ED Taskforce & Action Plan
In December 2014, I convened the Emergency Department Taskforce to provide focus and momentum in dealing with the challenges presented by ED overcrowding.
The Taskforce Action Plan published in April 2015 contains 88 actions which are the solutions tailored specifically to address the key challenges and causes of ED overcrowding.
I have attended all the ED Taskforce Implementation Group meetings to oversee the implementation of actions arising from the Plan and I can see that real progress is being made on implementing the Plan.
The 88 actions consist of a combination of immediate measures to target the pressure areas and also long-term sustainable solutions to reduce Emergency Department overcrowding.
During 2015 and into 2016, a number of initiatives have been implemented to ease ED overcrowding and impact on trolley numbers. These include initiatives to:
Increase bed capacity in hospitals for the winter months;
Reduce delayed discharges from hospitals by improving access to nursing homes, convalescence and homecare packages;
Recruit more medical and nursing staff into the health service, particularly in Emergency Departments;
Provide specific care pathways in Emergency Departments for older and frailer patients;
More efficient planing and management of patient discharge from hospitals, including early discharge planning from when the patient is admitted and weekend discharges so that patients can leave as soon as they are medically fit;
Improved access to primary care services to reduce reliance on hospitals;
Make best use of all the non-ED facilities available, such as medical assessment units, surgical assessment units, minor injury units and urgent care centres; and
Reduce the length of stay for patients who have been admitted by faster access to diagnostics among other activities.
b) Health service funding 2015-2016
The Government’s commitment to reversing the budget cuts experienced by the health services due to the economic downturn which commenced in 2008, is evident from the extent of the funding provided to the health service over the 2015 and 2016 periods.
In 2016, Health will have funding of around €13.2bn for current expenditure and €414m for capital expenditure, which is an increase of €900m and €36m respectively on the 2015 Budget. This represents a 7% increase on the budget for 2015 and a 12% increase on the voted budget for 2014. In contrast in the last three years of the last Fianna Fail Government public health expenditure was cut from €14.59 billion in 2008 to €13.73 billion in 2011 a cut of €860m as our population and its health needs grew and aged.
Of the gross 2016 Health Budget of around €15 billion, €5 billion has been designated in the HSE National Service Plan to services delivered by our Acute Hospitals. So roughly a third of health spending goes to hospitals, with 2/3 going to primary and social care, mental health, public health and disability.
In 2015 the Government made €117 million available to implement specific measures to reduce Emergency Department overcrowding pressures. This consisted of:
€74 million, which has enabled significant progress on reducing delayed discharges, lowering the waiting time for Fair Deal funding, and providing additional transitional care beds and homecare packages;
€18 million which has supported our hospital services over the winter period by providing additional bed capacity and other initiatives to improve access to care;
€25 million for services that provide alternatives to acute hospitals.
c) Services for Older People - Nursing Home Support Scheme & delayed discharges
Government policy is to support older people to live in dignity and independence in their own homes and communities for as long as possible.
Despite continuing pressure on the public finances the level of home and community based services were significantly strengthened last year and this will be maintained in 2016. What this means is that the HSE will be providing about 10.4 million home help hours, more than 15,000 Home Care Packages and over 300 transitional care beds. In addition, some 130 Intensive Home Care Packages will be provided to support the discharge from acute hospital settings of people with more complex needs.
There will, however, always be people who require a quality long-term residential care option. The Nursing Homes Support Scheme is crucial to achieving this. I think it is worth highlighting that this year the budget for the Scheme is €940m, an increase of €35m on last year’s projected spend. This year the Scheme will deliver over 1.2 million weeks of nursing home care to 23,450 clients per week. An increase of 649 clients per week on 2015. Waiting times for applicants approved for funding should not exceed 4 weeks.
This Scheme remains a key component of our supports for older people and involves a very significant financial commitment on the part of the State.
d) Additional Winter Capacity & Closed Beds Initiatives
Providing additional bed capacity has also been a key initiative to alleviate ED overcrowding. In July 2015, I introduced the Additional Winter Capacity and Closed Beds Initiatives in order to ensure that additional capacity would be in place in hospitals to support Emergency Departments during the winter peak period. As I’ve already outlined, €18 million has been set aside to open new beds and the reopen beds which had been closed.
The HSE and individual hospitals have made considerable progress in opening and reopening beds. Since Friday of last week, there are now:
209 new beds open,
112 previously closed beds have re-opened, and
a further 127 beds will open or reopen during Quarter 1, 2016.
The new reopened beds have been a crucial resource for many hospitals in allowing them to manage the high demand for emergency care at this time.
e) Recruitment initiatives
Recruitment of medical practitioners and nurses into our health service has been a major priority throughout 2015 and this continues into 2016. No one can not have noticed the major recruitment campaigns run by the HSE and hospitals to attract frontline staff.
Since this time last year, there are nearly 900 more nurses and nearly 400 more NCHDs working in the health service. In fact, under this Government, the number of NCHDs has increased by over 1,000.
On consultants, 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 March 2011, over 300 extra Consultants have been appointed, including 92 Consultant appointments between January and November 2015. Also, the number of Emergency Department consultants has increased from 56 to 84 under this Government which goes to emphasise the Government’s efforts to improve care in Emergency Departments.
f) Primary Care Initiatives
Outside of the acute hospital setting, measures are also being implemented in Primary Care to strengthen existing alternatives to hospital. Community Intervention Teams involve nurses visiting patients at home or nursing home, to administer IVs, monitor bloods, dress wounds
Other Primary Care initiatives which alleviate ED pressures include:-
expansion of GP Out of Hours services
increasing GP access to diagnostic services, such as x-ray and ultrasound;
developing minor surgery capacity and palliative care capacity in the community and providing additional hospice beds in Blanchardstown, Galway and later this year, in Kerry.
g) National Escalation Framework
In November 2015, with the HSE Director General, I issued a National Emergency Department Congestion Escalation Directive to hospitals on how best to deal with ED congestion.
The Framework is intended to ensure that appropriate escalation procedures are in place during high demand periods in Emergency Departments. Under the Directive, it is compulsory for each hospital to take specific steps to address overcrowding such as extra ward rounds, if trolley figures reach ‘red’ status on the TrolleyGAR or if any patient is more than 9 hours on a trolley, since a decision was made to admit him or her.
The HSE informs me that the National Escalation Framework has been implemented in all hospitals and that the Special Delivery Unit is currently undertaking an audit of the Framework’s implementation in 10 hospitals. These audits will provide feedback on how effectively the escalation procedures are working in different hospitals and enable further improvements to be made.
h) Scheduled Care Initiatives
While we are focusing on trolley numbers, we must not lose sight of the importance of effective management of waiting lists, because, as we know, today’s cancelled operations are potentially tomorrow’s Emergency Department presentations. The health service has 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.
In January 2015, I set maximum waiting times for inpatient / day case treatment and outpatient appointments of 18 months by 30 June and 15 months by year end and the HSE was provided with additional funding in the region of €50 million to facilitate achievement of these maximum wait times.
The NTPF Waiting List data, published on Friday last week, show that significant progress has been made by the HSE to reduce the numbers of patients on waiting lists during 2015. At the end of December 2015 the HSE achieved 95% compliance for the Inpatient / Day Case Waiting Lists and 93% compliance for the Outpatient Waiting Lists against the 15 months maximum wait time threshold.
What is particularly evident from the NTPF Waiting List data is that progress has been made in addressing the needs of those patients who are waiting longest. On the Inpatient / Day Case Waiting Lists, the number of patients waiting over 15 months reduced by 77% during December and the number of patients waiting over 18 months reduced by 70%. For the Outpatient Waiting List, the number of people waiting over 15 months for appointments has fallen by 54%. We cannot compare OPD waiting times with these or the last government, as they chose not to count or include them in official figures, even though they account for ¾ of all waiters.
It is also very welcome to see substantial reductions in numbers of patients awaiting routine GI endoscopy. These reductions have been facilitated by a dedicated GI Endoscopy Initiative undertaken by the NTPF which targeted patients waiting over 12 months.
Concerted efforts have also been made to reduce the Scoliosis Waiting List. At the end of December, there were no active patients waiting 15 months or more for spinal surgery at Our Lady’s Children’s Hospital, Crumlin.
Conclusion
Progress is being made.
There are now 321 more beds open with a further 127 beds to come on stream in Quarter 1, 2016.
Waiting times for Nursing Home Support Scheme funding have reduced from 11 weeks to 4 weeks;
Over 1,200 additional home care packages were provided to patients by end 2015;
289 additional short stay nursing home beds have been made available, including 224 in public facilities;
We have 900 more nurses and 300 more consultants, 72 of whom were appointed this year alone, not to mention the 28 extra ED consultants.
Nonetheless, we all agree that patients are still waiting too long. Staff have to work in very difficult conditions. It is unrealistic to believe that the situation can be transformed in weeks or months but it is not intractable. With sustained effort, resources and management focus, we will continue to see improvements. It is important to remember that high quality care is provided to patients in Emergency Departments across the country, and the vast majority of patients, who present at EDs, in fact 83% of them, receive timely care and are discharged or admitted within 9 hours.
I can assure the House of my ongoing commitment and interest and that of the Government.