John Moloney (Laois-Offaly, Fianna Fail)
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Rather than spending the few minutes I have talking about the financial statistics, it is important to note that there certainly has been no cutback by way of financial allocations. Neither have there been any cutbacks in the level of services. To be critical of the fact that the Government has neglected the health service does not take into account what has been done over the years.

I heard criticism a few minutes ago of the various Ministers of the Department over the years. When one recalls the mid-1990s, there were very few capital programmes being disbursed throughout the main towns and counties. It is fair to suggest that much of the health endeavour in those years was aimed at putting hospitals in place in most of the main towns in every county. We now have state-of-the-art hospitals. In the Laois-Offaly and Longford-Westmeath area over recent years, three modern hospitals have been built in Portlaoise, Tullamore and Mullingar. I make those points not to be parochial or to say that we have three hospitals so what about the rest, but to show that while the reality is that the health policy has not worked in every region, it has worked in some.

The points made a few minutes ago by Deputy Cooper-Flynn must be borne in mind as well. I do not believe for a minute that patients would be treated so shabbily in the midlands region. I certainly do not see or recognise any difficulty.

I presented as a patient at my own accident and emergency department in Portlaoise shortly before Christmas, thankfully for a short time. Nevertheless, I saw the activity levels, the turnaround in patients and the level of patient care. More recently I had to call to the Mater Hospital on a private matter and was in the accident and emergency unit at 8 p.m. There I saw at first hand the enormous pressure on the nursing staff. When I asked whether it was normally like that, I was told it was very quiet at that time and that the real pressure would be felt at around midnight.

Rather than indulge in general practitioner bashing, and I read the reports of the Irish Medical Organisation conference, it nevertheless must be taken into account, as the Tánaiste cited, that 75% of those who present at accident and emergency departments are discharged the same day. In other words, they do not require acute beds. An issue exists which needs to be dealt with by means of better services at primary care level. That is neither a cop out nor us neglecting our responsibilities in Government. The reality is that with a spiralling population and the enormous demands on the health service, a radical response is needed. I recognise the dramatic impact on the health service over the years wrought by changing population patterns.

I also recognise, however, that this Administration and its predecessor went out of the way to try to regionalise services. It has not happened in some places. Where it has, there is very little difficulty with either trolleys or accident and emergency units. Obviously the level of services is being delivered in those regions where change has been accepted. I again refer to my area, the former Midland Health Board. The cancer service based at Tullamore, the orthopaedic service, etc. has lessened the strain on hospitals in the capital. As long as this policy continues, I believe we can get to where we want to go.

It is important for Members to read the presentation Professor Drumm made some time ago to the Joint Committee on Health and Children in which he acknowledged the difficulties in accident and emergency departments. At the same time he recognised that some hospitals were working to a degree whereby there was no complaint. We must home in on that. The committee has invited people from the so-called successful hospitals to come before it to explain the procedures and processes involved which ensure that there are no complaints. On the other hand, we want to invite consultants and other staff from those hospitals which have not performed to the best hoped-for levels. Rather than penalise them by way of financial penalty, the Minister and the Department should identify initiatives that will recognise best practice and, most importantly, best outcomes. Until that time comes, there will be problems in certain hospitals.

The Minister and Professor Drumm have come before the committee, listened to concerns and outlined their responses to the problems, specifically as regards accident and emergency departments and the rising numbers. I have heard it said that the Government is closing its eyes to criticism. It is fair to point out that the Joint Committee on Health and Children has the facility to pursue specific issues and look for policy change. That is where we will see the responses, whereby the HSE and the Minister come before the committee, respond to various criticisms and come back on a three-monthly basis to resolve or at least explain problems.

I have always believed there is no quck-fix solution to problems in many accident and emergency units. Many of the problems are complex. A wide variety of actions will be required to address them, whether through a combination of reform, resource management to improve efficiency in such a way that suits the individual hospitals concerned or whatever. It is important to suit the individual hospitals concerned. Obviously the demands on a rural general hospital will be different from those on an urban central hospital complex. Therein lies the solution. It is not enough to have solutions at the same level for every hospital in the country. There should be some means of assessing the efficiency of hospital facilities to see if the systems in place are successful and, if so, to work from there.

I do not believe everything is as it should be. However, outlandish as it might sound, some years ago all the parties in the House came to recognise that the only way to sort out all the problems in the North was through a combined unified effort. If the Opposition believes we have a crisis on our hands——

Eamon Gilmore (Dún Laoghaire, Labour)
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After nine years.

Liam Twomey (Wexford, Fine Gael)
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The Deputy should resign from Government and let us sort matters out.

John Moloney (Laois-Offaly, Fianna Fail)
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I should have made the point that I did not waste my time reading out the 25 enormous financial increases in health introduced by this Administration. The Deputies do not want to believe them, although they are the facts. It is nonsense that, while people make a genuine effort to resolve the difficulties in the health service, as soon as an issue crops up somewhere, we spend the morning attacking the relevant Minister as if it was his or her doing. If we all believe in trying to sort out the problems in the health service, there should be a combined effort in support of the Government for a period of time rather than being critical of the huge advances that have been made in the past nine years.

Breeda Moynihan-Cronin (Kerry South, Labour)
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I wish to share time with Deputy Gilmore.

Séamus Pattison (Carlow-Kilkenny, Labour)
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Is that agreed? Agreed.

Breeda Moynihan-Cronin (Kerry South, Labour)
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I am grateful for the opportunity to raise a number of issues in the short time that is available and to support the amendment tabled by my colleague, Deputy McManus.

I wish to speak about accident and emergency services in Tralee General Hospital. There is a perception that the accident and emergency crisis is confined to Dublin, but I assure the Minister of State, Deputy Seán Power, that we have a crisis in the accident and emergency unit in Tralee General Hospital. In November last year 40 GPs picketed Tralee General Hospital. That was unprecedented for GPs. They were not looking for anything for themselves, they were trying to highlight the inadequacies and deficiencies in the hospital. They send their patients to the hospital to be looked after but — I regret to say this to Deputy Moloney — because of lack of funding their patients were not looked after as quickly as possible.

We lost our accident and emergency consultant, Mr. Seán O'Rourke, to another area because he was looking for a number of extra staff, including registrars, and they were not provided. A wonderful man has been lost to the health services in Tralee. The weekend before last the accident and emergency service in Tralee was extremely busy due to a number of accidents. Some of the people being treated did not even have the luxury of a trolley. They were standing up against the wall with IV drips in them. What is going on in the accident and emergency unit is unreal. The medical staff, porters, nurses, other staff and patients are under extreme stress because of the conditions there.

In recent weeks the Tánaiste stated that when she was growing up if one got sick during the night the GP came to the house. I assure her that the problems in accident and emergency units are not due to GPs. I also remind her that we are living in a different world. We cannot expect GPs to work 24 hours a day, seven days a week if they are to provide a proper service and have lives of their own. We cannot expect GPs to take the blame for the problems in accident and emergency services.

I speak from experience. I have been in the Dáil for 14 years and the problems with hospital beds has become acute in the past three or four years. When I entered the Dáil this was not an issue. I recently dealt with a case in which an elderly lady was to be discharged from hospital but she had nowhere to go as she had no immediate family. Her extended family pre-empted the fact that she would need to go into a nursing home and applied for a nursing home subvention. I raised this matter in the House previously. The Minister of State, Deputy Seán Power, was in the House on that occasion, but I will outline it again because it shows that while funding will not solve all the crises in the health service it will solve some of them if it is targeted in the right place.

The woman of whom I speak applied for the nursing home subvention on 30 November 2005. She was placed No. 467 on the waiting list. On 31 December she was No. 452 on the list and on 31 January 2006 she was No. 438. I rang this morning to find she is now No. 423. This woman does not have immediate family members but her extended family is helping out. She is currently in a nursing home. She could not remain in hospital as her needs were not of an acute nature. We should tackle this issue. Perhaps we could provide public beds in private nursing homes to allow some people who are in hospitals to go into nursing homes, or provide money for the nursing home subvention. In that way, at least those patients who are in a position to be discharged to a nursing home can be discharged.

Somebody in the Government will have to take responsibility for the health crisis. People will not accept farming it off to the HSE all the time. Funding is a political responsibility and the funding of nursing home care, extra hospital beds in community hospitals and accident and emergency registrars is vitally important. I do not accept that funding will not solve the health crisis. It will solve much of it. Plenty of money is available and the Government should stop passing the buck and deal with the issue now.

Eamon Gilmore (Dún Laoghaire, Labour)
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I thank Deputy Moynihan-Cronin for sharing her time with me. I rise to support the amendment tabled today by my colleague, the Labour Party health spokesperson, Deputy McManus. I listened to Deputy Moloney, a Member for whom I have great respect, and if there was ever a statement of admission of the failure of the Government to deal with the health crisis it was the appeal that has just been made by him. What do we get after nine years of this Government, in the best of times with unprecedented revenues available to it? We get the Tánaiste and Minister for Health and Children announcing a national emergency in respect of accident and emergency services in hospitals. We also get a highly respected and experienced member of a Government party and a member of the Oireachtas Joint Committee on Health and Children throwing up his hands in despair and calling on Members of the House to get together to solve the problem that the Government has failed to solve for the past nine years and asking the Opposition parties to——

John Moloney (Laois-Offaly, Fianna Fail)
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On a point of order, it was not despair.

Liam Twomey (Wexford, Fine Gael)
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Desperation.

Eamon Gilmore (Dún Laoghaire, Labour)
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——support the Government.

John Moloney (Laois-Offaly, Fianna Fail)
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It is a non-political issue.

Eamon Gilmore (Dún Laoghaire, Labour)
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When it comes to the crisis in accident and emergency services and other areas of the health service the Government is the problem, and that problem will not be solved until the Government gets out of the way and lets those of us who are prepared and able to deal with the problem resolve it.

In regard to accident and emergency services, there is no solving of the problem without increasing the bed capacity in our hospitals. I will illustrate this by reference to the experience in my constituency. I hear many constituents complain that if they need to be sent to hospital they are dispatched directly into St. Vincent's hospital. There was a time when they would have been sent to Loughlinstown or St. Michael's Hospital, the two local hospitals, but now they are only used as staging posts until the patients are transferred by ambulance to St. Vincent's hospital.

I have heard repeated complaints about the length of time people have to wait in accident and emergency departments even though it is acknowledged they receive very good care when they eventually get into a ward. St. Vincent's hospital cannot cater for the hospital needs of an area of the south east of this country stretching from Ballsbridge to Rosslare. The solution to the accident and emergency problem and the hospital needs of the people of my constituency and of neighbouring constituencies in Wicklow and north Wexford will not be met until there is a serious investment in the two local hospitals in the constituency I represent, Loughlinstown hospital and St. Michael's Hospital in Dún Laoghaire. No matter how many times it is called a major hospital, one hospital cannot physically be expected to cater for the needs of one of the fastest growing areas of population in the country. That problem is replicated many times throughout the country. It seems that the strategy is being pursued by stealth whereby accident and emergency services are being concentrated more and more in the large general hospitals.

Fiona O'Malley (Dún Laoghaire, Progressive Democrats)
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I will begin by paying tribute to the Tánaiste. I have a vested interest in doing so because she is my party leader, but 15 months ago she took on what is generally described as the most difficult political job.

Eamon Gilmore (Dún Laoghaire, Labour)
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It has got worse since she took over.

Fiona O'Malley (Dún Laoghaire, Progressive Democrats)
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I doubt that very much. Her enthusiasm and commitment to the task remain undiminished. It is a tribute to the person she is that she relishes a challenge. She has the courage and the vision and most importantly she is honest in recognising that she does not have the magic wand to provide the solution. She also acknowledges that neither does any other party in the House. She has the vision——

Eamon Gilmore (Dún Laoghaire, Labour)
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It is not a magician we need but a Minister.

Fiona O'Malley (Dún Laoghaire, Progressive Democrats)
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——and the courage, and those are what are required to bring about reform. We will bore each other recounting the changes that have taken place since 1997 in terms of resourcing, which has increased from €3 billion to €12 billion and will probably be higher next year. The question of resources is a myth at this stage — there is no question mark about resources. I listened to Deputy Moynihan-Cronin's contribution, her reference to the needy and that it is a question of resources, but I disagree. We would have solved all the problems if that was the case. I do not deny that resources need to be applied in different areas but that is a different matter to the reform that is required first of all.

We have a duty as a Government and as a Parliament to get value for money for our taxpayers. It is only natural that we are looking at what has happened to those additional resources that have been ploughed into the health service in recent times. Professor Drumm has referred to the assumption that all the problems can be solved by more capacity, more resources and more money. I am sorry that Deputy Gilmore will not listen to my final point. The assumption presupposes that the system is not at fault, and the Opposition Members, not to mind the public, are fooling themselves if they do not think the system itself is at fault.

I am pleased that Deputy Gilmore has come back to listen to more because I wanted him to hear that point in particular. If that were the case we would just need bigger and more. Deputy Twomey who is a doctor is more familiar than most of us with the service.

Liam Twomey (Wexford, Fine Gael)
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I am too familiar with it.

Fiona O'Malley (Dún Laoghaire, Progressive Democrats)
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We do not need to build a bigger system but we need to reform the present system.

Eamon Gilmore (Dún Laoghaire, Labour)
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The Government has had nine years to reform it.

Liam Twomey (Wexford, Fine Gael)
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Will the Deputy tell the House what the Government has been doing for the past nine years?

Eamon Gilmore (Dún Laoghaire, Labour)
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How much longer does the Government need? The normal term of a Government is five years.

Séamus Pattison (Carlow-Kilkenny, Labour)
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Allow the Deputy to continue without interruption.

Fiona O'Malley (Dún Laoghaire, Progressive Democrats)
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It is not politicians, the Government, the Minister or the Department alone that can do this, it must be done in co-operation with the people who work in the sector. It is regrettable that time after time when the Government has tried to introduce initiatives which the IMO wanted, the Opposition has put obstacles in the way. For instance, with the GP visit card, which was initially welcomed by Fine Gael and was to be introduced in the budget, it took a year to finally get agreement on it.

Liam Twomey (Wexford, Fine Gael)
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On what?

Fiona O'Malley (Dún Laoghaire, Progressive Democrats)
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On the GP-only card.

Liam Twomey (Wexford, Fine Gael)
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What about the 30,000 ordinary medical cards?

Fiona O'Malley (Dún Laoghaire, Progressive Democrats)
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This demonstrates what is one of the blockages in our health service.

Liam Twomey (Wexford, Fine Gael)
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What about the 30,000 ordinary medical cards?

Fiona O'Malley (Dún Laoghaire, Progressive Democrats)
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We must all work together to deliver a service.

Liam Twomey (Wexford, Fine Gael)
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The Deputy is misleading people.

Fiona O'Malley (Dún Laoghaire, Progressive Democrats)
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The IMO and the GPs in particular showed there was some issue in play other than patient care in their stand on that matter and that is regrettable. Thankfully the agreement is now in place.

Some of us who are members of the Joint Committee on Health and Children attended the GP-IMO conference in Croke Park recently. A delegate castigated the Government for having introduced a system whereby those over 70 who had not previously held a medical card were now in possession of what is described as a golden medical card worth four times the amount to a GP. It has caused problems in the service. The GP in question wanted me to answer for it. I pointed out to him that this was not Government policy but it was a question of their union deciding that they would not deliver this service and that they would demand more money to provide that service. We all acknowledge the disruption that has been caused in the placing of GPs certainly in Dublin city — I am not sure about other parts of the country. My area is well enough served but I know there are large areas in north and——

James Breen (Clare, Independent)
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They are lucky they are not in County Clare.

Fiona O'Malley (Dún Laoghaire, Progressive Democrats)
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——west Dublin where there is no incentive for GPs to provide these services.

I have been diverted from my point. I wish to underline the necessity and the importance of putting the patient back at the centre of care and at the centre of the service.

I refer to the nine to five service operating in many hospitals. Medical care cannot be delivered on a nine to five basis and both Professor Drumm and the Tánaiste are trying to change this. I acknowledge that anybody providing a service outside the normal hours should be properly recompensed and that is not a problem for anybody. It is a question of rostering. People in the health service must recognise that 24-hour rostering is essential because services cannot be closed down at 5 p.m.

The recent Tribal Secta Global Management report cited the request for an extra CT scanner in either Wexford or Galway — I am not sure which. The request was made because the existing CT scanner was not used after 5 p.m. This is nonsense. I know that CT scanners are very costly and, therefore, the country should be getting more than a nine to five service from these machines. As Professor Drumm stated to the committee, these are the things we must do. He said we have paid for a service and we need to ensure it is delivered.

I do not think the Tánaiste thought it was going to be easy to deliver an improved health service. Deputy Moloney referred to the fact that she might have been grateful for a certain amount of help from Members of this Parliament. I acknowledge it is the job of the Opposition and of all of us to be representatives of the people and we must highlight problems when they exist. However, we should not make political causes out of all of them.

We need to be careful of what we say this side of a general election because if we find ourselves on the other side subsequently, we will not automatically start decrying the health services——

John Moloney (Laois-Offaly, Fianna Fail)
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No fear of that.

Fiona O'Malley (Dún Laoghaire, Progressive Democrats)
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——or, indeed, lauding it. Deputies should be careful about that because it is our national health service to which we are doing damage.

James Breen (Clare, Independent)
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Unlike some on the other side, we will not do that.

Fiona O'Malley (Dún Laoghaire, Progressive Democrats)
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It is the patients we are dishonouring by doing it.

Liam Twomey (Wexford, Fine Gael)
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We know who to talk to all right.

James Breen (Clare, Independent)
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We will not do it when we get over there, I can assure Deputy O'Malley.

Fiona O'Malley (Dún Laoghaire, Progressive Democrats)
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Most importantly, it is the health workers, the people who devote themselves to the care of people, to whom we are doing a disservice.

Liam Twomey (Wexford, Fine Gael)
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Deputy O'Malley should not be misleading the House. It is the patients she is letting down.

Séamus Pattison (Carlow-Kilkenny, Labour)
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Deputy O'Malley without interruption.

Fiona O'Malley (Dún Laoghaire, Progressive Democrats)
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The patient experience we are most focusing on in the debate is that of accident and emergency. While it has been acknowledged by both the Tánaiste and Minister for Health and Children, Deputy Harney, and Professor Drumm that conditions in some accident and emergency departments are unacceptable, both for patients and for staff, the difficulties in accident and emergency are symptomatic of wider problems in the hospital sector which need reform. In particular, it is about blockages in the system.

We all are aware of people who are not in a position to be discharged because they do not have either facilities in their homes or somebody to take care of them, and who occupy acute beds as a result. They must remain within the acute system because there is nowhere for them to go on leaving it. That is not an efficient use of acute services. That is why many care packages have been put together in the recent budget by the Tánaiste and Minister for Health and Children and this will be a good way of freeing up beds. The difficulty in accident and emergency is because there are so few beds to which people may move. We all know what the problems are and we must get rid of the difficulties that arise through these blockages.

When Professor Drumm was before the Joint Committee on Health and Children, we heard about individual instances in certain hospitals, Kilkenny particularly, where practice is good. We need to have an individual responsible who will deliver the change and who will manage the services of the hospital in a more efficient way, and we must learn from best practice.

Paul Gogarty (Dublin Mid West, Green Party)
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I wish to share time with Deputies Ferris, Catherine Murphy and James Breen.

I agree wholeheartedly with Deputy Fiona O'Malley who is trying admirably to defend the indefensible.

Fiona O'Malley (Dún Laoghaire, Progressive Democrats)
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I do not find it indefensible.

Paul Gogarty (Dublin Mid West, Green Party)
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Deputy Fiona O'Malley is correct in saying that we need somebody who will manage the health service efficiently and it certainly is not the Tánaiste and Minister for Health and Children, Deputy Harney. A year after coming into office and having said there is a crisis, she is now trying to address it and state all sorts of platitudes before the general election in the hope of getting back in to office again.

If the Tánaiste and Minister for Health and Children had her way the health service would be privatised and hardly anything would be left except for the dregs to cater for the poorest of the poor. That is the way it is going. We need a state-of-the-art, publicly funded health service which is able to provide the capacity needed.

My colleagues, Deputies Gormley and Sargent, have referred to the mess in the health service. In the short time available, I want to point to a number of examples. On 19 April last, a constituent of mine was brought into St. James's Hospital with severe triple vessel coronary disease. He was told he would be looked after but, because it happened to be the Easter period, he was discharged. He now must wait three to four weeks for an operation. He could be dead within that three to four weeks and if that is the case, it is the responsibility not only of the hospital but of the Tánaiste and Minister for Health and Children and the Health Service Executive because ultimately it boils down to the resources being invested in the service. One can plan all one wants but it will not happen unless the resources are provided to back that up.

There is scope for investing cleverly. The Green Party has constantly spoken of the need for a three-tier health care system whereby one deals with the situation at local level first before going to accident and emergency. There are a number of well-run 24-hour private clinics. There are very few public ones. One could provide more public clinics where there would be a rostered general practitioner who is properly paid for his or her services, a registered general nurse and a certain basic modicum of facilities before a person would be sent to accident and emergency. At present, people still appear at accident and emergency units rather than go to their general practitioner. Others who go to general practitioners are still being told to go to accident and emergency. Surely there is a need for a middle tier where if somebody falls down when he or she is drunk and needs stitches, he or she can get them in a local 24-hour clinic.

I have used the following example previously, although I am not sure whether I used it in this Chamber. Being a GAA and soccer enthusiast, I got a stud through my toe a couple of years ago. It caused a little bruising and swelled up and I ended up going into St. James's Hospital because it happened in the evening. I spent eight hours there. Eventually, I was seen by a nurse who took a paper clip, heated it under a Bunsen burner and stuck it into my toe providing instant, if painful, relief. Why must a person go to a major hospital to get a paper clip stuck through his or her toe? That sort of basic service could be provided locally. If we started planning a regional and community-wide network of local tertiary treatment centres in the first instance, it would save the taxpayer money and ease some of the pressure on the accident and emergency departments.

Martin Ferris (Kerry North, Sinn Fein)
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At her party conference at the weekend the Tánaiste and Minister for Health and Children, Deputy Harney, and her colleagues were fond of quoting figures to prove how beneficial they had been to the country over their years in Government. One set of statistics conspicuously absent from any of the self-congratulatory speeches was that found on the Irish Nurses Organisation's website showing the numbers of people each day on trolleys in the hospitals under the Tánaiste's responsibility. This happens when we are living through a period of unprecedented wealth. Despite that wealth, there has been no improvement in the health service, especially in the past ten years. In fact, many would argue it has gone from bad to worse.

Yesterday 331 patients spent the day, for many not the first, on trolleys because no beds were available. In my town of Tralee, in Kerry General Hospital there were ten people on trolleys. Whether this is coincidental, on 8 November last I was asked to leave this House because I raised the conditions in the accident and emergency unit in Kerry General Hospital. Nothing has been done in the succeeding six months to improve that situation. Last weekend 17 people, including four on the permanent casualty beds and others sitting on chairs, awaited treatment in the accident and emergency unit in Tralee.

When I was in Kerry General Hospital a few weeks ago one man with a broken leg had been there for about six hours waiting to get treatment. On another occasion when I was there, in November last, a 74 year old woman had spent the entire previous night and that day awaiting treatment in the corridor and some of that time she spent sitting on a chair. Such cases continue to arise. This is not the fault of the hospital staff, who are attempting to work under extreme and difficult conditions without proper staffing levels or facilities to cope with the demand.

There is also the ongoing situation where cleaning is being inadequately performed owing to lack of staff and materials. I stated at the time Kerry was given a poor rating in the report on hospital hygiene that it was simply impossible for the staff to do a proper job and, in some cases, nurses were having to perform the work of cleaning staff.

The seriousness of the situation cannot be emphasised enough. Everybody who has spoken during this debate has alluded to the fact that despite the massive resources that are supposedly going into the health service, it is inadequate and needs to be rectified.

Rory O'Hanlon (Cavan-Monaghan, Ceann Comhairle)
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I point out to Deputy Ferris that if a Deputy is asked to leave the House by anybody in the Chair, it is never for an issue raised but for being disorderly in the House. Nobody is ever asked to leave the House because of an issue that he or she raises. A Deputy is asked to leave the House because he or she is disorderly.

Catherine Murphy (Kildare North, Independent)
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The accident and emergency trolley issue and hospital bugs are seen as the two major elements of the current emergency. They are very much a symptom of a wider problem, that is, the insufficient number of beds and support staff who should accompany those beds.

I emphasise that the trolley emergency must not be resolved at the expense of the postponement of elective surgery. One aspect I have come across repeatedly and recently is the sheer terror among those awaiting surgery, not just because of the surgery but because of their concern about the probability of their procedure being postponed. It is cruel for a patient to arrange their schedule and emotions around that surgery only for it to be postponed several times. There is a risk that in sorting out one problem, a range of other problems will be created. The same people could ultimately present as acute cases and this must be factored into the resolution of the accident and emergency department crisis.

A total of 24 patients were on trolleys in Naas hospital yesterday while the numbers in Tallaght and Blanchardstown hospitals were 20 and 16, respectively, giving a total of 60 patients on trolleys in the catchment area that includes Kildare. These hospitals cater for one of the fastest growing parts in the State but no planning has taken account of the expanding population in the region and we are experiencing the results of that. We are moving towards a system with a stronger primary care focus, which is the way to go. However, it is not a panacea and a planned response is needed. When people move into an area, new provision must be made.

James Breen (Clare, Independent)
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The Tánaiste tabled a motion of confidence in herself, but if the whip was not imposed, my former colleagues on the Fianna Fáil backbenches would table a motion of no confidence in her and her predecessor because of the mess they have made of the health service. Constituents of Fianna Fáil backbenchers are lying on trolleys waiting for beds. Six patients are on trolleys in Ennis General Hospital while 16 patients are waiting for beds in Limerick Regional Hospital. Later, the Fianna Fáil backbenchers will, like sheep going to be slaughtered, vote with the Government, which has let down the State's health service.

The accident and emergency department in Ennis hospital was so crowded a few weeks ago that patients were put in the reception area. I tabled a question to the Minister regarding whether there was a health and safety issue and she replied there was not. What would happen if a chair blocked an exit door to the Chamber and a fire broke out? Would it be a health and safety issue? What would the Minister say? There would be uproar, but poor patients are lying on trolleys blocking entry and exit doors to the hospital and that is not good enough. It is disgraceful that Government backbenchers and a few of my Independent colleagues will vote with the Government on this issue. The Ceann Comhairle is a lucky man he does not have to stand for election.

Rory O'Hanlon (Cavan-Monaghan, Ceann Comhairle)
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The Chair cannot be drawn into a debate.

Seán Power (Kildare South, Fianna Fail)
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If the Deputy had his way, he would also be a Fianna Fáil backbencher now.

James Breen (Clare, Independent)
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If the backbenchers are happy with what is going on, they do not want to be returned to the House because I know the message that will be sent by the people in the next election. Thanks be to God the people of Clare were not conned and I am delighted they saw through the Government parties during the last election campaign. They will see through them again next year when I am returned to represent their interests and speak out on their behalf. I call on the Government backbenchers to support the Opposition and vote down this disgraceful motion of confidence in the Minister.

Dermot Fitzpatrick (Dublin Central, Fianna Fail)
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I wish to share time with Deputies Keaveney and Carty.

We have just heard the opening speech of the 2007 election campaign from Deputy James Breen. I wish him well in his campaign in Clare.

James Breen (Clare, Independent)
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I thank the Deputy.

Dermot Fitzpatrick (Dublin Central, Fianna Fail)
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We will vote with the Government later because we have an excellent and outstanding Minister for Health and Children, who is grappling with the issues as they come up. I suspect they are not as easy to address as she may have surmised when she took up the post but she will deal with them and on 17 May 2007 she will be able to tell Deputy James Breen that the health services in Clare are 100% effective.

James Breen (Clare, Independent)
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I look forward to that with interest.

Dermot Fitzpatrick (Dublin Central, Fianna Fail)
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I am a member of the Oireachtas Joint Committee on Health and Children for my sins, and recently, Professor Drumm, the chief executive of the HSE, addressed the committee. He stated:

What needs to radically change are some of the outdated work practices which exist within our hospital systems, practices that do not serve our patients or staff and sometimes manifest themselves in people waiting an unacceptable length of time for diagnostics, outpatient appointments and both elective and emergency admissions. This is why we really have to ask ourselves why some hospitals are experiencing problems in their emergency departments and others are not.

Let us look, for example, at the process that occurs in some emergency departments. When somebody arrives with a GP letter, they can have up to five contacts with medical personnel before coming to the end of the process and a decision is reached on whether to admit them, threat them or transfer them. A patient can see an experienced senior nurse who then refers him or her to a junior doctor and, possibly, a registrar within the emergency department. If the patient is attending during normal working hours, he or she may be seen by a consultant. If there is a decision to admit, a junior doctor will be brought down from the ward in the main hospital to again assess the patient and this is despite the fact that the decision to admit has already been made by an experienced consultant. The junior doctor will then consult with his or her registrar to reassess the patient prior to admission.

Such work practices are unacceptable in 2006. Professor Drumm further stated:

Consultants highlight that they are on call and frequently attend for emergencies. This commitment is appreciated but is not sufficient to meet the needs of today's patients. For example, the majority of attendances at emergency departments take place between 5 p.m. and 1 a.m. We need emergency consultants and diagnostic personnel working during those hours when their expert decision making skills are most needed. We obviously have to be willing to pay for such a service from skilled professionals.

I agree with Professor Drumm in this regard. A hospital cannot have an accident and emergency department staffed by consultants between 9 a.m. and 5 p.m. and staffed by non-consultant junior doctors for the remaining time. As anyone who has worked in the medical profession in Dublin will know, such departments get busy between 10 p.m. and 3 a.m. This is when experienced, trained consultants should be on duty.

Professor Drumm stated:

I appreciate that emergency department staff can experience frustration with hospitals systems that need to become more efficient, for example, when admitted patients often have to remain in hospital awaiting diagnostic tests, which sometimes cannot be provided for a number of days because of excess workloads for X-ray and other departments. We need to extend the length of time that these types of services are available and, as a result, reduce the length of time people need to spend in hospitals. If we continue to put up with unwieldy and outdated practices in the health system, where patients and staff must navigate through cumbersome hospital processes, and do not address the gaps in our community and primary care, it is certain that we will need more acute beds. If we change our present practices and follow all those advanced health systems around the world, it is likely that we will have sufficient acute beds for our present population but we will naturally have to plan to accommodate our growing and, more importantly, ageing population.

Professor Drumm has told us we do not have to provide more beds but we need to be more efficient with our use of them. This can be done by extending the hours consultants and senior staff are on duty and ensuring experienced and expert cover is available during the most appropriate hours. He continued:

At present we have a shortage of publicly owned community long-stay beds. In addition, the spread of acute beds around the country may not be ideally balanced. The HSE is studying its overall bed requirements, particularly in light of growing numbers of acute beds being developed by the private sector and if a response is required, it will be based on patient need and evidence, not on inefficient processes.

In my constituency, a rapid access unit has been opened in St. Mary's Hospital where general practitioners can arrange to have elderly patients seen within 24 hours. This is one of the models we should follow.

I have been in practice for 35 years and my colleagues and I have never met the representatives of our local hospitals to discuss our mutual problems. We have never tried to arrive at a consensus on how to treat our patients expeditiously and with dignity. It is a communication problem again and I do not wish to blame any particular class for it.

Cecilia Keaveney (Donegal North East, Fianna Fail)
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I am delighted to make a brief contribution to this important issue. I have a report entitled Alcohol and Injuries in the Accident and Emergency Department: a national perspective. I am interested in this report and I note that alcohol has not been mentioned by a number of contributors. I am Chairman of the Oireachtas Joint Committee on Arts, Sport, Tourism, Community, Rural and Gaeltacht Affairs and we are examining the proposal to bring alcohol under the national drugs strategy.

The report to which I referred confirms that alcohol injuries carry a significant burden for accident and emergency services in acute hospitals in Ireland in terms of increased numbers in attendance, the range of presenting injuries and the high level of repeat visits. It also states that there is an increased risk for staff working in the accident and emergency departments due to the level of intoxication among patients, which has significant health and safety implications. A quarter of all those who arrive in accident and emergency departments present with an alcohol related injury, while others delay attending hospital so that the blood-alcohol levels can drop. Therefore, the figures in the report may be an under-estimation. We cannot afford to ignore the alcohol issue much longer.

Is the Government examining the experience in the UK with the alcohol bus? People are being picked up by the bus and if they only have a minor problem, they can be driven home rather than presenting at an accident and emergency department at the peak time of 3 a.m. on weekends. We must impose imaginative solutions like that and we should look at what other countries are doing.

The role of the GP is very important. There are more co-operatives working at that time of the evenings where people may not have access to patient records. As the GP is unsure and is liable to litigation, the person is referred to an accident and emergency department. I believe that there should be more support at primary care level. People could be x-rayed in the local primary care centre and we have excellent examples of those in Donegal. These centres could have their services strengthened and that may take the burden off the main hospital such as the one in Letterkenny. I hope the Tánaiste expedites the proposal on the Letterkenny accident and emergency department which is at the planning stage and which will add 70 beds to the accident and emergency department there.

The overall bed problem has been eased by the new 11-bed oncology unit, but I feel a manager should be put in place as soon as possible. Management is a very important issue for the efficient use of the hospital and the manager's post has already been advertised. Intervention should occur to ensure that we have a full multidisciplinary cancer team with a permanent consultant and radiotherapy as well as the expediting of the BreastCheck programme. Prevention is ultimately better than cure.

Damien English (Meath, Fine Gael)
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I am delighted to say a few words on this issue. I recently received a phone call from a lady in Navan who went to the casualty department in the hospital in Drogheda. She entered the department at 7 p.m. with severe pains in her stomach and back. She was only seen briefly at midnight and it was 4.15 a.m. before she was properly examined. During her nine-hour wait, she watched a child vomit on the floor in the casualty department, yet it was three hours before that was cleaned up. Someone cleaned the room at midnight and took three and a half black refuse sacks of rubbish out of the accident and emergency department. We are trying to prevent MRSA and other bugs in our accident and emergency departments, yet these departments are covered in filth. All that is needed is for one person to be put in charge of each accident and emergency department. A similar level of responsibility should occur on the wards.

During this lady's wait in the accident and emergency department, an ambulance arrived with a patient and had to wait for two hours before its trolley could be returned and it could leave again. The driver could not leave because the accident and emergency department in Our Lady of Lourdes Hospital needed the trolley.

A few weeks ago, the Tánaiste declared the accident and emergency unit situation to be an emergency, but it has been one for years. It is too late to be putting our hands up and wondering what to do about it. People on the Government side of the House will speak of the causes of this and how it cannot be fixed, while we will speak about why it can be fixed. However, if there is real political will in this House, we can make changes quickly. The smoking ban is a great example of this and it was carried out by the Department of Health and Children. It was done because it sounded good, but it was political will that delivered on that. As a young politician, that proved to me that we can do things in this House when we really want to do so.

I do not want to be told that it was the consultant's, the health board's or someone else's fault, because the buck stops with the Minister of Health and Children. I do not blame this Government alone, but we have been told for ten years that things are going to get better. We have had money and time to make changes in the past ten years, but we have not done so. We have had major problems, yet the buck has been passed to someone else.

The Tánaiste told the House today that certain things that will be done could not have been done under the old health board system. That is nonsense because the HSE is just the health boards with another layer on top. Nothing has changed because most of the same people are still employed. We did not have to wait for the advent of the HSE to make changes. We could have had changes a long time ago, but we did not make them.

The main problems with accident and emergency departments are quite simple. We need more beds, more staff and more resources. Day after day, the Taoiseach tells us that the problems in accident and emergency departments have nothing to do with resources, but that is not the case. Accident and emergency cover in my hospital was supposed to close down last November owing solely to a lack of resources. We were short of surgical staff owing to a lack of €100,000. That was a resource issue and while it has not been fully solved, we are getting there.

The problem was due to a shortage of money, which is a problem across the north east. We are about €60 million short per head of the population in the past five or six years. We are not getting the health service we need for the area. The accident and emergency department in my local hospital in Navan is a portakabin with about six trolleys. The hospital needs a purpose-built accident and emergency department. How can staff be expected to deliver a service to at least 20,000 clients per year? The accident and emergency unit has occupied a portakabin for a long time, yet the population it serves has trebled to 200,000.

Last March, the Tánaiste had the cheek to claim that the accident and emergency unit at Navan hospital was upgraded. It was painted and its chairs were rearranged but that is not an upgrade. We must have proper purpose-built accident and emergency units. A population of 200,000 needs an adequate building and sufficient staff. The surgical team in Navan hospital has one and a half surgeons, whereas most surgical teams have at least three. The team has been criticised for not performing well and reports point out problems in the hospital which arose from the underfunding of staff and resources.

I could continue for ages to discuss problems in primary care, home help services and public health nursing. Public health nurses can no longer do their jobs because there are not enough to cover the growing population. Deputy McManus noted that community care beds in County Meath have been reduced by 25, whereas the population has increased by 40%. We are not being looked after and there is no point in the Tánaiste expressing surprise that there is an emergency.

Rory O'Hanlon (Cavan-Monaghan, Ceann Comhairle)
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Three and a half minutes remain for Deputy Pat Breen.

Damien English (Meath, Fine Gael)
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The resources are not being put where they are needed. The people and medical staff of the north east should be given a fair chance.

Seán Power (Kildare South, Fianna Fail)
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Deputy English should give his colleague a fair chance.

Damien English (Meath, Fine Gael)
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We are here to solve the Minister of State's problems with the health system. There is no point in holding discussions without results.

Pat Breen (Clare, Fine Gael)
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The Minister of State claimed that there is a tendency among some commentators to highlight the perceived flaws in the health system. I can assure him that the commentators' perception is real but his is a fantasy. I acknowledge the excellent work carried out by medical and nursing staff in our hospitals, not least in under-resourced hospitals such as Ennis General Hospital. One crisis leads to another and I am reminded of how the Government first attempted to deny the rip-off culture that exists in many parts of the economy before acknowledging the reality of that matter. I only hope that the Government will do a similar U-turn on accident and emergency services.

I invite the Minister of State to visit Ennis General Hospital and to see at first hand the crisis that faces every hospital in the country. When it comes to the Hanly report, Ennis is similar to many other hospitals in being on the wrong side of the track. Hardly a day passes in which I do not hear complaints about the hospital's services and resources, appalling waiting conditions or patients lying on trolleys. The medical staff are beyond reproach for operating in such conditions.

Deputy James Breen raised the issue of the locked reception area doors. More recently, I learned of an elderly man with a heart condition who went to Limerick for tests and, upon his return, discovered that his bed was occupied. He had to stand for more than three hours because no chairs were available. Today, 119 patients are occupying this 88-bed hospital, including six on trolleys and many more in day wards. That does not describe the discomfort, misery and loss of dignity suffered by patients who present for care. The waiting room is cramped and people are often forced to stand for hours due to the lack of seats. Despite these issues, we are told there is no crisis.

I received a complaint this morning about a woman who presented to the hospital with a nose bleed. She was from west County Clare and had travelled 40 miles to Ennis, yet after waiting several hours, she was told to go to Limerick Regional Hospital. People in west County Clare have to drive more than 50 miles to Limerick and that in itself compounds the problem. Recently I spoke with a constituent from west County Clare who said he would be better off ringing the undertaker than making that journey.

Women of a certain generation have worked in tough times to build this State. Last week, we celebrated the 90th anniversary of the Easter Rising. We should look again at the ideals of the Rising and pay heed to its basic values. The people of County Clare and, in particular, those in the west whose journeys to Limerick Regional Hospital take longer than the golden hour, will not accept the downgrading of Ennis General Hospital. Over the past ten years, €20 million has been promised but, aside from a portakabin on the front lawn, not a penny has been spent in upgrading the hospital. The hospital does not even have a CT scan facility.

The recent report of the Nenagh Hospital Action Committee stated that small facilities provide better services. The cost per day to treat a patient in Nenagh is €711, whereas it costs €953 in Limerick Regional Hospital and €1,153 in Beaumont. A similar cost efficiency system applies to Ennis. I appeal to the Minister of State to make the development plan work for Ennis General Hospital and to free up accident and emergency units because if he does not, he will be forgotten at the polling booth in the next general election.

Jimmy Deenihan (Kerry North, Fine Gael)
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I wish to give two minutes of my time to Deputy Healy.

I welcome the opportunity to speak in this debate. I have raised the issue of Kerry General Hospital in this House on numerous occasions over the past three or four years but with little success. What has been said by Kerry doctors and representatives must have fallen on deaf ears because the situation there has deteriorated. When the hospital was opened in 1984 it had a throughput of 13,500 patients. Now it has a throughput of over 30,000, approximately 100 per day. The staffing level has increased to some extent but the senior medical staff has not increased apart from the appointment of senior house doctors. Kerry General Hospital has five senior house officers, SHOs, but no registrars and only a temporary consultant.

In 2003 a full-time accident and emergency consultant was appointed to Kerry General Hospital for the first time. In neighbouring County Cork, which has a little over double the population of Kerry, there are five accident and emergency consultants. The one consultant at Kerry General Hospital has left. Although he indicated over a year ago to the HSE that he was leaving, no full-time replacement has been appointed. There is a temporary locum there until May and after that a person will be appointed for six months. That is no way to treat the people of Kerry. The equivalent of approximately 28 nurses look after the accident and emergency department in Kerry. Just four of those are available after 5 p.m. and with no increase for the summer months, when the population of Kerry will more than double, those four nurses will look after an increasing number of patients, including an increasing number of night-time patients.

The Minister and the Minister of State appear to have no function in accident and emergency. They have washed their hands of it. It is disingenuous to blame the doctors, who must also live. An impression is being created through a deliberate campaign that doctors are expected to work 24 hours a day, seven days a week, which not even politicians do. There are people on this side of the House called "shinners" but the "spinners" are on the other side of the House. There is a deliberate campaign against the doctors of this country and it is unfair. After 5 p.m. there is only one senior house doctor in Kerry General Hospital and that doctor may have to make serious decisions. It is only a matter of time before something serious happens and when it does, who will be liable? I have warned the Minister. What has happened in Kerry is a disgrace. I am echoing what other speakers are saying. What is happening in accident and emergency departments is a disgrace and the Government is abdicating responsibility for it.

Séamus Healy (Tipperary South, Independent)
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I thank Deputy Deenihan for sharing his time with me. As somebody who has worked at the coalface of the health services for 20 years I was angered by some of today's contributions, particularly that of the Minister of State, Deputy Tim O'Malley, who blamed everybody — doctors, nurses, support staff, paramedics, clerical staff — for the mess the health service is in. The majority, if not all, health service workers go beyond the call of duty on a daily basis throughout the year and without the goodwill of those staff we would be in a worse situation than we are today. Although the Minister said it was not a question of resources it is time to call a spade a spade.

The crisis in the health service is the responsibility of this Government and the first Fianna Fáil-Progressive Democrats Government, which took 2,000 beds out of the system in the mid-1980s to late 1980s. That decision, which we in the health service fought, was the beginning of the crisis in the health service. There is no doubt that the pressure on accident and emergency services began with the withdrawal of those beds and it is important that they are returned to the system immediately. We lost 50 beds in St. Vincent's Hospital in south Tipperary and that created a serious problem there.

Ten years ago, I was a member of a hospital executive committee that recommended that an acute medical unit be put in place in south Tipperary and that it should be copied throughout the country. Ten years later, there is no unit. We hear talk about such units, but ten years later is too late. Those services should have been put in place long ago.

Seán Power (Kildare South, Fianna Fail)
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I thank Members for their contribution to this important debate. I found Deputy Deenihan's contribution interesting. I am not sure whether he meant that one cannot be a shinner and a spinner at the same time. Maybe the spinners are confined to one side of the House.

Caoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)
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He certainly would not be at that game.

Jimmy Deenihan (Kerry North, Fine Gael)
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There is a lot of spinning at present.

Seán Power (Kildare South, Fianna Fail)
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To deal with the issues raised, it is nonsense that there is a campaign with regard to doctors. Doctors play an important role in the provision of health care services. We very much appreciate the role they play and will continue to play in the provision of health care. We are in negotiations with doctors in different areas in trying to improve the service. I have no doubt that the vast majority of doctors will be happy to work towards improving health care services.

Deputy Healy referred to beds. He throws out figures off the top of his head.

Séamus Healy (Tipperary South, Independent)
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It is a fact. I was there.

Seán Power (Kildare South, Fianna Fail)
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If the Deputy is interested in the facts, I will tell him the facts.

Séamus Healy (Tipperary South, Independent)
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I was there. The Government closed 50 beds in St. Vincent's Hospital in Tipperary town. I was the hospital manager for the county and I know that.

Seán Power (Kildare South, Fianna Fail)
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I know.

James Breen (Clare, Independent)
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If the Minister of State knows, what is he telling us?

Rory O'Hanlon (Cavan-Monaghan, Ceann Comhairle)
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The Minister, without interruption.

Seán Power (Kildare South, Fianna Fail)
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The Deputy knows but he does not want to listen to what anyone else knows. The point I want to make is that the number of beds in public acute hospitals has increased by 1,528 since 1997. There was no reduction.

The Tánaiste outlined to the House this morning the wide range of actions which are being taken to address the problems associated with accident and emergency services. This issue will continue to receive the Government's priority attention until the problems have been resolved. We will continue to work with the Health Service Executive to tackle the problems that are occurring in some accident and emergency departments through a combination of reform and investment tailored to each individual hospital. Additional resources are being provided, reform is happening, targets are being set and incentives are being put in place.

While many of the country's accident and emergency departments operate very effectively, we recognise that the difficulties experienced in some accident and emergency departments cause distress for patients and their families as well as for the staff working there. There are 53 acute public hospitals, 35 of which have accident and emergency departments. The majority of those departments do not have difficulties and the difficulties that exist in a minority of departments are a cause of concern to the Government. We have put in place a number of measures to try to deal with the situation.

Accident and emergency departments are not stand-alone services. They are a critical part of a complex health care system. Their ability to function efficiently and effectively is heavily dependent on maximising the use of the beds and facilities in each hospital, well functioning practices and processes within acute hospitals and the availability of integrated primary and community services. The HSE is focusing on reforming the health system to ensure that the right care is delivered in the right place by the right people at the right time.

Every day approximately 3,300 patients attend accident and emergency departments. On average approximately 25% will require admission to an acute hospital bed. In some accident and emergency departments, these patients will wait for a number of hours, sometimes overnight, to be admitted. This situation is not confined to this country. Such difficulties are being experienced at present by many modern health services in other parts of the world. However, such delays are unacceptable to the Government. There has been much discussion on how to address the difficulties that arise from the delays and the fundamental issues that are causing them to occur in the first place.

The Tánaiste has outlined the many benefits that have accrued and continue to accrue to patients through the measures implemented under the accident and emergency action plan. It is accepted that there is a need to focus on building on the achievements of the plan. The HSE has developed a framework for improving the efficiency and effectiveness of accident and emergency departments that has three key strands, reducing and diverting accident and emergency attendances and admissions, reducing delayed discharges and improving efficiency and throughput across the whole hospital, not just in accident and emergency departments.

The HSE is focusing on those hospitals that are seen to be experiencing difficulties in the provision of accident and emergency services and has set individual hospital performance targets to be achieved, maintained and, in due course, surpassed. The short-term priority objectives are that no patient is to wait for longer than 24 hours before being admitted to an acute bed, no accident and emergency department is to have more than ten patients awaiting admission and the privacy and dignity of patients awaiting admission is to be preserved. The long-term objective is to ensure that no patient will wait longer than six hours to be admitted after the clinical decision to admit has been made.

To assist the identified hospitals to achieve their targets, the HSE has established a dedicated accident and emergency task force. This force will oversee the implementation of the HSE framework and will work closely with the hospitals to establish clear targets for performance improvement and develop tailored solutions aimed at delivering sustained improvement in accident and emergency services. Not all hospitals have problems with accident and emergency services and where hospitals have problems they do not always arise from the same source. The task force will assist each hospital to identify the particular challenges it faces in the delivery of its services and to identify the potential solutions appropriate to their particular circumstances. It will work with the hospitals to introduce a system of "whole hospital" performance measures to improve the patient's journey not alone through the accident and emergency department but through the entire hospital system from admission to discharge.

In the immediate term the HSE is facilitating the freeing up of acute hospital beds by making more appropriate facilities available for those patients whose discharge from hospital is being delayed because they cannot, for a variety of reasons, return to their homes. The acute beds being vacated by these patients will be ring-fenced for use by patients who are waiting in accident and emergency departments to be admitted. The HSE is also fast-tracking the introduction of admission beds and other facilities to allow patients to await admission in comfortable surroundings outside the busy accident and emergency environment to ensure their privacy and dignity is preserved. These facilities will also enable the work of the accident and emergency department to flow more freely and the department to operate more effectively.

The achievement of improvements in accident and emergency services is dependent on fundamental changes in hospitals and in other areas of the health service. It requires improvements in the processes and procedures in hospitals to ensure that they operate in the most efficient and effective way, the introduction of rigorous admission and discharge planning processes, the broadening of access to diagnostic facilities and the enhancement and development of primary and community care services. We must ensure that all the existing beds and facilities in acute hospitals are being utilised fully and appropriately by ensuring that beds are occupied only by those who require acute care. We must also ensure that essential diagnostic facilities are available when required, not just during normal office hours. We need to better integrate primary and community care services to allow people to be treated, where appropriate, outside the acute hospital system and to put in place the necessary supports to avoid unnecessary hospital admission.

There is no single, simple solution in dealing with problems in accident and emergency. For example, on one day in March there were 411 patients in Dublin hospitals who had been medically discharged but were still occupying beds. We have put in place measures in a number of areas in an attempt to provide step-down facilities so that patients are not occupying beds after being discharged. The increase in the provision of home care packages will assist greatly in that regard. Last year there were 1,100 home care packages and this figure will increase by an extra 2,000 before the year is out.

Deputy English referred to the experience of a constituent of his. The case he outlined is not one of which we can be proud and it cannot be tolerated. However, to improve the delivery of services in accident and emergency departments we have assigned to each hospital a chief executive officer or other named person whose responsibility it is to deliver an improvement in accident and emergency services.

A few years ago the health service was judged on the length of time it took people to have an operation, whether they spent six, 12 or 24 months on a waiting list. We established the National Treatment Purchase Fund, which has dealt with that very effectively. Now the health service is judged purely on how accident and emergency services work.

I have had the pleasure of visiting hospitals around the country, and one that I have visited several times is St. Luke's in Kilkenny, where staff have provided their own medical assessment unit and work very closely with local GPs. They would admit that they do not have the best facilities in the country. It is not all about resources but about teamwork and introducing modern practices to meet challenges that exist today but were unheard of before. While it is very important to have an efficient and effective admissions policy, that on discharges is equally important. We must learn from best practice and what has worked well. Managers of hospitals throughout the country should consider St. Luke's in Kilkenny and see if they can imitate what it has done very successfully.

We acknowledge that there are difficulties in accident and emergency departments, and many of those who have had a family member waiting on a trolley will realise the difficulties and embarrassment caused to them, patients and staff. However, we have put in place several measures to address the situation, which receives top priority.