Joint Committee on Health and Children
Meeting
Thursday 15th January 2015
Opening Statement
by
Tony O’Brien
Director General
Health Service Executive
Good afternoon Chairman and members of the Committee.
Thank you for the invitation to attend the Committee meeting this afternoon.
I am joined today by:
 Pat Healy, National Director Social Care
 Angela Fitzgerald, Deputy National Director, Acute Hospitals Division
 Dr. Colm Henry, National Clinical Advisor & Programme Lead for Acute
Hospitals
1. Introduction
The pressures on EDs experienced over the past two weeks are not new or
unexpected. As I have highlighted previously to this Committee, the over 65
population is growing by approximately 20,000 per year and those over 80 by
4% annually. Due to reduced budgets over the past number of years, the
development of the required capacity within our community services to deliver
Home Helps, Home Care Packages, short stay and long stay residential care
has not kept pace with this demographic growth. Furthermore, acute hospitals
have experienced increased presentations and avoidable admissions, increased
numbers of delayed discharges and unacceptable numbers of patient’s on
trolleys in their emergency departments.
The data informs us that the numbers of emergency presentations in 2014 is up
2% on 2013 and emergency admissions are up 1.8% on 2013 levels. The main
factor leading to the current ED pressures relates to higher numbers of delayed
discharges in acute hospital beds, when comparing this year to same period last
year. On the 6th of January there were 770 delayed discharges reported across
the acute hospital services. This was approximately 150 more than at this time
last year and this has led to a consequent increase in the numbers of patients
on trolleys requiring admission particularly on the first week of the year.
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This was despite both the hospital and community investing in transitional care
beds during the course of 2014.
2. Measures Implemented to Address Winter Surge
Hospital Escalation Measures
Winter planning is an embedded response within acute hospitals and
community services. In order to manage increased demands Hospitals have
been required to be at a state of escalation since Autumn 2014. This is part of
the normal planning in place to deal with the expected surge in demand in EDs
where Hospitals invoke escalation plans which includes the opening of
additional overflow areas, curtailing non emergency surgery, providing
additional diagnostics and working in an integrated way with their community
service colleagues in strengthening discharge planning. Hospitals have
continued to take these steps, since September 2014 as required, so that
patients who need to be admitted to hospital are admitted to a bed as soon as
possible.
In readiness for the demands of the winter period, during the month of
December the acute hospital system cancelled non-urgent elective activity to
ensure maximum capacity was available to deal with emergency admissions.
Primary and Social Care services in particular escalated their plans to facilitate
discharges through the provision of home care, aids and appliances, access to
community hospital beds where available etc.
In addition, the Minister for Health convened the Emergency Task Force which
supported the measures being undertaken by the hospital and community
services to prepare for the anticipated additional demand for services during the
key period post Christmas.
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Additional Resources
Recognising the increase in delayed discharges and the fact that sufficient
funding has not been available for the past 6 years during the recessionary
period, the Minister has managed to secure a total of €25m as part of the
Service Plan for delayed discharge patients in 2015.
Preparatory work for its implementation commenced in November 2014 and
additional resources were allocated for Delayed Discharges in December. This
funding came on stream on January 1st of 2015
€3m in December NHSS
As delayed discharge figures reached their highest level by the end of
November 2014, as an interim measure prior to the 25m coming on stream, an
additional allocation of €3m was provided in December to enable the early
release of the additional 300 Fair Deal approvals immediately. This was in
addition to the regular release of 700 places, bringing the overall allocation to
1,000 places for the full month of December, 2014.
Transitional Care Beds
Also in December, 165 additional transitional care beds were funded and
targeted at hospitals in the greater Dublin area to facilitate speedy discharges.
Home Care and Home Supports
Additional Home supports were provided with a specific focus on supporting
acute hospital discharge prior to the Christmas period. In fact during Christmas
week 120 Home Care Packages were provided in total, with 87 related to
patients in the acute hospitals.
The combined efforts of the above initiatives saw a net reduction of 109 delayed
discharge patients with approx 700 Delayed Discharges reported at the end of
December 2014.
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2015 Service Plan €25m Package-Further detail in relation to the additional
funding
The full €25m package is being implemented since January this year as follows:
Nursing Home Support Scheme €10m
This additional resource will support in a full year the 300 extra places allocated
under the scheme in December 2014. This has had the impact of reducing the
placement list to 1,160 on the first week in January and reducing the funding for
Fair Deal from 15 weeks to the current 11 weeks.
Short-Stay Residential care €8m
This is being used to provide an additional 115 short stay beds.
• 50 of these short-stay beds have been earmarked for provision in private
nursing homes for the greater Dublin area.
• The remaining 65 beds will be open in Mount Carmel on a phased basis
commencing March / April 2015 as a dedicated community hospital for
Dublin.
Home Care Packages (HCPs) €5m
This will provide 400 additional HCPs benefiting 600 discharges across targeted
Dublin hospitals during the course of the year, to facilitate patients to return to
their own homes in the community.
Community Intervention Teams (CITs) €2m.
The CIT Service is expanding its service levels in the greater Dublin region and
will deliver services to an additional 8,000 CIT patient cases. In addition new
CIT services are being established in Kildare, Louth and Waterford servicing the
main hospitals in these regions and providing direct access to GPs and Nursing
Homes thereby facilitating patients having to attend hospital unnecessarily.
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3. Additional Measures
In response to the continuing pressures in our ED departments, all of the focus
of our efforts during the month of January, has been to maximise the discharge
of patients from our acute hospitals who have completed their acute treatment
either to home with home care supports where required or to more appropriate
residential care.
To achieve this we have sought to eliminate “red tape” as much as possible and
during the month of January, as an exceptional measure, all patients who are
clinically discharged, but who require ongoing levels of residential care are
being matched with suitable nursing home placements following clinical review.
This will see a potential movement of 250 patients who are currently in acute
hospitals to other suitable facilities,
While much of my previous commentary has focused on delayed discharge as a
factor, it is important to note that there are 28 emergency departments in Ireland
and the challenges faced vary between each location:For example, in Beaumont where there has been a persistent level of delayed
discharges and number of people on trolleys, there is a direct relationship with
the shortage of residential capacity in North Dublin.
However in Letterkenny for example, where over the weekend of the 3rd- 5th
January, 2015, there were over 31 people on trolleys, the problem was not
related to delayed discharges but rather related to a particular spike in the
number of unwell elderly presenting at the hospital
Another example is St. Luke’s Kilkenny which is a level 3 hospital with a very
good reputation for integrated working across hospital and community and for
maintaining low levels of delayed discharges and trolley waits and on Monday
January 5th there were 22 patients on trolleys
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4. What Has Worked Well
The current mainstream and integrated efforts at National level are enabling a
cohesive and consistent response to cope with the demands.
In addition:• The leadership role of Clinical Directors, consultants and nursing
management in carrying out additional ward rounds and discharge
planning is proving effective in alleviating the pressures in ED.
• The role of primary care and social care in:• extending CIT coverage, facilitates early discharge or hospital
avoidance where possible, also
• the use of public beds to decant patients from acute hospitals has
contributed significantly in dealing with demand issues.
• Early release of NHSS funding arrangements in December, coupled with the
provision of additional Transitional Care Beds and additional Home Care
Packages allowed discharge to continue throughout the month of December
and the crucial Christmas period, and at this point no one on the delayed
discharge list is waiting for HCP funding
• Collaboration across hospitals in terms of enabling bed access has also
assisted in reducing the delayed discharges e.g.
• Rehab beds in Cappagh for Connolly and Drogheda
• Use of elective beds in Navan for Drogheda
• Optimisation of Model 2 hospitals – Ennis, Nenagh, Bantry & Mallow
supported wait times for limerick and the South West
• The ongoing escalation of matching patients, (250), who are medically
discharged with nursing home care placements, is proving beneficial in
yielding capacity.
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5. Deficits in service
There are recognised deficits in key service areas which support the discharge
process particularly of older people:•
Home Help: the level of HH service has reduced significantly over the past
number of years from €211m to €185m currently.
•
HCP: The funding available for HCPs has remained relevantly static since
2008.
•
Public Residential care beds are key component of service provision and
must be retained at existing levels despite the impending issues with
compliance on infrastructure.
•
Reliance on agency, medical and nursing, due to market conditions, together
with associated challenges in terms of recruiting and retaining senior decision
makers, is impacting on the ability open additional capacity
6. Summary Section
The outcome of the review of the NHSS, currently being undertaken by the
DOH, will need to provide longer term solutions to place the scheme on a
sustainable footing, recognising the demand led nature of the scheme and an
ageing population. The development of the required capacity across primary
and social care is essential to meet the demographic growth in a predominantly
elderly population.
The challenge for re-registration of public long-stay beds with HIQA is a
significant issue to be dealt with over the coming months as there is insufficient
capital funding available to meet all the requirements and there are over 30
large units who provide in excess of 2,500 beds and where there is, currently,
insufficient funding in the capital plan to bring this infrastructure to the required
standard.
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I would like to take this opportunity to acknowledge the discomfort and in many
cases stress caused to patients and those who have experienced our EDs over
the past period of time and to reassure them that we are doing everything we
possibly can to deal with the situation. I would also like to thank all the staff,
nurse’s, doctors and others, in these services for their diligence, patience and
hard work amidst such difficult circumstances.
This concludes my statement and I have added some additional notes as
information for the members. Together with my colleagues we will be happy to
take any questions.
Thanks you.
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Additional Speaking Notes:
Deficits in service
There are recognised deficits in key service areas which support the discharge
process particularly of older people:•
Home Help: the level of HH service has reduced from a high of 11.98m hours
delivered to 55,000 people in 2008, to a current level of 10.3m hours
delivered to 47,000 people, showing a reduction of 14% being supported by
the service. The funding level was reduced from a high of €211m to €185m
over this period.
•
HCP: While the numbers being supported by HCP have increased year on
year to the current position of 13,057, the average value of each HCP has
fallen as the funding available has remained relatively static since 2008.
•
Public Residential care beds are key resources in the continuum of care, as
short-stay beds serve as an intermediate care provision across hospital and
community providing respite, assessment and step-down care. There is a
necessity to maintain the bed stock availability in the public system and this
will be a challenge given the requirements for improved infrastructure under
the regulations as inspected by HIQA over the coming months.
•
Reliance on agency, medical and nursing, due to market conditions, together
with associated challenges in terms of recruiting and retaining senior decision
makers, is impacting on the ability open additional capacity
Ends
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