Emergency Department Review

Ministerial Statement – in the Northern Ireland Assembly on 10th February 2014.

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Photo of Edwin Poots Edwin Poots DUP

Thank you.  It is good to put the Minister of Finance in his proper place.

The statement concerns actions that I have commissioned that are aimed at ensuring the safety and quality of the service that our hospital emergency departments (ED) provide, hence reassuring the public that they can have full confidence in these services.  The review's primary focus is the Belfast Trust, but the work will look at emergency departments in the regional context.  I am sure that there will be issues and lessons that will be relevant across Northern Ireland.

In recent weeks, there has been a continuing debate, not least in the Assembly, about the pressures that emergency departments face.  Questions have been asked, and rightly so, about whether those pressures are routine.  Are they caused by a shortage of staff or funding?  Are ambulance turnaround times too slow?  Are winter pressures more acute than normal this year?  Are those pressures and the underlying causes peculiar to Northern Ireland or are we witnessing a national phenomenon that is explained in part by the growing elderly population or by an inability to attract junior doctors to work in emergency medicine?  All those are questions that we need to address if we are to sustain and to improve the high standards of emergency care in the Province.

In response to the 28 January Assembly motion, I referred to the wide range of measures that we have put in place to manage the vastly increased workload on Health and Social Care (HSC) so that we can meet and service the needs of our population, which is growing older.  I also stated that we are mindful that the performance of our emergency departments falls behind that in some other parts of the United Kingdom.  I am keen to learn from the widest range of peers and to benchmark against the best. 

In this context, I referred to our involvement with GB expertise in the Northern Trust, for example, and said that I was giving consideration to how we could utilise similar expertise to test whether there are more things that we could do better in our emergency departments, particularly in how they integrate with the rest of the hospital.

I have spoken with members of staff in different specialities and at different levels in the Royal Victoria Hospital (RVH) in recent weeks.  Other staff in the Belfast Trust have made their views heard through correspondence and engagement with the Regulation and Quality Improvement Authority (RQIA) and the Public Health Agency's (PHA) 10,000 Voices project.

On 29 January, I wrote to the Committee for Health, Social Services and Public Safety indicating that I was actively considering a review with external expert input.  Following the Adjournment debate on 4 February, I sent a letter to the Committee confirming that I had decided to seek assurance for the public and for myself as Minister that our EDs are providing care of the highest quality and safety, and to identify areas where there may be opportunities to make improvements.  I advised that this would take the form of an independent review bringing in expertise from outside Northern Ireland.

Taking account of the advice that I have received from clinicians and professional staff working in our emergency departments, I commissioned the RQIA to do two things to help ensure that the Belfast Trust and the wider health and social care system can act as effectively as possible on the issues arising from recent events and to ensure that there is a full and open process of review.

Firstly, I instructed RQIA to carry out inspections at the RVH site.  Over the weekend of 31 January, RQIA assessed the quality of care and dignity that was afforded to patients in the emergency department and the acute medical unit (AMU).  Secondly, I decided that rather than having a Health and Social Care Board-led review of the major incident that was declared at the RVH last month, it would be better for there to be a review under RQIA’s role and powers.  The RQIA has agreed to carry out this wider review, which will be led by Dr David Stewart, the RQIA's director of reviews and medical director.  The other members of the review team will bring expertise from all the essential disciplines that are required in the speciality of emergency care.  I do not wish to mention names until final confirmation has been received, but I can advise the Assembly that members will include a national expert in emergency medicine, a senior nurse, an operational manager with a successful track record in unscheduled care and an expert on ambulance-related issues.  I have today published the terms of reference for this work.

RQIA has provided immediate feedback on its inspection at the RVH to the Belfast Trust, the Health and Social Care Board, the Public Health Agency and my Department on its preliminary findings.  I have been advised that the inspection identified a range of issues, which cause me and my Department to have serious concern about whether the Belfast Trust is consistently performing to the high standards that I require in executing its responsibilities to patients and staff.  I recognise, however, that some of these are wider issues that cannot necessarily be addressed by the trust on its own.  The emerging findings help to put all the concerns that had been circulated into a clearer context.  Nevertheless, this is a disappointing outcome to the inspection and reflects the unacceptable experiences that many of us have had related to us by some patients and staff.  I am resolved that this will be fully and comprehensively addressed as a matter of priority.  RQIA will provide me with a preliminary report on its findings later this week.

I want to share with the Assembly the aspects of the immediate feedback that have given me cause for concern.  These early findings require our immediate attention.  The inspectors spoke to more than 100 staff across a range of roles and functions.  The inspection has confirmed concerns about staffing levels in key areas, allegations of bullying, staff under intolerable pressure and a system of care that does not function fully as it was set up to do.  The concerns relate to the emergency department itself, to the acute medical unit, which is a 60-bed unit for the assessment and treatment of admitted patients, including many admitted through the ED, and to some aspects of the wider hospital and trust functions.  There are genuine and heartfelt concerns from clinicians about the impact that this difficult situation is having on patients.

The emerging findings recognised that the model of care and the intended approach to managing the treatment and placement of patients in the hospital is good but that the system has, on occasions, struggled to cope with the large numbers of patients who are awaiting admission.  It appears that one root of the problem is as much in the delay in discharging patients who no longer need care in the acute setting as in the flows into and through the hospital.  When large numbers are waiting for discharge, it is not always possible for patients to be placed in the correct specialty ward, where their particular conditions can be treated in the best possible way.  It is well known that when patients are outliers — that is, that they are in a ward not specialising in the care of their particular condition — it is more difficult to provide the specialist care of the required quality and to do so as safely.

The inspection found that, in some settings and/or at some times, there are not enough doctors and nurses to provide appropriate care to the number of patients in the system.  In some cases, this means staff working in areas that ideally they would have more experience to undertake.  The pressure on staff limits the time to undertake professional supervision and appraisal.  Sickness absence among nursing staff in the AMU is high.  I understand that the trust has already taken some steps to address these issues and expects to appoint additional medical and nursing staff quickly.

Any reference to potentially unsafe care needs to be addressed with caution as all HSC organisations and all staff have clear statutory and professional obligations to provide safe care.  Consideration of such allegations must be measured and proportionate as these are preliminary findings and we need to assure people facing emergencies that their needs can and will be met safely.  Disproportionate or hasty interventions could be very damaging.  However, we have to face the fact that concerns about safety have been expressed in the comments that led me to commission the inspection, and some significant points seem to have been confirmed in the inspection.  I have no doubt that the Belfast Trust is doing all it can to ensure safety and is already acting on the key findings.

Risks to safety in the emergency department itself arise in the times when its functions are impeded by having too many patients at one time.  Physical access to patients can be difficult for staff.  There is a lack of space in the resuscitation area.  Cubicles in the focused assessment area are being used at times to care for patients while they await transfer to specialist hospital beds.  There are often many patients waiting for admission who need nursing care, including administration of drugs.  This is difficult to carry out in an open environment.  Beyond the ED itself, staffing levels in the AMU need to be sufficient to care for the needs of patients who are, by definition, acutely ill, and the trust also needs to find ways that reduce the risks associated with the care of patients who are outlying in other wards, given that they require the clinical team from another ward to attend to their needs.

The inspection also found concerns about the environment and patient experience.  There is insufficient space in the ED for the number of patients waiting.  Patients waiting on trolleys are very close to the next patient.  The ED can be noisy, draughty and cold as it is not designed to operate as a ward environment.  The AMU consists of 60 beds, and the size and layout of the ward are difficult and confusing for families and patients.  There is insufficient equipment in the ED and the AMU.  The present conditions make the delivery of personal care by the nursing team in the ED difficult.  Clinical observations and procedures are carried out in an open environment. The provision of meals and drinks are hampered.  All of this points to issues of respect and dignity that are unacceptable.  The patient tracking system is identified as not working well, and some patients' discharges are not happening in as timely a manner as staff would wish.

References to a bullying culture cause me particular concern.  We have access time targets for unscheduled care, and I make no apology that these have been applied for many years and form part of the performance management function of the HSCB in relation to all trusts.  I think that it would be wrong to say that it is acceptable for patients needing emergency care to wait for more than 12 hours for admission or discharge, and that is clearly the view that the public express.  However, my message has always been that quality and safety must come first.  Also, the access time targets are intended to promote good care and reduce the risk of poor patient experience.  It appears that concern about the 12-hour and four-hour targets for emergency care may have led to some unacceptable behaviour by some staff on some occasions. 

It is important that we achieve positive change in that culture and approach.  My message is, and has been, very clear:  patient care comes first, and no one should ever do the wrong thing to meet a target.  Front line staff should be able to focus on the quality and safety of care.  It is the responsibility of senior managers to ensure that it is possible for front line staff to do that and to meet the targets.  That includes the responsibility to ensure that sufficient staff are available and that systems are working effectively.  Senior managers know that if a task is impossible for any reason, they have the right and the responsibility to say so, as they are accountable to the Department for the threefold responsibility of providing high-quality, safe services that deliver the ministerial targets within the available resources.

Against that background, I am glad to say that the inspection confirmed that there is an overwhelming desire from staff to be part of the solution, and I want to assure Members that that will happen.  In response, the Belfast Trust has acted quickly to address the RQIA's emerging findings.  I will say more about that in the days ahead.  However, I stress that I have not yet received the considered and full findings even of the immediate inspection.  It is important that we await the report on the inspection and the fuller review before reaching considered conclusions. 

Although I recognise the gravity of the situation, I wish to reassure the public and the Assembly that the Belfast Trust will continue to provide services in the RVH’s emergency department to meet the needs of its population, as a result of the commitment of all its staff.  It is acting to manage the risks to safety that have been highlighted.  However, we need to ensure that that is embedded in how care is organised and delivered.  The trust’s management team has responded with an open and fully transparent approach to the RQIA’s inspection and is working constructively with the board, the PHA and my Department in moving forward. 

It is right to express high appreciation for all staff who provide emergency care in the Belfast Trust for their dedication and commitment to their patients, and, most obviously, to all the front line staff who have kept going with a Blitz-like spirit, and also to the senior managers who are wrestling with highly complex and challenging responsibilities.  I urge Members to recognise the great complexity of the situation:  if easy solutions were available, they would have already been adopted.  I want to thank the staff for their candour in expressing their views to the RQIA.  I understand that the staff have welcomed the inspection, and I hope that they now have confidence that their concerns will be fully addressed.

The RQIA’s wider review will report to me by June.  Although the focus of the review is on the RVH as the Province’s major trauma centre, undoubtedly there will be learning that can be of benefit more generally across the system.  The review will, therefore, identify and recommend opportunities for all parts of the healthcare system to contribute to improving emergency care in Northern Ireland.  It will look at how the whole system could remove some of the burden on emergency departments and offer a much improved patient experience.

I hope that the Assembly will appreciate that it is important to make progress in a considered and measured way, listening to the views of front line professionals and patients, mindful of the importance of ensuring at all times that the public retain confidence in our hospitals and continue to use them appropriately, not because I say so, but because the staff make it so. 

Occasionally, the system has to respond to extreme pressure, such as that in the RVH on 8 January when the trust activated its major incident plan, or the major incident declared by the Northern Ireland Ambulance Service at the Odyssey Arena last Thursday.  In both cases, the system implemented its escalation plans to ensure that patient safety was maintained and that the necessary resources were made available.  I should like to take this opportunity to commend the Northern Ireland Ambulance Service and the Belfast and South Eastern Trusts for their action on Thursday evening in responding to what was a very serious and potentially volatile situation.

I have made it clear from my first day as Minister that the underlying objective for the entire health system is to protect and improve the quality of services that we deliver.  The health service must be safe, effective and totally focused on the patient, as they are at the heart of everything that we do.  Today, I assure the Assembly of my commitment to continue to work to improve the care provided for all patients, not least those who use our emergency departments. 

I look forward to receiving the RQIA’s report in June.  It will be an important report, and it will complement the substantial work already being undertaken by HSC to improve emergency care in the short term and in the medium to longer term through Transforming Your Care.

Photo of Maeve McLaughlin Maeve McLaughlin Sinn Féin 12:15 pm, 10th February 2014

Go raibh maith agat, Mr Principal Deputy Speaker.  I thank the Minister for his statement.  The initial RQIA findings are quite damning.  Your statement referred to speaking to over 100 staff and confirmed concerns about staffing in key areas, allegations of bullying, staff under intolerable pressure and a system of care that does not function fully as it was set up to do.  That is nothing new to us in the House or, indeed, the wider community.  A year ago next month, a report from the College of Emergency Medicine clearly outlined that procedures in the Belfast Trust were neither safe nor sustainable.  There was an earlier A&E improvement group.  Given that the Minister is widening the review to look at emergency departments in a regional context, does he now fully accept that there is a crisis in our emergency care?

Photo of Edwin Poots Edwin Poots DUP

Waiting times are coming down for emergency care.  We are getting better outcomes in our responses to major critical illnesses such as sepsis, stroke, heart attack and major trauma.  None of those aspects is experiencing a crisis situation.  You are looking at improvement right across the system and at better care than was ever delivered previously.

We have a situation in which staff are working under immense pressure.  I identified that, which is why I brought the RQIA in to assist us in speaking to staff and identifying their issues.  Consequently, I made today's statement in support of the staff who deliver the service.  It is absolutely essential that those staff are working to their optimum and getting the responses that they need from the management system and other parts of the hospital to ensure that delivery of care in emergency departments reaches its optimum output.  All that is focused on delivering better working conditions and support for the staff who are at the front line of our hospitals providing front line services.

Emergency departments are always highly pressured places, but staff are feeling under more pressure than usual.  Where does that pressure come from?  It comes from managers.  Where does the pressure on managers come from?  It comes from me.  Where does the pressure on me come from?  It comes from you.  It all directly comes back to the House, which is demanding higher and higher standards.  We are living within a particular budget and expect staff to deliver for us.  We have a growing population, so more and more people require emergency care.  That is the essential problem.  Can we do it better?  I think that we can, which is why I want assistance and expertise from other places that are doing it better.  That is what this is about.

Photo of Jim Wells Jim Wells DUP

The Minister referred to the situation at the Odyssey last Thursday night.  Will he give the Assembly his initial views on what caused that major issue for A&Es and what he and his Executive colleagues can do to ensure that similar events are not repeated?

Photo of Edwin Poots Edwin Poots DUP

What happened at the Odyssey had a fairly significant impact on our emergency departments.  Emergency departments are always prewarned if anything is going to happen.  My wife used to work in an emergency department and does not like flying because so many calls came in warning of potential air incidents.  Emergency departments are promptly warned that they could have a major incident on their hands, and that was the case on Thursday night with the Odyssey.  Some 100 young people required treatment and care.  Some of that was carried out by the voluntary sector, much of it was carried out by the Northern Ireland Ambulance Service on site, and 17 people attended emergency departments.  From the first reports, it had been anticipated that many more people would need to go to emergency departments.  The cause of the problem was alcohol and drugs.  The people attending emergency departments were 15-, 16-, 17- and 18-year-olds.  None of them should have been drinking alcohol, and the drugs were illegal.  Let us be very clear that, as a consequence of taking materials that they should not have taken, young people ended up in our emergency departments. 

Let us be also clear that eight out of 10 people who attend emergency departments at weekends are there as a result of taking alcohol.  So society has a role to play in ensuring that we deliver care for people who really need it.  Very often, actions that people take, and foolish actions that people take, contribute to the pressurised environment that we are talking about.  Emergency doctors and nurses, and other staff in the facility, very often operate in an environment where they are under huge pressure as a consequence of people attending and behaving very badly as a result of having taken alcohol.  All these things have to be taken into account.  There are also things for other Departments and Committees to take on board to ensure a society that has greater respect for the work that is being carried out in our emergency departments.

Photo of Fearghal McKinney Fearghal McKinney Social Democratic and Labour Party

I remind the Minister of a statement that he made on 13 January in the wake of the situation at the Royal:

"Last week's circumstances were exceptional, and it is important not to confuse an exceptional circumstance with overall performance". — [Official Report, Vol 90, No 5, p41, col 2].

"I just wish that our politicians and, indeed, our media would be more mature in how they assess things." — [Official Report, Vol 90, No 5, p42, col 1].

In that context, and given the announcement today, I offer the Minister the opportunity to apologise to those who rightly raised the issue in the media and on the Floor.  Given that position and the apparent position today, I think that I am right to be sceptical.  The review may be an assessment of events internal to an emergency department, but we believe that there are external influences.  Will the review look at the decisions, which we believe were wrong, that influenced the crisis in the first place?

Photo of Mitchel McLaughlin Mitchel McLaughlin Sinn Féin

Let us keep questions to the statement as concise as possible, please.

Photo of Edwin Poots Edwin Poots DUP

Thank you, Mr Principal Deputy Speaker

The apology should come from the Member and, indeed, those Members who continually castigate a system that delivers for the people of Northern Ireland and ensures the survival of more people who attend hospital with a heart attack, stroke, major trauma or sepsis when, in many other circumstances, they would not survive.  I am disappointed that the Member has not apologised for that.

Photo of Roy Beggs Roy Beggs UUP

I thank the Minister for his statement.  Some weeks after the Belfast Trust's declaration of a major incident at the Royal Victoria Hospital and the diversion of ambulances from Craigavon hospital, the Minister denied that there was a crisis in A&E in Northern Ireland.  Why is he only now advising us of a review of A&E, having denied that there was a crisis?  Is it a result of tomorrow night's 'Spotlight' programme on A&E and the spotlight that will be shone by the Health Committee later this week?

Photo of Edwin Poots Edwin Poots DUP

We will wait and see how maturely that programme handles things and how well it puts the case for the good things that are happening in hospitals, or whether it is just another session of attacking the healthcare system.  I had decided, before learning anything of 'Spotlight', to ask the RQIA to look at what was going on in the Royal Victoria Hospital.  That was not on the back of any Assembly Members or the media.  That was on the back of talking to people on the ground and to staff.  That is one of the benefits of having a local Minister who is prepared to go to a hospital immediately after there has been a difficulty to see what is happening on the ground, arrange to meet people thereafter and identify the issues and problems.  Staff said that they were operating under immense pressure and did not feel that they were getting the support throughout the hospital that would allow them to ensure that ED output flowed more smoothly.  It is about paying attention to the needs of the local community and the people who serve that local community and doing something about it.

Photo of Kieran McCarthy Kieran McCarthy Alliance 12:30 pm, 10th February 2014

Once again, it takes a crisis or major incident to effect an urgent investigation.  Let us hope that the review will bring some change.

It appears that we are losing experts in the field to regions outside Northern Ireland where conditions are much more attractive.  What consideration will be given to the introduction of incentives to encourage medical staff to specialise in emergency medicine and remain in Northern Ireland?  Will the Minister concede that the continued reduction of 3% per annum in the budget makes Transforming Your Care impossible to fulfill, and, as such, ill people will continue to suffer?

Photo of Edwin Poots Edwin Poots DUP

If Mr McCarthy wants to do something about the health budget, perhaps he can ensure that we get some money off the Department of Justice, DEL or some other Department that will enable us to spend more.

In spite of the fact that we had the 3% cut that the Member refers to, we have been able to employ 100 more doctors and increase the number of nurses who are employed in the Health and Social Care system.  The Member may not understand that.  He is on the Health Committee, so he should know and understand that we have spent resources more wisely, sought to reduce waste and employed more staff on the front line.  Therefore, I do not accept that implementing Transforming Your Care is an impossibility.  It is absolutely essential that we implement it; otherwise, the problems will keep coming at us.

I understand that we are in the middle of the process of implementing Transforming Your Care.  One requirement of the additional £30 million that the Minister of Finance was able to allocate to us was to take on more staff to carry out domiciliary care, and the money has enabled us to do that.  It is very important that we keep more people in their own home, support them to be in their own home and support our older population. 

What some Members fail to recognise is that we are successfully keeping people living longer.  Sixty per cent of our hospital beds are taken up by people who are over the age of 65.  The more successful that we are, the more work that we will create for ourselves, and more pressures will be applied.  If the Assembly wants to take a different view on budgets, it is for the Assembly to take that view.  If it wants to identify that health needs greater resources, that is a matter for this Assembly.  We are living within the resources that we have, and we are doing it well.

What we have in the hospital at present is a situation in which staff are operating under a lot of pressure.  We believe that we can assist them to ensure that we resolve the issues and problems.  That is what I am proposing to do today, and that is something that the House should welcome.

Photo of Gordon Dunne Gordon Dunne DUP

I thank the Minister for his statement, for his work in trying to make A&Es more efficient and for challenging managers to work more effectively.  Does he agree that we should not be seeing adverse incidents in the health service?  How does Northern Ireland's handling of such incidents compare with that of other places?

Photo of Edwin Poots Edwin Poots DUP

Adverse incidents arise because of a number of circumstances.  Sometimes, they can arise in the community.  Very often, they will arise before they reach an emergency department.  They can be the result of vulnerable adults, children in care, vulnerable children, and so on.

When standardised against hospital mortality rates for the five trusts compared with those of the 146 English acute trusts, the Belfast Health and Social Care Trust is at 99·1% on the index.  That is pretty close to the national average.  The same applies for serious adverse incidents.  Northern Ireland is not falling behind other parts of the United Kingdom in the quality of healthcare and social care that it provides for people.

Photo of Christopher Hazzard Christopher Hazzard Sinn Féin

I thank the Minister for his statement and welcome the fact that he is having a review into the crisis.

He poured scorn on those of us who, he says, castigate the system.  We do not castigate the system, rather, we simply want to call into question those who are on world-class salaries yet are unable to run a world-class health system in the North.

On the question of widening the review to look at hospitals such as Downe, can the Minister give assurances that the trust that people have lost in those who govern the health system will be rebuilt throughout the review?  Go raibh míle maith agat.

Photo of Edwin Poots Edwin Poots DUP

Perhaps the Member has just returned from Wexford — from another country — in the past few hours.  If he had fallen ill there, he would have got a lesser standard of treatment than if he had fallen ill here.  Perhaps Sinn Féin should recognise that, whilst Northern Ireland, in United Kingdom terms, could do better, it looks pretty good against the Republic of Ireland.  That is what you would like to take us into, of course; I recognise that.

I understand that recruitment to emergency departments is challenging.  It is not just challenging here; it is challenging in other parts of the United Kingdom and in the Republic of Ireland.  Of course, that will be an issue for Downe Hospital.  I have identified quite a number of doctors who have chosen to go to other countries, such as Australia.  Around one quarter of emergency doctors in Australia come from either the United Kingdom or the Republic of Ireland.  I have asked why that is the case.  Very often, people talk about better working conditions, managers who are more responsive to the needs of the doctors and so forth.  Those are areas that we can do something about and make being an emergency practitioner here more attractive.  They also indicated that, within the hospitals, they felt that they got better support from the communities — the people who attended emergency departments — and that it was less abusive. 

Perhaps you and everybody should stand with our emergency staff and say that the abuse that they take at times is wholly unacceptable.  As a community, we need to ensure that we support our staff in those instances, as opposed to demanding and demanding and demanding more of the staff on behalf of people who abuse the system.

Photo of Paul Givan Paul Givan DUP

I commend the Minister; whilst others try to grab the headlines, he seeks to grab the difficult issues and tries to resolve them.  With regard to assuring himself that he is hearing from front line members of staff who are working in the emergency departments, what efforts is he taking to meet them and speak with them, as opposed to hearing a message that may well be filtered — this is a concern of some of the staff — through senior management?  Some of the staff who have contacted me have indicated that the failure of the South Eastern Trust to maintain the services at the Lagan Valley was having a detrimental impact on the Royal Victoria Hospital.  What efforts are being taken to resolve that?

Photo of Edwin Poots Edwin Poots DUP

The Member knows that I have sought to meet, and have met, members of staff who are working on the ground.  As a consequence of having met the staff directly and identified the issues, we brought in the RQIA and carried out that piece of work.  The report will be initiated by others who have expertise on the issue. 

We have approached Dr Taj Hassan, for example, who is a vice-president of the College of Emergency Medicine, to participate in the review.  The Chair of the Committee referred to the previous review; Dr Hassan was one of the key architects of that review.  I am sure that he will want to assure us of the full implementation of that review if he is able to take up the post.  Dr Hassan has agreed that he is prepared to do this, but he needs to get the authority of his employers, and that is being sought.  There has to be final confirmation of that.

The RQIA has been talking directly to the staff, identifying those issues, on the back of us talking directly to the staff.  I am telling the House that, having identified the issues, we want to go further and do something about it.  We want to ensure that our staff work in the optimum conditions, because staff working in optimum conditions will provide the best level of service for the people who need it.

Photo of Seán Rogers Seán Rogers Social Democratic and Labour Party

I thank the Minister for his statement.  We all commend the work of the staff.  Minister, do you accept that the closure of the Downe Hospital at weekends and at night has put increased pressure on the Royal and the Ulster Hospital, considering that 40% of the Belfast Trust's patients are treated at the Ulster's accident and emergency?  Will you widen this out to look at A&E provision outside the Belfast area and how that affects the Downe and so on?

Photo of Edwin Poots Edwin Poots DUP

There is not evidence to suggest that the pressures that were identified in the Royal Victoria Hospital were a consequence of the Lagan Valley and Downe circumstance.  The Member referred to a large number of people, particularly from east Belfast, who use the Ulster Hospital.  I should also refer to a large number of people who live in the South Eastern Trust area, particularly in the Colin area, who use the Royal Victoria Hospital as their base.  So, there is a degree of counterbalance to that.

The South Eastern Trust has had trouble attracting the requisite number of doctors that would ensure that the service could continue in the Downe Hospital.  I have impressed upon the trust the importance of going out and being more vigorous in its recruitment and to seek to ensure that we get more staff there.  That will ensure that we can have as strong a service as possible in the likes of the Downe and the Lagan Valley Hospital and that we can seek to ensure that we treat people outside the key sites.

I make it very clear that the Ulster Hospital and the Royal Victoria Hospital are the acute hospitals in that region.  That is where people are best placed for acute care.  I think that it is absolutely appropriate that a lot of the people, particularly older people, who go through emergency departments with issues that involve admissions, are admitted directly to the likes of Lagan Valley Hospital and the Downe Hospital.  People with many of the minor injuries should not be travelling to the South Eastern Trust to the Ulster Hospital or, indeed, to the Royal.  We need to ensure that steps are taken to avoid those circumstances, and I have impressed that need upon the trust.

Photo of Leslie Cree Leslie Cree UUP

Minister, thank you for the statement.  I am looking at some of the figures, and I see that the performance on four-hour waits at A&Es across Northern Ireland has continued to decline every year since you took over in 2011.  That may just be a coincidence.  However, the external review at Antrim produced a degree of improvement across a wide range of services.  I wonder, on behalf of the constituents of North Down, and, indeed, further afield, when we can expect similar investment in staff levels, improved management and, of course, resources at the Ulster, which you just mentioned.

Photo of Edwin Poots Edwin Poots DUP

Perhaps it is also a coincidence that the 12-hour waits have been coming down since I came into office.  Nonetheless, we have given investment for each trust to have additional beds and support in the hospitals, particularly over the winter period.  So, they have all received finance to assist them through the winter period when the pressures are somewhat higher.  That is a course of work that has been carried out. 

The Ulster Hospital has also taken on additional consultants over my time.  Indeed, we have taken on additional doctors and nurses across the system.  So, in spite of the constrained finances that exist across the UK, which have been applied here in Northern Ireland, we have managed to employ more doctors and nurses to deal with people on the front line of services.  We are offering more domiciliary care, and we are engaging in offering more social care support to people.  In all those measurements, we are doing more than was previously the case.

Photo of Ian McCrea Ian McCrea DUP

I welcome the Minister's statement.  Having previously welcomed the turnaround team that he introduced to Antrim Area Hospital, I certainly welcome what he has decided on with the RQIA.  No doubt, that will bring some benefit to aid the healthcare workers in the emergency departments. 

The Minister referred to the number of people who come to the A&E departments with alcohol-related problems.  As part of signposting people to minor injury units, has the Minister given any consideration to ensuring that the emergency departments are not overused by people who should not be there?

Photo of Edwin Poots Edwin Poots DUP 12:45 pm, 10th February 2014

In our hospitals, we need to look at having an emergency department that is purely an emergency department; where the triage takes place and that admits people to an emergency department.  Others would remain in an acute services department, minor injuries or something that has another description, because what is an emergency department? 

I named the four issues that take most lives:  sepsis, stroke, major trauma and cardiac incidents.  We provide excellent care for those things, and it really grates on me that Members do not even bother to acknowledge that excellent care and the better standards in all those things.  In fact, if you had a stroke in 2012-13, the chances of you dying were 16·8% lower than in 2008-09.  We are doing better on those major things, and perhaps people would be decent enough to acknowledge the good care that is being provided.  However, in doing that, do we separate at the door of the hospital those kind of treatments from the other treatments that involve admitting people with chronic illnesses, which is acute care?  Indeed, should minor injuries be separated as well?  We need to look at and address those issues, and I hope that, as the report comes to a conclusion later this year, we will have very clear recommendations on the way forward to ensure that we can provide the best possible care across the board. 

It is important that public confidence is not diminished as a result of people carping and seeking to make a headline for themselves.  It is important that public confidence is maintained in our health and social care system, and the fact is that people are being seen quicker and are getting better treatment than was the case a number of years ago.  We should focus on that at this time as well.

Photo of Jim Allister Jim Allister Traditional Unionist Voice

Can I ask the Minister this directly:  have any trolley waits or delays led to or contributed to any fatalities?  Given the catalogue of failure that has been recited today, does the buck ever stop with the Minister?

Photo of Edwin Poots Edwin Poots DUP

When Ministers learn something, they do something about it, and I am telling the Assembly today that we are doing something about it.  The Member knows very well the problems in the Northern Trust area, which is his area, and if he is in contact with his constituents, they will tell him that they are getting a much better service after the intervention of the Minister.  I got criticised because I asked someone to step down because I did not think that they were carrying out their job as well as they should have been.  Subsequent to that, there has been a dramatic improvement in the Antrim Area Hospital and in the Northern Trust.  Mr Allister could have paid tribute to us for the service that we have provided for his constituents.

Photo of Steven Agnew Steven Agnew Green

The Minister said in response to a previous supplementary question that there was no evidence that the closure of the Downe and Lagan Valley A&Es in the evenings and weekends contributed to the major incident at Lagan Valley Hospital.  However, an answer in an AQW that he provided to me shows that approximately 20% of the patients admitted that night were from those areas.  Will he give a commitment that, should the review signal that this is a problem and is contributing to the problem, he will seek to solve the problems in recruiting staff for those A&Es rather than simply keeping them closed?

Photo of Edwin Poots Edwin Poots DUP

When he got the answer, the Member obviously did not check the figures for the previous year and the year before that.  He may not be aware that the Royal Victoria Hospital is a regional facility.  So, it takes people from across Northern Ireland.  It is the major trauma facility and the lead hospital for a series of specialisms.  So, of course it will serve people from outside Belfast.  I do not think that we should discriminate against people outside Belfast for specialisms.  And, of course, it also takes a large number of people who migrate to it from the Colin area, naturally, and indeed from the Lisburn area; but there are substantial numbers of others, in the Belfast Trust area, who migrate to the South Eastern area to use the Ulster Hospital facilities, as the Member should know.

Photo of David McNarry David McNarry UKIP

It is clear that confidence in the service is enjoyed by many.  However, revelations damaging that confidence are not, I contend, based on lies told by anyone.  How competent is the system for dealing with revelations via complaints, and can we all be confident that the system itself is efficient and impartial?

Photo of Edwin Poots Edwin Poots DUP

As the Member knows, healthcare is always in a very fluid situation.  Millions attend our hospitals during the year and 70,000 staff work in them.  We are spending £4·5 billion.  That is a massive scale.  Does anybody think that you can operate a system like that and not hit problems?  I think that the Member asks how we respond to those problems, and that is what is important. 

I hope that, at trust level, responses are good and effective.  That is not always the case and, sometimes, we have to intervene.  That is why I am intervening in this instance, to ensure that the trust gets the support it needs to ensure that it delivers the service that the public desires.  That is our aim, our goal and is why we are giving support to the trust in this instance.

Photo of Pam Cameron Pam Cameron DUP

I thank the Minister for his statement and welcome the review.  I also welcome the marked improvements in the Antrim Area Hospital which is in my constituency of South Antrim.  I ask the Minister for his assessment of how our emergency departments perform with genuine life-and-death emergencies.

Photo of Edwin Poots Edwin Poots DUP

With respect to the performance of emergency departments in those genuine life-and-death situations, we have identified that improvements are being carried out.  For example, one of the recent innovations is a 24/7 cath lab, which has been installed at the Royal Victoria Hospital and which will be in place later this year at Altnagelvin Area Hospital.  That will reduce mortality among people who have heart attacks. 

We have already indicated that we have reduced the number of people who die as a result of stroke.  We are doing well with regard to sepsis and we are doing better with regard to major traumas.  So, in those key areas of life-and-death situations, which is what people really perceive and what EDs should really be about, we are doing better and the public can have confidence that if they fall ill with a major serious illness the appropriate expertise will be able to deal with them and provide the best possible care for them.  On some occasions — a very small number — it may fall short, but in the vast majority of incidents, over 99% of cases, people will be well treated.

Photo of Mickey Brady Mickey Brady Sinn Féin

Go raibh maith agat, a Phríomh-LeasCheann Comhairle.  I apologise for having missed the start of the Minister's statement.  I thank him for it.  Earlier, he referred to Wexford.  Sinn Féin is not yet in Government in the Twenty-six Counties, but you can be sure that, when we are, health will be a priority.

The Minister accepts that a shortage of staff contributes to some of the problems in A&E.  You said in your statement that the trust has taken steps to address the problem by recruiting staff.  Why was that not done earlier?  People have been talking about this long-term problem for at least 18 months.

Photo of Edwin Poots Edwin Poots DUP

Additional staff have been recruited.  One of the things that we want the report to identify is that the appropriate number of staff is employed and that the shifts are right to allow us to respond to people.  All those things can be looked at to see whether improvements can be made.  Representatives of the College of Emergency Medicine came over last March to look at the system and reported to us in August.  A series of steps have been taken to implement their recommendations, and work is ongoing with regard to full implementation of the recommendations.  I trust that the process that I have announced today will hasten that and ensure that those recommendations are fully and more quickly implemented.

Photo of Dolores Kelly Dolores Kelly Social Democratic and Labour Party

The report makes stark reading.  The SDLP has always been pleased to stand with staff to bring the issue to the Minister's attention.  It is a somewhat belated response but is, nonetheless, welcome. 

The statement refers to A&E units not being equipped to be wards because they are not the right environment.  Is the Minister aware that, to the best of my knowledge, on Saturday night past, no beds were available in the Belfast Trust?  The lack of bed availability is having a direct impact on A&E waiting times and trolley waits.  Will the review acknowledge that and examine that difficulty, which is leading to the problems being experienced by A&E patients?

Photo of Edwin Poots Edwin Poots DUP

Of course I recognise that.  That is one reason why I propose to bring in expertise.  If the Member had been listening earlier, she would know that one problem in our emergency departments is the whole hospital environment and the ability of other parts of a hospital to take people out of emergency departments at the appropriate times.  People are not being discharged quickly enough, and emergency departments have more to do.  We believe that there can be further improvement in that regard, which is a key element of what we are doing.  We are bringing a team together to look at that to ensure that the whole hospital system works as effectively as it should do, which should lead to a major reduction in the pressures on our emergency departments.

Photo of David McIlveen David McIlveen DUP

I also apologise for being a little detained in getting to the Chamber this afternoon.  Unlike some of the Minister's predecessors, he has clearly been speaking to front line staff in the health service.  Will he elaborate on the impact of those who have, either through the media or in the House, used flyaway headline-grabbing descriptions such as "crises" to castigate those in the front line of the health service?  What has been the impact on morale, particularly for staff who find themselves in such a situation?

Photo of Edwin Poots Edwin Poots DUP

If we look at international news, we will probably see crises.  There is probably a crisis in England, where people are having significant problems in accessing services such as healthcare because of flooding.  We have had difficult situations to manage.  They have been highly pressured situations, but Members wish to drum them up into something else so that they can grab a cheap headline.  I am not interested in cheap headlines; I am interested in outcomes.  Our hospital outcomes are better than they were a number of years ago.  We continue to improve outcomes because we have brilliant front line staff who provide a great service for us.  I am proud of them, and I am standing with them.  I urge all Members to stand with us.

Photo of Pat Ramsey Pat Ramsey Social Democratic and Labour Party

I welcome the Minister's statement.  I note his reference to the unfortunate incident at the Odyssey last Thursday night, when 100 young people created an emergency situation because of alcohol and drug misuse.  Will the Minister, along with me, acknowledge the many thousands of young people across Northern Ireland who behaved responsibly and maturely and are tarnished by the unfortunate incident last week?

Photo of Edwin Poots Edwin Poots DUP

The majority of young people in Northern Ireland are good young people.  I was at an event on Saturday night with many young people who are going to Poland to help young people there who are in very needy circumstances.  I was in conversation with someone from Mr Ramsey's part of the world who had witnessed some young people getting onto a bus.  He said that the amount of alcohol being loaded onto that bus resembled a mini-off-licence.  It was wholly irresponsible of the private coach hire company to allow that to happen.  It is against the law, and it is the Department of the Environment's responsibility to enforce it.  It is my intention to set up a meeting to include people from the PSNI, the DOE, which has a very significant job to do in enforcement, and the Odyssey to identify how we can reduce the risk of things like this happening again.

If you go to the Odyssey or other parts of Belfast on a Saturday night, you will find smaller but significant numbers of young people in similar circumstances, and many will end up in our emergency departments.  We cannot continue with this attitude to alcohol.  Our young people consume far too much of it.  Over the weekend, I got a letter from an emergency department consultant in which she said that she feared that, in 10 years' time, there would be an explosion of young women who had developed liver problems as a consequence of the total abuse of alcohol in their teenage years.  The House needs to do something about that.