Good afternoon Chairperson and members of the committee. I thank them for the invitation to meet with the committee to discuss St. Brigid’s district hospital in Carrick-on Suir, County Tipperary. I am joined by my colleagues, Ms Helen McDaid, head of services for older persons, South East Community Healthcare; Ms Anne Walsh, director of nursing, St. Theresa's District Hospital, Clogheen, County Tipperary; and Mr. Ciarán Ruane, estates manager, HSE capital and estates department. I take this opportunity to thank committee members for the invitation to address the committee and discuss Petition No. 48 of 2021, Save St. Brigid’s Hospital.
I acknowledge the testimony given to the committee by the delegation representing the local community in Carrick-on-Suir when it discussed St. Brigid’s district hospital at the meeting held on 19 January 2023. In addition, I commend everyone who worked at St. Brigid’s Hospital over the years on their dedication, commitment and excellent care. I also thank the local community in Carrick-on-Suir for their support for St. Brigid’s down through the years. I understand that St Brigid’s Hospital was much valued by the local community in Carrick-on-Suir and surrounding environs. Please be assured that we are continuing to work hard to ensure the population has access to high-quality community services. I hope the details we share today will explain the reasons for the difficult but necessary decision to repurpose St. Brigid’s and discontinue the provision of short-stay inpatient services on-site.
St. Brigid’s Hospital was a short-stay unit with 16 beds, including three palliative, two respite and 11 convalescent beds. There were no long-stay residential beds at the hospital. The design and layout of the hospital was largely reflective of the time period in which it was built. The current premises was first designated in 1817. Overtime, it became a district hospital providing general medical, dental and maternity care. The service, thereafter, changed to provide short-stay services. The older and main part of the hospital comprised of three floors, with resident bedrooms on the ground and first floor. There were three single en suite palliative care rooms on the ground floor.
In addition, there was one twin bedroom and one single bedroom on the first floor. There were two five-bedded wards on the first floor. Those wards were utilised for convalescence and respite care services. Those rooms, in particular, represented the most challenging shortcomings noted in the HIQA report.
As part of the south-east response to the Covid-19 public health emergency, St. Brigid's was designated as a Covid-19 step-down facility to support flow from the acute hospitals. As demand for Covid-19 step-down beds was not required to the level initially predicted, south-east community healthcare utilised the staffing resource from St. Brigid's to meet demands in community healthcare services, including assigning staff to testing centres and long-stay residential units at the time.
As for the rationale for discontinuation of short-stay inpatient services, in summary, St. Brigid's was not considered suitable to support the level of refurbishment and adaptations required to resume short-stay inpatient services in line with Safer Better Healthcare guidelines and infection prevention and control requirements. Prior to the Covid-19 pandemic, the design and layout of some parts of the premises was unsuitable. The current building simply did not facilitate the environment which a modern service should provide from an infection prevention and control perspective, given the layout of the premises and the inadequate space and facilities available.
Previous HIQA inspections highlighted significant non-compliances pertaining to the physical infrastructure of the premises inclusive of the inadequate space available in the two five-bedded wards to provide safe and effective care to patients. The limited space posed a restriction on movement for staff delivering care at the bedside. Even with the use of bed screens provided, some patients with reduced capacity or mobility and-or high care needs could not undertake personal activities in private. There was a lack of storage space in the two five-bedded wards and the one twin-bedded bedroom. HIQA reports indicated that there was only 76 cm of space between the beds in the two five-bedded wards, which was deemed not acceptable prior to the Covid-19 pandemic. One of the five-bedded wards did not have showering facilities, and occupants were required to go downstairs, via the stairwell or lift, to access showering facilities.
Prior to the Covid-19 pandemic, it was accepted that substantial shortcomings were identified in the premises, which needed to be addressed to operate the service in line with SI 415/ of 2013 - the Health Act 2007 (Care and Welfare of Residents in Designated Centre for Older People) Regulations 2013; SI 293 of 2016 - the Health Act 2007 (Care and Welfare of Residents in Designated Centres for Older People) (Amendment) Regulations 2016, commencing 1 January 2022; the national standards for Safer Better Healthcare; resumption of services in a Covid-19 environment, with a specific focus on infection prevention and control; fire regulations; and HIQA standards.
In 2018, consideration had been given by hospital management, in conjunction with HSE estates and technical services, to add an extension to St. Brigid's Hospital, with a view to addressing the environmental challenges. However, the building itself and the surrounding grounds and parking areas did not, and do not, allow for an extension of sufficient size, and it was opined that it would not be possible to make the existing building compliant. An opinion was provided that the adjacent site was not suitable for construction. In addition, it was noted that the area is on a floodplain, which would be concerning, and to a lesser extent the area includes a right of way that restricts options. It was also opined that there was insufficient space to the front of the hospital, which estates advised meant there was no realistic option of extending the hospital in order to meet the guidelines.
The works required included a large extension, primarily to the rear of the hospital, with a new entrance required at the front. Aside from the design constraints associated with modifying and extending this old building, two major challenges presented: first, the onerous planning requirements, particularly in respect of flood prevention as regards sustainable urban drainage systems; second, the limited size of the site. It was obvious that there was little or no space outside the building to accommodate the extension and, as such, additional land would be required, which in this area was not recommended. In addition, the building had a number of fire safety issues, particularly in respect of compartmentation and horizontal and vertical evacuation. The staff were aware of these issues and were conscientious in ensuring that the risks were minimised. However, shortcomings were identified in a HSE estates fire inspection in November 2019 that would have required significant alterations. In 2020, at the time the HSE was attempting to resume services in a Covid environment, a risk assessment was completed advising of risk of harm to clients and staff due to concerns about healthcare-associated infections.
In 2020, HSE estates and technical services opined that upgrade works were not viable. The HSE was left with no choice but to discontinue short-stay inpatient services at St. Brigid's Hospital, having considered its future appropriateness to provide inpatient services and the overall planning and provision of older persons' services across the south Tipperary catchment area. The services for older people health management team of the community healthcare organisation, CHO, is committed to reviewing continuously our services, including in south Tipperary, as part of the overall south-east community healthcare area and in line with population health planning and Sláintecare principles. We are committed to the ongoing development of modern services across the region. There is an ongoing building programme for our older persons' services, with current builds in Clonmel and Thomastown, County Kilkenny. Under the national enhanced community care programme, there has been a fundamental shift in the planning and delivery of healthcare services, moving away from hospital-based activity to community-based services for people in their own homes.
The population of south Tipperary is served by both public and private nursing home beds. There are currently 147 HSE public beds across four units and 522 private nursing home beds across 13 private nursing homes.
It is important to note that people in Carrick-on-Suir and surrounding areas who require convalescent, respite and-or palliative care services are being supported in HSE settings in the south Tipperary area, including St. Theresa's Hospital, Clogheen, HSE Cluain Árann, in Tipperary town and HSE St. Anthony's unit, in Clonmel.
Palliative care services are developed in line with national policy, Sláintecare, the HSE’s palliative care development framework and the palliative model of care. Level 2 palliative care beds are provided in the context of services also available to palliative care individuals within the south-east community healthcare area. An example is the south-east regional palliative care centre in University Hospital Waterford, which provides 20 in-patient beds and which has the expertise of a specialist palliative care multidisciplinary team. Level 2 palliative care beds are currently provided in St. Anthony’s unit, Clonmel, St. Theresa’s hospital, Clogheen, and Cluain Arann, Tipperary town. In addition, it is our experience that people are choosing to remain at home for end of life and our services are supporting that choice.
We remain committed to providing quality community health services for the population of Carrick-on-Suir and the wider region. To preserve the community ethos at the existing St. Brigid’s hospital site, it was determined that St. Brigid’s could be utilised as a hub for integrated community services. The site is ideally located beside the primary care centre and thus allows for optimum team co-location.
The primary care centre is located on the same campus as St. Brigid’s hospital building. This purpose-built development opened in 2018 with a number of HSE staff and services located on-site, including public health nursing, allied health professionals and civil registration.
The community healthcare network 5 area encompasses Carrick-on-Suir, Clonmel, Cahir and Clogheen, with staff located in St. Brigid’s and the primary care centre. The community healthcare network management team and the GP lead are based in St. Brigid’s. The chronic disease management team accesses St. Brigid’s as a base and for outreach to other sites across south Tipperary. Staff currently based in St. Brigid's hospital extend across clinical and administrative areas, and details are provided in our written submission.
Regarding engagement with staff who worked at St Brigid's district hospital, south-east community healthcare undertook an engagement process with the St. Brigid's staff members with a view to ensuring that they were supported and accommodated during this time. The HSE carried out a series of meetings collectively with staff and their unions and also with individual staff members. Again, I reiterate our appreciation of the staff who worked in St. Brigid's down through the years.
I hope this detailed account will provide the rationale for the discontinuation of short-stay in-patient services at St. Brigid's hospital. The further development of primary care and community services within an acute community services campus to serve Carrick-on-Suir and its environs will, in line with Sláintecare, see the further transition of services to a more community-oriented local population approach.
