I move:
That a supplementary sum not exceeding £10 be granted to defray the charge which will come in course of payment during the year ending on the 31st day of December, 1975, for the salaries and expenses of the Office of the Minister for Health (including Oifig an Ard-Chláraitheora), and certain services administered by that office, including grants to Health Boards, miscellaneous grants, and certain grants-in-aid.
The House has already approved of an original Estimate of £177,022,000, a Supplementary Estimate of £414,000 in respect of financial and other assistance for thalidomide children, and a further Supplementary Estimate of £36,725,000 in respect of a range of pay and price increases.
When moving the latter Estimate in the House last week I mentioned that if the House agreed I would provide an opportunity for Deputies to debate the general hospital development plan and that I would for that purpose arrange for the introduction of a token supplementary of £10. This is the basis for the present motion. There has been a full debate already, earlier this year, on the general Health Estimate and no doubt I can look forward to a very full debate when the 1976 Estimates come to be moved. For this reason I intend devoting all of my speech today to the national hospital plan. In doing this, I think I will be meeting the wishes of Deputies, while accepting at the same time that the debate can be as free ranging as Deputies wish and as the Ceann Comhairle rules. I shall of course be happy in my reply to deal with matters other than the national hospital plan which arises in the course of the debate.
When I assumed office as Minister for Health two-and-a-half years ago there was no plan available for the ordered development of the general hospital system in the country. The last general hospital plan covering the whole of the country was determined some 30 to 40 years previously. This was concerned with the planning and construction of county hospitals or the adaptation of other institutions into county hospitals, which have been the basis of the hospital system since then. I am conscious that, since that period, on the local authority side there have been a number of regional hospitals built or adapted to meet particular needs in particular areas, but there was a total lack of a co-ordinated plan on which hospital development for the future could be based. On the voluntary hospital side there had also been no long-term, co-ordinated plan for their development, even though the Hospitals Commission did good work of co-ordination at a lower level.
It is true that a real effort was made to devise such a plan with the establishment of the Consultative Council on the General Hospital Service in 1967, under the distinguished chairmanship of Professor Fitzgerald. There is much valuable material in the report which that council produced, not least of which was the emphasis which they placed on the urgent need for a plan such as I have described. It is an appalling indictment of our hospital services that this distinguished council could write in the following terms:
In their present from few of our general hospitals are in a position to give this service. Fewer still, if any, are in a position to cope with the coming advances. As we have pointed out in earlier paragraphs, our hospitals are too many, too small and too independent of each other. The available resources are too thinly spread...
We are satisfied that the present structure of our hospital organisation is out-moded and is now a hindrance to good medicine, good teaching and economic operation. We believe that if it is to be adapted to meet fully the requirements of modern medicine this can be achieved only by radical changes involving a departure from many long established concepts in regard to organisation, staffing and operation of hospitals.
These criticisms, written by consultants expert in the field of hospital care and, so far as I am aware, not seriously challenged as to their accuracy and relevance, represented for me on my taking office as Minister for Health probably my greatest single challenge. The Fitzgerald Report, in its detailed recommendations, created controversy and had defects, and was not found generally acceptable, but its message of the urgent need to improve our hospital services and to make the plans on which a good hospital system could be based was a task which I knew had to be tackled during my period of office.
I have drawn up a plan. Decisions have been taken, decisions have been announced, and those decisions will be implemented. May I suggest that this situation is incomparably better than the policy of drift and indecision which was so severely criticised in the Fitzgerald Report and which continued right up to the day I took office.
Deputy Haughey in the motion now on the Order Paper invites Dáil Éireann to condemn the national hospital plan as unsuitable and inadequate. I do not agree with him on this, of course, and I will be interested to hear whatever criticisms of the plan he may have. But I would point out to him that I have taken decisions which previous Administrations avoided. Even though everyone accepted the need for a hospital plan for the last 20 years or more sive Administrations avoided the complex decisions required. I took those decisions within two-and-a-half years of taking office and I believe that I took the right decisions.
For the purposes of this debate, I want to describe to the House in broad outline, the steps which I took to ensure that the hospital plan which would be evolved would receive the kind of consideration which an issue of this importance deserved; that a decision would be taken as quickly as possible having regard to the complexities, importance and cost of the service; and that not alone would the resultant plan be both suitable and adequate, but it would be the best possible plan that could be devised. Consideration of, and decisions about, the new hospital plan were divided into two parts—first, the situation in Dublin and secondly, the situation in the remainder of the country.
Taking Dublin first, the Government announced their decisions about the new general hospital plan for Dublin about 12 months ago. This followed the presentation of a special report by Comhairle na nOspidéal, and I would like to pay a special tribute to that body for their work; not alone in relation to the formulation of proposals for the Dublin area, but for the work they carried out in relation to the rest of the country. Their's was an impressive involvement in what was a complicated exercise and, for the magnificent contribution which the comhairle have made in this area, I would like to express publicly my gratitude.
The Dublin decisions, it will be recalled, were to have three major general hospitals on the north side of Dublin city—that is the Mater Hospital, the James Connolly Memorial Hospital and a new hospital which, it is proposed, should be located at Beaumont. Provision was also made for three similar hospitals on the south side of the city—that is St. James's Hospital, St. Vincent's Hospital, Elm Park, and a new hospital in the vicinity of Newlands Cross. I think it is fair to say that this decision was generally welcomed. The Dublin plan was widely regarded as both suitable and adequate, as meeting the needs of the area, and indeed the wider needs of the country, in so far as certain major specialties are concerned. I have every reason to expect, therefore, that, when the Dublin plan is implemented, we will provide a first-class hospital service for the Eastern Health Board area for the future.
Since this decision was announced 12 months ago, consultations have taken place with the authorities of all the major hospitals in the city. A joint working group representing the comhairle, and including officers of my Department, were set up subsequently to prepare a consultation document indicating the factual situation regarding specialist departments in each of the acute hospitals in Dublin, the general strategy which should be adopted on the future development of specialist departments in the six centres already mentioned, and indicating the various options in relation to the allocation of specialist departments between those centres. The working group were also asked to advise on the role of the existing specialist hospitals and their relationship to the main hospital centres proposed.
This committee have been working for some months now and, when I have received and considered their report, I intend to consult the interests concerned inviting their views about the report, so that, hopefully, the end result will be a blueprint of the type of development which should take place in each of the six centres which I have already mentioned. This is an essential prerequisite to realistic planning. In the meantime, however, pending the outcome of the deliberations of the working party, a project team, comprising representatives of St. James's Hospital Board, the Federated Dublin Voluntary Hospitals, inculding members of the professional staff, and my Department, have been established to take the St. James's Hospital development further along the road. Deputies know there is a long standing commitment to the provision of extra new beds at that institution and, in fact, the Government afforded the St. James's development a priority rating.
In addition, in so far as the proposed new hospital at Beaumont is concerned, I have already informed the Dáil, in reply to a recent parliamentary question, that negotiations are in progress to obtain a site of about 35 acres at Beaumont Convalescent Home. The owners, the Sisters of Mercy, have agreed in principle to the acquisition of this site and discussions are proceeding with Dublin Corporation on town planning and service matters. Possible sites for the new hospital in south-west Dublin are also being explored.
I think that any fair minded person will agree, that the reaching of a decision on the Dublin hospital service of the future, and the steps which I have outlined which have already been taken since that decision was announced, represent a real advance in a comparatively short space of time. The Dublin hospital service is of particular importance to the people in the Eastern Health Board but, because of the degree to which major specialties are centralised in the capital and because of the association with and benefit from the medical schools in the city, it is of importance to the rest of the country also.
In so far as the rest of the country is concerned, Deputies will be aware that I announced, on the 21st October, 1975, details of the general hospital development plan for the areas outside of Dublin. In a 20 page document I set out the general considerations which I had in mind in approaching this task. I explained how wide-ranging consultations took place, and, area by area, I gave the existing factual position as regards hospital services. I outlined the solutions put forward by the working groups which worked in each area, the action taken by me in receiving deputations, the recommendations of the various health administrative bodies, and, finally, my conclusions and the reasons for them.
I have provided a full and frank exposition, in that document, of the events leading up to the decisions and of the decisions themselves, and of the views of all the bodies, whether they were in accord with my decisions or whether they took a different line. I deliberately decided on this type of comprehensive exposition in an effort to inform the public in the frankest possible way and to put on record, in a readily available form, all the factors, pro and con, which influenced my decision. While I do not wish to go over all the details of that long document, there are some points I would like to make, while some recapitulation of the general theme is, I think, appropriate at this point.
Deputies will remember that at my request, Comhairle na nOspidéal produced guidelines for the development of hospital services for the future in September, 1973. These guidelines set out standards for the general hospital of the future, and were of cardinal importance in the determination of subsequent policy. They provided that:
(1) The general aim should be to organise acute hospital services so that the population served would be within a radius of 30 miles of the hospital centre;
(2) the minimum staffing of such an acute hospital would consist of two consultant surgeons, two consultant physicians, two consultant anaesthetists, two consultant radiologists, one consultant pathologist, one biochemist and depending on caseload, two consultant obstetrician/gynaecologists and one consultant paediatrician.
(3) A minimum scale consultant staffed hospital, conforming to the guidelines, should usually serve a population of around 100,000 but, where there were special considerations, such as low population density, a lower figure would be appropriate, ranging down to 75,000 persons in exceptional circumstances.
These guidelines were not drawn up by me as Minister for Health, but by Comhairle na nOspidéal at my request. Comhairle na nOspidéal comprises a majority of medical experts and it was their guidelines which were used as the basis of my subsequent decisions. I would like to emphasise this fact and to say also that I adhered to these guidelines in all but two cases. In these cases, due to planning uncertainties which I shall describe later and, just as importantly, due to recommendations made by the health boards concerned, I felt it prudent to move away to some degree from the basic guidelines. This happened in the cases of Mallow and Nenagh, for reasons I will describe, and I was pleased to note that Deputy Haughey agreed with me on both these decisions.
In all other cases, the guidelines were adhered to by health boards and I should say that, in all the consultations which followed the introduction of these guidelines, they were not seriously questioned by anybody to my knowledge. The comhairle, in putting forward the guidelines, emphasised the shortcomings of the present hospital system and argued strongly the need to organise the general hospital service on a broader medical and technological basis.
I quote what they said, from the introduction to the guidelines:
Developments in the practice of medicine in hospitals, particularly since the second world war, have laid increasing emphasis on the contribution of laboratory, radiological and other scientific investigation to patient care and, in addition, have called for the involvement of a number of clinical consultants in dealing with difficult problems of complex disease and injury. The general move in the direction of a shorter working week has also been felt in the hospital service and there is wide recognition of the importance of avoiding the dangerous effects of fatigue on the quality of work of people whose duties involve sustained concentration.
All of these developments, coupled with the beneficial tendency towards a greater degree of specialisation by consultants, have pointed towards the need for the organisation of general hospital services on a broader medical and technological base within the hospital and an enlarged population catchment related to the increased capability of the larger hospital. In short, the idea of a single-handed surgeon or physician attempting to provide a twenty-four hour service with the assistance of supporting medical staff and less than adequate laboratory and radiological services is no longer acceptable from the point of view of the patient's best interests.
The Comhairle would, therefore, like to stress the importance, for achieving a high standard of patient care, of ensuring that in as many situations as possible, a fully satisfactory hospital organisation is provided. Large hospital centres would be highly desirable in situations where the population would justify this. However, the Comhairle, recognising the twin difficulties of mountainous terrain and sparse population in parts of the country, acknowledges the appropriateness of smaller hospitals to cater for such situations. They would emphasise that such smaller hospital should be within a reasonable distance of a larger hospital centre where some of the more specialised facilities would be available. (Limerick Regional Hospital is an example of the scale of such a larger hospital). This should permit patient care problems of special difficulty to be handled on a joint resource basis and should encourage a spirit of mutual assistance on a wide range of activities.
Following the acceptance by me of those guidelines as a basis on which plans could be drawn up there followed what I can describe to the House as probably the most widespread and most democratic system of consultation on the hospital services that has ever been carried through. In every health board area a working group was set up, with membership drawn from the health board, the comhairle itself and the regional hospital Board, to consider in the context of the guidelines what realistic options existed for future policy. Each working group produced its options and in every area the county health advisory committee within the health board had an opportunity of giving their opinions. All these opinions were presented to me. The options of the working group were then relayed to the comhairle, to the health boards, to the regional hospital boards and they were invited to give their views on the solution which in their opinion was most appropriate to the particular area. These also were submitted to me and I have outlined them very clearly in the document which I have published.
In addition I had very many requests for deputations from particular areas and I have given an account of those in my published statement also. These deputations were received in the majority of cases by myself, or occasionally by another Minister acting on my behalf, reports on all of which were given to me. I was equipped then probably as no Minister ever was before with advice from all quarters—some of it conflicting, some of it undoubtedly based on local interests, but much of it objective and all of it well argued.
As I have said already, it was quite clear to me from an early stage that no matter which way the decisions went some people would be disappointed. This was inevitable given the fact that choices as to location had to be made.
In the event I made my recommendations to the Government, and the Government took their decisions after long and earnest consideration. If I had been starting off with a clean sheet, with no existing hospitals in the country, my task would have been a comparatively easy one; but I was dealing with a situation on the ground, with an existing hospital service which could not be ignored. While I expect criticism and am willing and anxious to explain and defend my decisions, I totally reject the suggestion that my plan should be condemned as inadequate or unsuitable. The vast bulk of the decisions are strictly within the guidelines set out by the comhairle. In addition, they are in line with the recommendations of the health boards, which are the statutory bodies set up to administer the hospital services, or most of them, in the eight areas into which the country is divided.
This last point is of critical importance. The decisions which I took in relation to hospital locations were not only almost all within the terms of the guidelines set down by Comhairle na nOspidéal, but each and every one of them were in agreement with recommendations made by our health boards. I should say that I paid special attention to the recommendations of each health board. I did so, firstly because these boards are the main agencies for administering health services in this country and therefore speak with intimate knowledge and authority on behalf of their regions. Secondly, health boards comprise local public representatives of all parties, together with representatives of the health care professions working in the region. For these reasons I took the views of our health boards very seriously indeed and as I have said, accepted their views.
I hope I have said enough on this matter to refute the Irish Medical Association's allegation that the comhairle's guidelines were overthrown for political reasons and that medical recommendations have been ignored. The plan is based on medical recommendations and in almost all respects is consistent with the views of Comhairle na nOspidéal, over which body I exercise no control. In addition, as I have said, it is consistent with the recommendations of our health boards, over which on this issue I exercise no control either.
If I may take the health board areas one by one, I would like to refer to the decisions taken and very briefly the reasons for them.
As regards the Eastern Health Board area, I have already referred to the decision to provide six major general hospitals in the city, and this will of course affect the whole of the area of the Eastern Health Board.
As regards the Midland Health Board area, the working group put forward three possible solutions which would satisfy the guidelines of the comhairle:
(a) One large general hospital at Tullamore;
(b) Two smaller general hospitals at Mullingar and Portlaoise;
(c) Two smaller general hospitals at Athlone and Portlaoise, although this was considered by the working party to be the least desirable.
All of the health administrative bodies except one favoured the selection of Mullingar and Portlaoise as the development centres, and these bodies were the Midland Health Board, Comhairle na nOspidéal, the Dublin Regional Hospital Board and the Laois Longford and Westmeath County Health Advisory Committees. The only voice against was from the Offaly County Health Advisory Committee, which favoured the establishment of a large general hospital in Tullamore.
I decided that the advantages of having two hospitals in Mullingar and Portlaoise heavily outweighed the advantage of a single hospital at Tullamore for a number of reasons. First of all the two hospitals are better located to cover road accident work, as they are on major routes from Dublin; and, secondly, they are capable of expansion to the size required rather more easily than the Tullamore Hospital is. The selection of Athlone would have meant the development of a new building on a new site and I do not accept that its location is the best, having regard to developments which have taken place in adjacent towns. Those who disagree with me and say I was wrong must say what they would have done in my place. If you select Tullamore then you reject Mullingar and Portlaoise. There is no other choice.
Let me emphasise that the development of Mullingar and Portlaoise will take a considerable time to accomplish and that, in the meantime, hospitals in the area, including Tullamore, Athlone and Longford, will continue as they are with an unchanged role. It is clear, however, that Tullamore, Athlone and Longford should become community hospitals. I shall have something further to say later on about the working of these community hospitals. Let me say again clearly and without ambiguity that those hospitals I have mentioned will not close down. They will change their role in time, and each of the three will contribute in a co-ordinated and meaningful way to the hospital services for the entire area.
As regards the Mid-Western Health Board area, the working group put forward one solution to satisfy the guidelines and this was for a major hospital complex at Limerick city and a smaller general hospital at Fnnis. The Mid-Western Health Board, the Comhairle and the Regional Hospital Board agreed with this, subject in some areas to a number of detailed recommendations regarding hospitals and services in the area. The health board recommended in addition, that Nenagh Hospital should be retained and up-graded. The Clare County Health Advisory Committee agreed to the working group's recommendations. The Tipperary NR County Health Advisory Committee recommended that Nenagh Hospital should be retained and up-graded, while the Limerick city and Limerick County Health Advisory Committees agreed with the working group's recommendations and made a number of detailed recommendations themselves about hospitals and services in the Limerick area.
Comhairle na nOspidéal set up a sub-committee, to which local persons were appointed, to consider the practical arrangements for dealing with hospitals in the Limerick city area in particular, but these discussions proved inconclusive and agreement was not reached. It is clear that further studies need to be carried out. Senior officers of my Department will initiate those studies and will visit the area at my request next week.
I have accepted that Ennis County Hospital and Nenagh County Hospital should be retained in the area and that joint staffing arrangements should be made between Nenagh Hospital and some of the Limerick hospitals, to ensure adequate consultant staffing for Nenagh Hospital and to overcome the difficulty of operating it as a single surgeon hospital. Nenagh Hospital was one of the centres of controversy and I note that Deputy Haughey, when invited in a public interview to comment on my decision about Nenagh, indicated that he, too, would have retained it. I welcome his endorsement and support for my decision, because I think it is the right decision, in view of the difficulty of forecasting future population trends in the Limerick area and in view of the present uncertainty about the future hospital pattern within Limerick city itself.
As regards the North-Eastern Health Board area, the working group put forward two possible solutions to satisfy the guidelines:—
(a) A large general hospital at Cavan and a large general hospital at Drogheda.
(b) A large general hospital at Cavan, a large general hospital at Drogheda and a smaller general hospital at Dundalk.
The North-Eastern Health Board and the Louth County Health Advisory Committee recommended the latter. Comhairle na nOspidéal and the Dublin Regional Hospital Board favoured Cavan and Drogheda as the centres for development. The Cavan County Health Advisory Committee was satisfied with either option. Monaghan County Health Advisory Committee was satisfied with either option, if Monaghan were substituted for Cavan. The Meath County Health Advisory Committee went for the three centre development, but wanted Navan substituted for Dundalk.
I think this summary indicates the kind of difficulty facing a Minister in making decisions. Because of the difficulties in this area, which were highlighted by deputations which I received, I arranged that an on-the-spot assessment of the capabilities of the institutions in the area would be made by a team of senior officers from my Department. I have received and considered their report and I am satisfied that the Monaghan County Hospital is not so sited or constructed as to be capable of expansion into the kind of general hospital envisaged by the guidelines. In addition, a suggestion that St. Davnet's Psychiatric Hospital be incorporated in the county hospital development was not considered to be well based. Furthermore, Monaghan is not geographically as well situated as Cavan. Cavan also has an existing medical hospital which is capable of expansion into the type of general hospital appropriate to the new situation.
My decision, therefore, was to retain Drogheda and Dundalk as general hospitals and to develop a general hospital in Cavan. In addition, there is a modern orthopaedic unit at Navan, which I considered should be retained as the regional orthopaedic unit and developed for that purpose, working in conjunction with the Drogheda and Cavan Hospitals. The County Hospital at Navan is not, in my view, suitable for development as a major general hospital. In addition, the North-Eastern Health Board wish to involve the board in the James Connolly Memorial Hospital, Blanchardstown, as serving a considerable part of the population of Meath. I favour this development also. I have decided that Monaghan Hospital should change its role and become a community hospital and in this way continue to play an important and significant part in the hospital service of the future.
As regards the North-Western Health Board area, the working group put forward one solution only, which would satisfy the Comhairle guidelines, that is, a general hospital at Sligo and a general hospital at Letterkenny. All the health administrative bodies agreed with the working group's recommendation, but the Leitrim County Health Advisory Committee asked that there should be no interference with the status of the County Hospital, Manorhamilton. Letterkenny and Sligo will, accordingly, be designated as the general hospitals for the area and Manorhamilton will be continued as a community hospital with close links with Sligo Hospital.
As regards the South-Eastern Health Board area, four solutions were put forward by the working group. The first was for a hospital centre at Wexford, Kilkenny and either Clonmel or Cashel, and this the working group considered to be seriously deficient as leaving Waterford city without a general hospital. The second was a hospital centre at Kilkenny, Waterford, and either Clonmel or Cashel and this also they considered to have a major deficiency, in that a sizeable portion of the population of County Wexford would not be within a radius of 30 miles of a hospital centre. The third was a hospital centre at Wexford, Kilkenny and Waterford, while the fourth and last was a major hospital at Waterford linking with satellite centres at Wexford, Kilkenny and either Clonmel or Cashel.
In the event, the first two I have mentioned received no support at all. Comhairle na nOspidéal and the Regional Hospital Board favoured the Wexford, Kilkenny and Waterford solution and the health board and the five local health committees agreed with the four hospital centre solution of Waterford, Wexford, Kilkenny and either Clonmel or Cashel. I have decided in this case to support the health board four centre solution and to consider further whether Clonmel or Cashel should be the centre for the South Tipperary area.
As regards the Southern Health Board area, the working group put forward one solution to satisfy the Comhairle guidelines, that is, a hospital centre at Cork, and a major hospital at Tralee and recommended that Bantry Hospital would continue in its present form as an exceptional measure to serve an isolated area. Comhairle na nOspidéal and the Cork Regional Hospital Board agreed with the working group's recommendation and so did the Southern Health Board who added, however, that the Mallow County Hospital should be retained and upgraded. The North Cork Advisory Health Committee endorsed the Southern Health Board's view; and the South Cork Advisory Health Committee, while accepting the working group's recommendations, also asked that the Mallow decision be reviewed. The Kerry Advisory Committee agreed with the development of a major hospital at Tralee.
I have approved of the development of a major hospital in Tralee and a project team has, in fact, been established on which my Department is represented. It has made extremely good progress in the planning of the new hospital there. In addition, Bantry will be retained, in the special circumstances, as a general hospital.
The position as between Cork city and Mallow is a complex one. A new hospital of 600 beds is being built at present in Cork and, in addition, a number of voluntary hospitals operate in the city. Comhairle na nOspidéal, with my agreement, set up a sub-committee last year which recommended that another major hospital be built in the north-east of Cork city. The sub-committee envisaged the ultimate integration of the voluntary hospitals into this structure. The committee also recommended interim arrangements, which would affect the voluntary hospitals considerably. I have received the views of the various interests in Cork on these proposals and there is disagreement about the recommendations. I find I will need to have discussion with the local interests before the final pattern of the Cork city development can be determined. These discussions are being initiated and senior officers of my Department are to visit the area next week.
I explained in my statement the need to take a cautious approach to the planning of the Cork area for many reasons, including particular difficulty in establishing population projections and uncertainty about the future hospital pattern within the city. For these reasons, I have decided, in addition to the development of Tralee and the retention of Bantry, that Mallow Hospital should also be retained and that discussion would be initiated about the joint staffing of Mallow Hospital in association with one or more of the Cork city hospitals, to ensure that Mallow would have adequate staff and that the difficulty of operating it as a single surgeon hospital would be overcome.
These then, in summary, are the decisions I took in relation to future general hospital development. We could not allow the situation to continue whereby the absence of firm decisions on a hospital plan precluded development from taking place. Indeed it can with truth be said that the failure to adopt a plan over the years led to a situation where general hospital development was held back, to the detriment of our hospital services today.
The plan which I have published constitutes a reasonable balance between the obvious need for fewer and larger hospitals, and the need for a geographical distribution which provides for reasonable access to hospitals on the part of patients. The latter cannot easily be discounted. I know that many members of the medical profession tend to favour a hospital system which comprises a few, very large hospitals. Such a system would certainly be more convenient for the medical profession and would offer them a wider range of facilities than would normally be available in somewhat smaller hospitals. But the fact remains that most patients and their families feel the need to be within a reasonable distance of hospital services. In my opinion, the inconvenience and hardship caused to them by travelling long distances for hospital care outweights the advantages to be gained in fewer and larger hospitals.
In my plan, I have attempted to achieve the best of both worlds. No one will be more than 30 miles from a general hospital and yet each hospital will be able to provide the full range of facilities normally associated with a general hospital. In addition, major national specialities will be located in our larger hospitals, which will be well enough staffed and equipped to carry out complex work of the highest level.
Before concluding, I would like to comment on the small number of criticisms which I heard about the plan. Deputy Haughey criticised it on the basis that the expenditure which will be involved and the scale of development envisaged has not been spelt out. That criticism, with respect, is based on a misunderstanding of the plan. The plan is concerned with indicating the locations at which general hospital development will take place in the future. That was the first decision which had to be taken and it is taken in this plan. Until the locations were decided and announced it was not possible to undertake the detailed studies required to determine development and expenditure needs.
I am now proceeding as rapidly as possible to plan the actual, detailed implementation of the proposals. Already project teams have made considerable progress in planning the new hospital in Tralee and the major extension at Letterkenny. Also, I have informed the Western Health Board that a project team should be set up to plan the development of Castlebar hospital. In addition, I am asking each health board about the priorities for development in their area, from which I can immediately determine our national building priorities.
Until all of this detailed evaluation is carried out, it will not be possible to indicate with accuracy the overall expenditure which is likely to be required. On the basis of tentative estimates, however, I can inform the House that gross capital expenditure is likely to be of the order of £65 million at present price levels excluding the cost of development in Cork and Limerick cities. This is very much a tentative estimate, while the final figure will not be known until the detailed planning to which I referred has been carried out.
As far as the length of time which will be required to implement the plan is concerned, again it obviously is not possible to give an accurate forecast at this time. The pace of implementation will depend firstly, on the availability of resources, which in turn depends on the rate at which economic recovery takes place and, secondly, on the speed at which detailed planning and building can be carried through.
The detailed planning and building of modern hospitals is a complex matter. In the case of the Wilton Hospital, which is at present being built in Cork city, the time involved from briefing to opening will be of the order of 8½ years. I will certainly do what I can to minimise unnecessary delays in this regard as far as the new hospital plan is concerned.
It should be possible, given the right economic circumtances, to implement the hospital plan in less than 15 years. I would emphasise, however, that this is a tentative estimate only and one which is dependent on the factors I have mentioned.
I have also heard the criticism that my plan does not go far enough towards rationalising our present general hospital system, and that we will still have too many hospitals in the country. I must reject this criticism also. I have already pointed out that my plan strikes a reasonable balance between the need for fewer and larger hospitals, on the one hand, and the need for a widespread geographical distribution of hospitals, on the other. This reality can be demonstrated in the following way.
My plan will, in fact, lead to a reduction in the number of general hospitals from 54 to a maximum of 33. On the other hand, I only propose to reduce the number of urban centres at which acute hospitals will be located from 27 to 23. What the plan achieves, therefore, is a very major reduction in hospital numbers, while, at the same time, retaining hospitals in almost the same number of urban centres as before. We will, therefore, create a situation in which there will be considerably fewer and larger hospitals in the country, while no individual will need to travel more than 30 miles for acute hospital care.
This seems to me to be rationalisation at its best. My plan takes account both of the need for better hospital care in larger centres and of the need of ordinary people to feel that they can receive hospital attention within reasonable proximity to their homes.
I have been asked on a number of occasions to outline more clearly the role and function of the proposed community hospitals. As I said previously, some existing county hospitals and some of the larger district hospitals, such as Athlone and Ballina, will take on this form.
The determination of the exact role which each community hospital will play will be worked out at a later stage in consultation with the relevant health board and will depend primarily on the needs of the area. But there should be no misunderstanding of the importance of the role which these hospitals will be called upon to play.
The community hospitals will be centres at which a wide range of out-patient services at consultant level will be provided. They will be centres to which patients could go both before and after treatment in acute general hospitals and at which consultants from the main hospital centres will attend as required. Some specialised services, such as radiology, could appropriately be based in community hospitals also.
The precise role of each individual community hospital and its relationship to the surrounding general hospitals will be worked out in detail later. I think I have said enough, however, to indicate that I envisage that they will play a highly important role in acute patient care in the future. They will provide a very important link between the community and the very expensive services available in our acute general hospitals, a link which will be very valuable both from the point of view of convenience of the patient and in terms of minimising expenditure.
As Deputies are aware, Comhairle na nOspidéal have recently published a discussion document on the role of these smaller hospitals. It will form the basis of discussion with our health boards in working out the details of each community hospital's role and I hope that Deputies who are members of health boards will contribute their views on this matter at the appropriate health board meetings.
I believe that the present hospital plan is a good one. I was faced with a number of difficult decisions, but I took them because the future of our hospital services depends on sound planning being carried out now. There can be no more delays or equivocation.
We must press on, as we are doing, towards providing a modern general hospital system in this country. As I have said already, I will carry out the detailed planning and development envisaged in the plan as quickly as possible and no effort will be spared on my part to secure high quality hospital care for all our people.
In conclusion, I know that people in some areas of the country are disappointed that their hospitals will not be retained as general hospitals in the long term. Equally, I know that some people may be disappointed that their district hospital will not become a general hospital. I understand their disappointment. But I would ask them to understand the dilemma which faced me. We cannot have expensive, modern general hospitals in every town, or even in every county. It simply is not either economically possible or medically feasible. Choices had to be made and they were made on the best information available, following widespread and comprehensive consultations.
For the first time in more than 30 years we now have a plan. While local interests may quarrel with some of the individual decisions taken on it, I think it can be said that, seen as a whole, it is suited to the needs of this country.
