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Dáil Éireann debate -
Wednesday, 15 Dec 1999

Vol. 512 No. 7

Priority Questions. - Hospital Admissions.

Alan Shatter

Question:

13 Mr. Shatter asked the Minister for Health and Children the guidelines, if any, he will issue to health boards and to each hospital concerning patient admissions following general practitioner referrals as a consequence of the judgment delivered by the Supreme Court in a case (details supplied) on 12 November 1999. [26976/99]

In the first instance the Supreme Court has returned the case in question back to the High Court for retrial. In this context, the Deputy will appreciate that it would not be appropriate for me to comment in any specific detail on matters relating to the case. I would, however, propose to review the issue raised by the Deputy on conclusion of that court case.

On the general question of guidelines for patient admissions, the Deputy will be aware that a decision on whether to admit a patient is taken on the basis of the judgment of the assessing clinician. Admissions following general practitioner referral in the normal course will be prioritised by the relevant consultant, whereas a patient presenting as an emergency at a hospital accident and emergency Department will be assessed by the clinician or clinicians on duty who will take a decision on the appropriate form of treatment, including whether to admit the patient.

The general issue of the responsibility entrusted in junior hospital doctors for clinical decision making is necessarily tied in with the wider issue of medical staffing structures in acute hospitals. As the Deputy is aware, this is being considered through the ongoing work of the Medical Manpower Forum. The main purpose of the forum is to improve hospital services for patients, while also benefiting hospital doctors through changed work practices, greater career opportunities and improved teaching and training.

The forum has not yet submitted a report but is preparing an interim one, which I understand is nearing completion. I will be awaiting the outcome of the forum's deliberations, which I hope will reflect a consensus among all the relevant stakeholders on the way forward, before taking any policy decisions in this area.

Will the Minister acknowledge that the decision delivered in this case by the Supreme Court in November requires the State to radically change the approach to hospital admissions in circumstances where an experienced general practitioner refers a patient to hospital recommending that he or she be immediately admitted and that it is no longer possible for any junior doctor acting as a clinician to take a different view from that of the general practitioner and refuse admission in such circumstances? If such refusal takes place and there are detrimental health consequences, the hospital and health board concerned will be liable in damages.

As I have said, the case has returned to the High Court for retrial and must be considered sub judice. Most of the judgment which I have read – Deputy Shatter kindly forwarded a copy of it – refers to the liability of the original general practitioner in regard to the non-referral at that stage. Without going into specifics, issues that arise similar to this case can and must be resolved in the wider context of medical manpower planning. As I said, it has been one of my priorities to get agreement from all the stakeholders on this issue on the basis that there must be a number of changes in work practices.

Quite apart from any specific issue raised in this case, I wish to deal with the generality of the question. There is need to change work practices to improve patient care in order to ensure that a quality service is provided 24 hours a day, seven days a week. For me to say any more than that at this stage would not perhaps be fair in terms of the specific case involved. However, I have stated on many occasions that we need to change the way hospitals operate in terms of manpower planning and the availability of staff, particularly in respect of providing services 24 hours a day. That is an important aspect of the forum's deliberations.

The forum is close to producing an interim report and this should be available next month. I hope we can reach a consensus on those issues. That is the first objective.

Is the Minister stating that this important Supreme Court judgment of 12 November last had not been seen by him or officials of his Department until I made it available when tabling this question on Thursday or Friday of last week? Will he acknowledge that the issue determined by the Supreme Court is not one for review, in any shape or form, in the High Court and that it is now absolutely clear that a legal obligation has been imposed on health boards and hospitals where, if an experienced general practitioner refers a patient and recommends immediate admission to hospital, no doctor below the position of consultant can properly refuse to admit? Will he further acknowledge that it is in the interests of patients that the medical assessment of experienced general practitioners concerning patients who are well known to them is not second guessed and set aside by junior hospital doctors who have a good deal less experience and lack comprehensive knowledge of particular patients' medical history?

I am not prepared to discuss the specifics of this case which, I am advised, has been returned for retrial.

It has been returned for retrial in respect of damages, not in terms of the legal principles involved.

As indicated in my reply, until such time as that specific issue is dealt with I will not deal with the matters to which it gives rise. The general question to which the Deputy refers is not new and I am probably the first Minister for Health and Children to address it with the people and the medical interests concerned in order to ensure that patients receive a better level of service, 24 hours a day. That requires obtaining agreement from people who are contracted to provided services for the State to make certain changes. I am adopting an inclusive approach in that regard in the hope that a consensus approach can be arrived at so that we can proceed.

No work was previously done in respect of this issue, which is at the top of my list of priorities, but many rhetorical speeches were made in connection with it. I do not wish to pre-empt the forum's report, because the objective is to see if agreement can be reached, but I hope that the issues that are raised generally by the Deputy's question will be adequately dealt with in terms of future work arrangements. It is important and in everyone's interests that this happens. I do not want to comment further on the specific case to which the Deputy referred.

A final supplementary, Minister.

We have already spent eight minutes on this question. In fairness to his colleagues who are waiting for answers to subsequent questions, the Deputy should put a brief supplementary.

Will the Minister acknowledge that this is an area of great difficulty and that it is a gross dereliction of ministerial duty not to have by now provided guidelines to each health board and hospital in the State regarding the implications of this vitally important Supreme Court decision which lays down legal principles to protect patients?

Guidelines introduced on the basis of the current staff complement will not solve this problem. What is required is a fundamental change in the work arrangements of those who are employed in our hospitals. I intend to ensure that such changes are brought about.

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