Much has been said about the configuration of services. Unfortunately, when we cannot access information it is very difficult to know exactly what the Minister means by configuration. The Minister says we are scaremongering by using terms such as downgrading and closure. A great deal of what has happened, in particular in the North-Eastern Health Board region, is done by stealth and in piecemeal fashion. We do not work out what is happening. We must look at what configuration means. The local needs of communities must be balanced by the centre of excellence approach. Certain medical procedures can be provided by smaller hospitals in uncomplicated cases.
Ceisteanna – Questions. - Other Questions (Resumed).
The Deputy must ask a question.
We must bear in mind that serious cases need to be stabilised before they can be moved to a major centre of excellence. Downgrading services in hospitals and moving to centres of excellence may increase anxiety because journey times can also increase. It is important that other reports such as the Brennan and Prospectus reports are published so that we can find out what is being proposed. These are significant issues for the local communities involved. I am particularly concerned about obstetric and paediatric services.
The purpose of Question Time is to elicit information from the Minister. A number of Deputies are offering. It is not appropriate for the Deputy to make a long contribution.
I agree with that, but it is difficult for us to get hard and concrete facts as to what the Minister has in mind for the health services.
Too much spin.
Everything involves producing a report or coming up with a new idea, but nobody can sit down and say, "If you read that now, you will know what will happen with the health services." We thought that was what the health strategy was about, but that seems to have gone by the wayside as well and we are now relying on—
Deputy Twomey, you are using your colleagues' time making what appears like a Second Stage speech.
That is true, I would agree with the Ceann Comhairle in some respects.
I would remind the Deputy that this is Question Time; perhaps he would give way to Deputy Gormley.
Is the Minister aware that up to 40% of babies are born in the three major maternity hospitals in Dublin, that these hospitals are among the largest in Europe and that this has real cost implications? All the evidence is showing that the larger the institution, the more it actually costs. Why, therefore, is the Minister centralising even more services? It does not seem to make sense. The Minister is the one who gives out about the costs which must be incurred as a consequence.
Would the Minister agree that the Irish model of maternity care is highly interventionist in its character and that this also has cost implications? We know that Caesarean sections, for example, cost three times as much as an ordinary delivery. Is this an area the Minister feels he can influence? Is it possible at this stage to get away from this interventionist style which has evolved in this country? That would enable us to have more natural births and also to reduce costs significantly.
I agree to a certain extent with Deputy Twomey's points on the need to balance the needs of patients, in rural communities in particular, in terms of access to services but also in terms of provision of transport, accommodation and facilities which will mean that the referral on to specialist centres will not represent the degree of inconvenience which it does at present.
From what I understand of it so far, the Hanly report – there have been different drafts and the final draft is not completed – is not recommending the closure of the major maternity hospitals which have more than 1,000 births. In terms of configuration of services, the report basically maps out what certain size hospitals should be doing, what is appropriate, safe and best for those particular hospitals to do in order that they then can go away and do it properly, and then what is best, safe and appropriate for other hospitals. That is what we mean by the configuration of services.
By definition, many hospitals will not be doing everything. The Deputy is correct in terms of minor surgical procedures and issues like that which can be done, but in my view that is not possible with some of the major specialties at the other end of the scale to which I referred earlier. Nor is it desirable that, for example, certain cancer procedures or surgical oncology interventions in regard to cancer of the colon, lung or pancreas would be carried out in a hospital where a consultant may do only ten a year – we will be dealing with that in a later question. I would not be happy about that from a safety or quality point of view.
While we have come a long way with cancer services, we still have some distance to go. I believe in the idea of having centres of excellence for cancer treatment and, ultimately, the patient will too. If any patient out there had a choice upon diagnosis to honestly answer the question "Where would you like to go, what would be the first priority for you in terms of accessing a service?", he or she would say, "I want to go to the place that gives me the best chance of surviving this". That is the fundamental question we all must ask ourselves in terms of how we plan and prepare the new services, ideas – these are not necessarily new ideas – or proposals which will emerge from the medical task force and the Hanly report. As a society we need to honestly face up to that and perhaps bite a number of bullets in the process. No doubt it will be politically challenging.
On maternity services, one must look at the evolution of the maternity, midwifery and obstetric services over recent decades or over the past 100 years. There has been a tremendous improvement in safety, survival rates and infant mortality over the past 20, 30 or 40 years. There are other pressures on obstetricians and consultants, some of which are insurance-led, which may be one of the factors related to increased intervention. When one considers the tremendous developments in neo-natal care for example, one begins to understand why we need centres of excellence in the maternity area. That is not say it is not possible to have midwifery-led units and some health boards are now making proposals on that front. We are developing a nursing and midwifery strategy in the community which is nearing completion.
When will that be?
I hope it will be very shortly. The nursing division of my Department has been working on that for quite some time in consultation with all the interested parties. Many births can happen in the community without any difficulty. We have had a very good scheme in Holles Street, the evaluation of which I launched recently. This has been quite a success in terms of a midwifery-led development under consultant protocols. It seems to marry the best of both worlds with clear safe protocols in place.
Would the Minister like to comment on the fact that the midwifery-led scheme in Galway has been collapsed? Following his comments on reorganisation in hospitals, does the Minister not accept it is silly for him to ask for a positive response from us when we have not seen the report? As we all know three major reports are due to be published. Is the Minister aware that some of these reports were initially promised to be available last February? It is now May and we are still waiting. When will the Hanly report be published? Surely the Minister would accept it makes debate very difficult when he can give quite wide-ranging comments on a report but refuses to publish it. When will these three reports be published?
I cannot give a specific date. The Hanly team expects to complete its work around mid May. Some fine-tuning might be required after that. A further meeting of the group will take place in the middle of May so obviously it will be a number of weeks after that. It has been a very wide-ranging exercise involving about 300 meetings and consultations. Some elements of the report have been leaked which has led to a debate, which is understandable. However, I ask people to hold judgment until the report is published. I am commenting because I am answering questions about maternity, accident and emergency services, and so on. These are legitimate questions asked by Deputies in response to the leaking. It is too soon to have public meetings about something that is not contained in any report and that has been happening throughout the country.
There will be many of them after it is published.
The Deputy would be disappointed with public meetings at the moment.
I asked when the reports would be published.
I have given the time scale for the Hanly report. There is an issue as to whether we should do the three together along with the Prospectus Strategy Consultants report and the Brennan report on financial reform of the health service. All three together could be a significant mouthful to digest in one week. However, we are looking at a six-week period. Obviously the plan is for them to go to Government first for approval.
Does the Minister acknowledge that changes in training rules being implemented by the Royal College of Surgeons in Ireland as signalled by the Irish Medical Organisation have been in the offing for some considerable time? What steps is the Minister taking to ensure that current provision of accident and emergency services throughout the hospital network in the State will continue unaffected by these changes and that people in communities and all of us traversing the country have a guarantee that those accident and emergency services will remain in place?
The situation in the Monaghan and the North-Eastern Health Board region has been referred to on a number of occasions this afternoon. The hospital in my community in County Monaghan has remained off call for almost 12 months. Ambulances responding to accidents in our immediate community cannot deliver patients to Monaghan General Hospital but are obliged under diktat of the health board to bring those patients a considerable distance to other hospitals at some considerable risk, as we have only too sadly recorded in our community. What is the Minister doing to ensure the restoration of Monaghan General Hospital to on-call status? Will he ensure that accident and emergency services and, indeed, the level of maternity care that our community both demands and deserves, are provided there.
I do not interfere with the protocols issued by the Royal College of Surgeons in terms of accrediting hospitals for training purposes, in particular training for non-consultant hospital doctors, the quality of that training and so forth. The key principle of the Hanly report is to move to a consultant-provided service as opposed to a consultant-led one which is what we have at the moment. We are currently too dependent on doctors in training which is giving rise to the annual or biannual problems in many hospitals around the country in regard to whether they will have junior doctors, they will get accreditation and so on. We need to transform that situation and the ultimate way to do that is to move from a system that is too dependent on doctors in training to one which is consultant-provided. In essence there would be more consultants and a trade-off between the number of consultants and junior doctors that currently exists.
Jointly with the North-Eastern Health Board, we appointed Mr. Kevin Bonner to carry out a full report on the issues around the Monaghan situation. I do not intend to intervene in the way the North-Eastern Health Board discharges its duty in terms of protocols for major accidents. It is common sense and a basic principle in terms of accidents, as Deputy Twomey alluded to earlier, that anyone involved in a serious accident should be stabilised at the nearest hospital. He or she can then be moved on to the correct centre where proper effective interventions can take place in terms of multidisciplinary teams of consultants on standby. That is established practice and that has happened for years without any hue and cry.
We are talking about now.
It is interesting that when I announced the appointment of additional accident and emergency consultants three years ago everyone started roaring and shouting about accident and emergency consultants, but they had nothing before that and many hospitals had never even contemplated having them. As soon as we announced an increase in the number every area in the country wanted one.
The Minister says he will not intervene or interfere but I argue that it is long past the time he did both.
I am sorry but the Deputy will have to find another forum to argue his case.
I wish to ask the Minister two quick questions, both of which are related to his commitment to increase the number of beds in the system. I presume he would regard the Coombe Hospital as a centre of excellence and one where, to quote him, it is safe to provide maternity services. What does he have to say to a young Dublin woman who went there recently to deliver her first baby who did not have a bed but was put in a wheelchair for seven and a half hours after giving birth? Would he regard this as being consistent with the commitment to have sufficient beds in the system? He talked about a commitment to provide beds but is there not an inconsistency in providing money last year for 265 additional beds only to have 250 of them closed yesterday? Is it an efficient use of resources to provide beds and then not fund them?
The Minister said he did not want to use the word "downgrade" but he spoke of the reconfiguration of services based on size rather than catchment area which gives rise to the issue of accessibility. He said he will not interfere in regard to the Royal College of Surgeons and the provision of supports because there will not be two consultants in some of the smaller hospitals to support accident and emergency services. In light of the fact that this year's budget is not based on last year's outturn and from the points made by the Minister it appears evident to many of the smaller hospitals that they are threatened with downgrading.
I am not aware of the individual case referred to by the Deputy in terms of the Coombe Hospital which has provided excellent services.
The service was excellent but the person would like to have had a bed.
I will check on that individual case with the Coombe Hospital, now that it has been raised in the House. We are aware that maternity hospitals have been under considerable pressure in Dublin for a variety of reasons over recent years. The Coombe Hospital has always discharged its functions in an excellent manner and the quality of service provided by it and, indeed, the other maternity hospitals in Dublin has been quite exceptional in many instances.
In terms of bed capacity, we must remember that the entire system is not ERHA-based. The 502 beds to which I referred are in operation. I can give specific information of where the various boards made proposals to us and we provided ring-fenced funding for this which was followed up this year in the budget. It is not true that 250 beds were closed yesterday.
They were announced. Some of them were closed.
There was an announcement that it was intended to close 250 beds and, as I said in reply to an earlier question, meetings are under way to try to ascertain the full nature of that situation and to discuss the difficulties that have been flagged by the Dublin academic teaching hospitals.
In terms of Deputy Naughten's question, the reconfiguration is not on the basis of the size of hospitals, it is on the basis of quality and health outcomes – what is best for the patient in terms of giving the right service and what particular hospitals can do best in their appropriate circumstances. It is also dictated by factors such as the consultant and junior doctor issue that I mentioned earlier. We are all aware that there is a European Union directive which is putting pressure on the Government to reduce the working week of junior doctors to 48 hours per week by 2009, which is in turn putting pressure on the system here. That is creating its own imperative for change and combined with the need to provide a more consultant-provided service is dictating the pace of the reforms that will emerge. The fundamental principles underlying the change relate to quality and patient safety.
There is still a question mark over Portiuncula Hospital and Roscommon County Hospital.