Adjournment Debate.

Hospital Services.

Mr. B. Smith

I am grateful to the Ceann Comhairle for giving me the opportunity to raise this important subject and am glad the Minister for Health and Children is present to hear my concerns again.

Last June, through parliamentary questions and on the Adjournment debate, I raised concerns about the threat to surgical services at Cavan General Hospital. I expressed particular concern about the threatened withdrawal by the Royal College of Surgeons in Ireland of recognition of five surgical trainee posts in the hospital. The Minister for Health and Children was requested last August by the chief executive officer of the North Eastern Health Board to establish an inquiry following the suspension of two consultant surgeons.

I secured another Adjournment debate in early February on the difficulties facing the surgical department at Cavan General Hospital. It has been stated repeatedly that the suspensions arose from interpersonal difficulties between two eminent surgeons in the department. I outlined in the debate and elsewhere that those interpersonal difficulties should have been dealt with firmly and in good time by the senior management of the health board. Unfortunately, the health board was lacking in such firm management and necessary human resource management. Health board management failed to address serious emerging difficulties and the subsequent inquiry has been much too slow.

Over the years I regularly met people who outlined their great satisfaction with the work and expertise of consultant surgeons attached to Cavan General Hospital. I also acknowledge the excellent work done and treatment provided in the medical department and in the gynaecology and obstetrics unit. The personnel attached to the hospital in all disciplines are rightly held in high esteem by the communities of Cavan-Monaghan, north Longford, south Leitrim and north Meath and people appreciate their commitment, professionalism and dedication to duty.

Unfortunately, a number of outcomes following surgical procedures or medical treatment give rise to legitimate grievance and mourning for families and, sadly, no way back for the patient. Previously, by way of parliamentary question, I raised with the Minister the need to involve the Royal College of Surgeons in Ireland, RCSI, in advancing and extending the work of the surgical department in the hospital. I was glad to learn that the North Eastern Health Board has sought the advice of the RCSI and is working closely with the college in this regard. I am also glad the Minister met the medical board of the hospital some time ago and I hope the proposals tabled at the meeting can be advanced.

This matter also relates to additional resources for the surgical department. An additional consultant surgeon is needed and I request the Minister to make such an appointment as quickly as possible. The people of Cavan believe that the surgical department of the general hospital has the potential to deliver an excellent service to its catchment area. Leadership and support for the department is necessary to achieve that outcome. There should be improved co-operation and exchange of personnel between the two surgical departments at Cavan and Monaghan hospitals.

A hospital the size of Cavan General Hospital should have special links with one of the large teaching hospitals in Dublin such as the Mater Hospital or Beaumont Hospital. Such links could be used for exchange of staff and other necessary support, especially when difficulties or pressures might emerge. The suggestion should be explored.

The health board, in recently reviewing a limited number of surgical cases, should have called on the expertise of a professional from another health board area. If the next of kin in the cases under review have concerns about the treatment of relatives, they should be treated with the utmost consideration and an independent review of such cases should be undertaken without delay. I hope the Minister can impress upon the health board the need for such consideration and I thank him for his efforts and commitment to date in dealing with these difficult issues.

Mr. Crawford

It is no pleasure for me to raise the problem relating to the Cavan-Monaghan hospital group again. I thank the Ceann Comhairle for allowing me do so and I thank the Minister for coming to the House at this late hour to listen to the contributions of both myself and Deputy Brendan Smith. He and I are often on different sides on issues but we share similar views on this matter. We both want the Cavan-Monaghan hospital group to work properly.

Much of what is happening in the hospitals must be addressed by the management of the hospital and the North Eastern Health Board. Two eminent surgeons were allowed to sustain a personal dispute for ages. The dogs on the street knew about it, yet the dispute was not dealt with by senior personnel. Dunnes Stores, Tesco or other businesses could not be run that way. The issue has been left in the Minister's lap and he has had problems addressing it. This dispute is the source of the problem at Cavan General Hospital as locum and other short-term appointments had to be made. Ultimately, surgeons in whom people can build trust need to be appointed or re-appointed on a permanent basis.

A shiver went down the spines of the people of Cavan-Monaghan last Thursday when the report on hospital services was highlighted by the media. In addition, Frances Sheridan, aged nine, passed away tragically recently. I visited her home together with our local councillor, Aidan Boyle, and we saw her lying in her coffin wearing her first communion dress. She was the star of the Christmas variety show and, while she was sick, she asked for her lessons to be sent home so that she could keep up with her work.

An environment of trust must be created. It was not acceptable to the people of Cavan-Monaghan that Mr. Finbarr Lennon, an eminent surgeon in Drogheda hospital, was brought in to conduct an inquiry in Cavan. He is not seen as an independent person. His report makes sad reading. It is even more difficult to understand that he should suggest the way around this problem is to provide extra staff in Drogheda. How would people go from Cavan to Drogheda in an emergency? Surely the experts should be appointed to Cavan General Hospital. As a layman, the way I see the problem being solved is to ensure that appointments are made to Cavan General Hospital and that Monaghan General Hospital is brought back on call. There is no reason that goodwill cannot exist between the two hospitals. If Cavan and Monaghan hospitals were set up as a joint hospital project by the health board, surely it would be under a single manager and it should be possible to send staff from one hospital to the other.

An aged person had to be moved from Monaghan General Hospital to Drogheda, when a surgeon was available, but all that was needed was an anaesthetist. I do not want to be critical for the sake of it, but the crisis has to be dealt with urgently. I do not mind whose head rolls, whether the hospital or health board management, but it certainly should not be that of the patients in Cavan and Monaghan hospitals. The patients must come first. I know the Minister will have a prepared script, but I hope he has listened carefully to the points raised by Deputy Brendan Smith and me. We both speak in sincerity when we say we want a proper service.

Minister for Health and Children (Mr. Martin)

I thank Deputies Smith and Crawford for raising this issue on the Adjournment.

This has been a very difficult time for the people of the Cavan-Monaghan area and in particular their, public representatives and the staff at the hospital.

Mr. Crawford

I pay tribute to the general staff who are doing and have done a tremendous job.

Mr. Martin

It has been a difficult time for the hospital community. I reiterate my profound sympathy to the Sheridan family on their tragic loss, which we discussed in this House last week.

I welcome the opportunity to respond to the House on the various issues raised by Deputies Smith and Crawford regarding surgical services at Cavan General Hospital. At the outset, responsibility for the provision of services at Cavan General Hospital rests with the North Eastern Health Board. In this regard, I met earlier today the chief executive of the board and the board's medical adviser to discuss the position at Cavan General Hospital and, in particular, the findings and recommendations in Mr. Lennon's recent report to the board. I was assured by the board that all necessary steps are being taken to ensure the provision of a high quality, accessible and safe service to the people of Cavan and Monaghan. I will deal later with specific elements of the board's response.

Following the introduction of the clinical indemnity scheme in July 2002, all health care organisations are required to have in place systems to collect information on clinical incidents and to report them to the clinical indemnity scheme.

In 2003, the North Eastern Health Board introduced an integrated incident reporting system based on international best practice. This is a very positive development as it is through the willingness of staff to report incidents that an organisation can build systems of high quality and safety.

Approximately 26,000 incidents were reported nationally in 2003. In the north-eastern region, 2,500 incidents were reported in the Louth-Meath hospital group and 750 were reported in the Cavan-Monaghan hospital group. Of these 750 incidents, the board's risk adviser recommended that the views of a consultant be obtained in 15 cases treated in the surgery department in Cavan General Hospital. Accordingly, the board's medical adviser was requested to carry out a review in this regard.

On 4 March 2004, the North Eastern Health Board published the medical adviser's report which contained a number of recommendations with regard to surgical services at the hospital. My Department is informed that Mr. Lennon has met the relevant medical and executive staff at the hospital to discuss his recommendations, as well as those made by Professor Tanner, director of surgical affairs at the Royal College of Surgeons in Ireland, who has been advising the board on the configuration of surgical services at the hospital. Arising from these discussions, I understand that agreement has been reached on a number of key issues, namely, that Professor Tanner's proposals on the general and surgical audit will be implemented. This will involve regular audit meetings held by the department of surgery and a monthly review of the process, involving Mr. Lennon. This is absolutely essential in terms of instilling confidence in the surgical department and I am glad to see Professor Tanner's proposals being taken on board and that the surgeons, Professor Tanner and Mr. Lennon are engaged in constructive dialogue.

In response to Deputy Smith's request for additional resources, I will be supportive of any plans by the North Eastern Health Board to put procedures in place to increase the volume of appropriate elective surgery at Cavan General Hospital. At today's meeting we impressed the need for a management system and so on at Cavan-Monaghan hospitals, to respond to Deputy Crawford's point. As a result of my meeting today, I am assured of the board's confidence, that as a result of the implementation of these recommendations at the hospital, emergency on-call surgical services will continue to be provided at Cavan General Hospital. In this regard the board held interviews today for the recruitment of a fourth surgeon to Cavan General Hospital and is confident that an early appointment will be made to augment the existing surgical complement at the hospital.

I have asked the board to be proactive in looking at the permanent staffing position and to take appropriate steps in that regard. That would have some resource implications, a point raised by Deputy Smith. I am anxious to be supportive of the board in its endeavour to deliver a resolution to these issues in the Cavan-Monaghan context, with synergies between both sites and people working together, as has been said. I am anxious to see that happening here.

The board has stressed that it is committed to ensuring there is a joint approach to the provision of hospital services across the Cavan-Monaghan group and is actively working to ensure agreement on this issue on both sides. I wish the board every success in that regard. I ask all parties to these discussions to work together to bring about a comprehensive package that will lead to a new era for the Cavan-Monaghan hospital group. I will continue to liaise with the board on developments in this regard.

On the cases which were reviewed by Mr. Lennon, the Department is advised by the board that it will offer an independent review of the care and treatment to the next of kin of any of the patients whose cases were reviewed, who have concerns about the treatment of a relative at Cavan General Hospital. Let me stress again that it will be independent of the board and I have been informed by the board that the Royal College of Surgeons in Ireland will have a role to play in nominating such an independent person from outside the board's area.

The issues raised on the provision of services at Cavan General Hospital are being addressed as a priority by the North Eastern Health Board with a view to ensuring the provision of a comprehensive and safe range of services across the Cavan-Monaghan hospital group. I will continue to liaise with the board on the implementation of the various recommendations put forward to effect the delivery of an appropriate range of services on a group basis to the population of Cavan and Monaghan.

Dr. Cowley

I am very grateful to the Ceann Comhairle for the opportunity to raise this important matter on the Adjournment. Mr. Seamus Birrane has been waiting to be called for an orthopaedic appointment for the past two and a half years. He was seen by Mr. Prasad, locum consultant orthopaedic surgeon, on 4 December 2003. Mr. Prasad had classed him as a "very urgent" case. I have written to Mr. Devitt who is the new orthopaedic surgeon in Merlin Park hospital, Galway, stressing the urgency of the situation.

Mr. Birrane is in constant pain, in spite of pain killing medication. He cannot get around and is confined to a chair. He cannot tie his shoelaces without help. He is in pain all the time and has no quality of life. He sleeps very little because of this pain. I feel strongly that it is not acceptable that he should be left any longer without the treatment he requires, namely, hip operations. One hip is as bad as the other and the question is which hip will be done first. He had a massive heart attack some years ago, which he survived, and he deserves a quality of life that he does not have at the moment. He is 70 years of age and he is crippled. He deserves to spend his golden years with his wife and free from pain. He is incapacitated. He has a car and it is unsafe for him to drive in his current condition. Both his hips must be replaced which is why it is imperative to begin the process as soon as possible. He has lost his quality of life, freedom, mobility and peace of mind. He is never free from pain. He deserves better. It is a scandal that he is in this situation.

In the Western Health Board area people must wait four years to be seen. The situation of the man in question is not unique for there are thousands waiting. I became involved in politics through a campaign I began some years ago to establish an orthopaedic unit. People in Mayo had to travel the almost the same distance for services as it is from here to Galway. Older people who break their hips continue to die due to the terrible distance involved. It is not acceptable.

While an orthopaedic unit has been put in place and one consultant has been appointed, only trauma services are available. In Mayo we have an intensive care unit and the facilities to perform hip replacement operations, but the unit is not geared up. A request has been made for staff, but only two thirds of the staffing numbers asked for have been approved. We need a full complement of radiologists at Mayo General Hospital and adequate laboratory staff for transfusion. These are essential parts of the chain which must be put in place to ensure the service can be complete. If the hospital is not fully resourced, it cannot carry out the work it needs to do. There is a great need for this work. Mr. Birrane's circumstances are neither unique nor acceptable. It makes me sad. What is life about if the health service fails to cope with people who have a need like this?

I met Mr. Birrane and his family and I was disgusted that he could be left to wait for so long. What kind of health service do we have if this is the result? An orthopaedic unit comprising a ward and theatre has lain idle in Mayo for two years. While it is supposed to begin to operate, the Department has failed to provide the resources needed to ensure that the unit can function adequately to perform necessary hip replacements. Why should people have to travel to Merlin Park? It would be much more appropriate to carry out their operations at Mayo General Hospital which has an intensive care unit.

Will the Minister examine the cases of people like Mr. Birrane and ensure the resources are put in place to provide a proper orthopaedic service at Mayo General Hospital? We deserve no less.

Mr. Martin

I remind Deputy Cowley that the provision of health services for people who live in County Mayo is a matter for the Western Health Board in the first instance. It is not normal practice to discuss the circumstance's of an individual patient's case in the House.

Dr. Cowley

I asked the family if it would be acceptable.

Mr. Martin

The Deputy should let me finish. I did not interrupt him. I just want to explain.

We have made inquiries of the Western Health Board about the case referred to by the Deputy. The board has advised me that it is hoped to call the patient for surgery over the next six to eight weeks. While I do not know the details of the individual case, I am curious as to why he has spent two and a half years waiting. The national treatment purchase fund has been up and running for well over a year to deal with cases in which the wait is longer than 12 months. We have placed advertisements in newspapers and asked health boards to forward details of patients.

Dr. Cowley

A patient must wait four years to be seen by a consultant.

An Leas-Cheann Comhairle

Allow the Minister to speak without interruption.

Mr. Martin

I am talking about someone who is on a waiting list for a hip replacement operation. Through the national treatment purchase fund, 11,000 people have been treated who were waiting longer than 12 months for various operations in various specialities. We have advertised the phone number and informed general practitioners and health boards of the scheme. To be fair to Deputy Cowley, he has described the difficult circumstances of the gentleman in question. He should not be in the situation the Deputy outlined. A reason the treatment purchase fund was introduced was to deal with public patients

Dr. Cowley

One has to wait a year to get on the treatment purchase fund.

Mr. Martin

The waiting time has gone down to six months in most health board areas. Anyone waiting longer than six months on a public hospital waiting list can now be attended to via the treatment purchase fund. If any Deputy knows of any other case in which someone who has been seen by a consultant and recommended for orthopaedic surgery remains on a waiting list for this long, I urge him or her to contact the treatment purchase fund and advise it of the details.

Dr. Cowley

A person has to wait four years to get on to a waiting list.

An Leas-Cheann Comhairle

Allow the Minister to speak without interruption.

Mr. Martin

I am talking about the case before us. The case of this man has already been assessed and an operation has been recommended. I am simply saying that the facility of the national treatment purchase fund was available to that patient.

Orthopaedic services in the west are provided at regional hospitals in Galway, including Merlin Park to which the Deputy referred. To develop regional orthopaedic services in the west, the Government has provided for a new orthopaedic trauma ward and theatres at University College Hospital, Galway. The development has recently been completed as part of the second phase of the major capital development on the hospital site which cost more than €100 million. The transformation of the hospital into a major regional centre is a demonstration of the great commitment of Fianna Fáil and the Progressive Democrats to the west. The people of the west will no longer have to travel to Dublin for many services.

A new orthopaedic unit has been built at Mayo General Hospital as part of the more recent €48 million investment in the infrastructure at the hospital. Fianna Fáil Deputies in Mayo deserve some credit for lobbying intensively for the unit. While Deputy Cowley has had his interest in the project, public representatives in the west from all parties have had an interest as well. It fell to the Fianna Fáil-led Government with the Progressive Democrats to make major investment in the infrastructure at Mayo General Hospital. When the service is up and running, it will bring orthopaedic services to Mayo General Hospital for the first time and will operate with the regional orthopaedic service to serve the people of Mayo. A new consultant orthopaedic surgeon has recently taken up his appointment at the hospital.

We provided the Revenue funding for this unit some years back but, for some reason, the board was not in a position to start it up. My officials have had discussions this year with the board which has indicated that, in the context of the 2004 service plan, the Revenue funding will be provided for the roll-out of orthopaedic services.

Dr. Cowley

The resources are still inadequate.

Mr. Martin

This significant additional investment will make a major contribution to the improvement of orthopaedic capacity in Mayo and Galway.

Dr. Cowley

That will only happen if the necessary funding is provided. I hope the Minister will ensure it is.

Security of the Elderly.

Mr. S. Ryan

The scheme of community supports for older people, which was first introduced in 1996, is important, especially to those who feel vulnerable and isolated or who have been victims of crime. While the scheme has been successful in assisting thousands of older people, its rules and regulations must be reviewed with a view to meeting the needs of the elderly and ensuring transparency in its commercial aspects.

One of the scheme's most significant flaws is the limited time available for applications and the fact that people never know the day or the month they may become widowed, ill or a victim of an attack. A mechanism must be found to address such a scenario at any time during the calendar year. The fact that thousands of vulnerable people are unaware of the scheme is a matter of further concern. Even if they are aware of it, there is not always a functional voluntary group available to complete the application form. These shortcomings must be addressed as the care of the elderly must continue to be the scheme's priority.

I have received representations from a number of small and medium-sized companies in the security alarms businesses who have alleged that the tendering process for the work has been taken over systematically by at least one commercial group which uses community-based organisations as a cover to breach the scheme's guidelines. This is done with a view to becoming the dominant supplier and installer. Having investigated the matter, I am satisfied that the scheme is open to abuse and being abused. Applications to the scheme are invited from locally-based organisations which apply on behalf of older people. Ultimately, these organisations will seek quotes and choose the security equipment they consider best. While I fully subscribe to this, the scheme must be transparent and there must be a level playing pitch for all suppliers. This is not currently the case. A multinational company, Tunstall Group UK, has secured the business of the most significant and largest of the successful applicants at the expense of other, mostly Irish, companies.

How has this occurred? There is a link between Security of the Elderly, which applied for more than 1,000 people this year, Emergency Response and Tunstall Group Limited. I have seen a letter, dated 13 August 2003 that outlines the position. It states:

This grant is given on a yearly basis and can only be applied for by a group rather than individuals, e.g. Homehelp, Community Care and Neighbourhood Watch groups. [The letter then refers to difficulties regarding extra paperwork etc.] I, on behalf of Emergency Response can now offer to take on this paperwork for the individual groups and assist them in applying for the people in their area who need the added security of having a monitored alarm.

They are carrying out work on behalf of voluntary groups.

I have another document that states: "Emergency Response merges with leading global provider. Tunstall Group Ltd., Europe's leading provider of personal home reassurance systems acquired Emergency Response Ltd. on the 5th of June 2001." The managing director of Emergency Response said: "We have been working with Tunstall for several years and it was a natural evolution to become part of the Tunstall Group." Here we have the link between those organisations that are applying for a group but are not supposed to be doing so under the scheme. I have received correspondence from a security company in the south. It strongly stated that a foreign multinational now has control of the majority of this business, continues to aggressively ignore the laws and guidelines that bind other companies and seems to do as it pleases with the apparent blessing of the Department.

I want an improved scheme for the elderly. I want the scheme to be fair and transparent for all concerned; nothing less is acceptable. I ask the Minister to take into account some of the issues I have raised before the new scheme is introduced later in the year.

Minister for Community, Rural and Gaeltacht Affairs (Éamon Ó Cuív)

I thank the Deputy for raising this important issue. The scheme was first introduced in 1996. It is now operated on an annual basis and was transferred to my Department in 2002. Approximately €2.4 million has been allocated for this scheme this year.

The scheme is advertised each year and applications are invited from local voluntary and community groups to apply on behalf of older people in their area. Money is provided for the groups and not for individuals. My Department assesses applications from these organisations. However, the applicant organisation is responsible for selecting the supplier and for the purchase and installation of the equipment. The Department has no role in this process. It is a requirement of the scheme that voluntary or community based groups seeking funding must satisfy the defined eligibility criteria of the scheme, comply with Government tax clearance procedures and provide satisfactory accounts in respect of previously paid grants. Those eligible for assistance under the scheme are persons aged 65 and over who are living alone or living in households made up exclusively of older people, or of older people and other people who are dependent and vulnerable and who are financially unable to install or purchase the equipment concerned themselves.

The scheme provides funding for small-scale physical security equipment, such as strengthening of doors and windows, window locks, door chains, door locks and security lighting and socially monitored alarm systems, such as the "panic button" pendant which is worn around the neck or wrist and operated via the telephone. Funding is not available under the scheme for conventional intruder alarms or smoke alarms. Under the terms of the scheme funding is available towards the once-off cost of obtaining or installing the relevant equipment. Annual monitoring fees or maintenance fees associated with socially monitored alarm systems are not provided for under this scheme and as these are levied by private service providers, my Department has no role in setting them.

The scheme provides a maximum of 90% of the once-off costs, inclusive of VAT, associated with the purchase and-or installation of this type of equipment. However, the actual grant varies in light of individual circumstances and needs and takes account of the overall demands that must be met. In general, grants will cover between 50% and 90% of the total costs and applicants must show how the balance of funding will be obtained.

My Department monitors the scheme on an ongoing basis to ensure that those organisations receiving funding under the scheme are complying with all the regulations and requirements. An independent review of the scheme, completed in 1999, found that the security and social support of a large number of people had been greatly enhanced by the scheme. I do not think anyone doubts this and I understand that the Deputy is not suggesting this. It also noted that while the primary purpose of the scheme was to respond to the security threat to elderly people, it also had an important health and community care effect. My Department is currently undertaking a review of the scheme rules and guidelines prior to advertising the 2004 scheme in the coming months.

Since I became Minister, with the Minister of State I have sought to examine these schemes to determine whether they are proofed against abuse. I am concerned to note that there has been a professionalisation of the voluntary and community sector in a number of areas. There are people who now see this as a vehicle for doing considerable business. I will take on board the concerns the Deputy has raised and ensure this matter is investigated. I will ensure there is a level and free playing pitch when we advertise the scheme again.

When we spend public money, it is important that those at whom it is targeted derive the benefit. There must be proper competition and all companies, regardless of their size, should have a fair chance of tendering for this work. The community sector is now more developed than in 1996. We must look at the groups that are providing this service to ensure they are bona fide groups.

The Dáil adjourned at 10.40 p.m. until10.30 a.m. on Wednesday, 10 March 2004.

Dáil Éireann debate - Tuesday, 9 Mar 2004