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Dáil Éireann debate -
Tuesday, 10 Feb 2009

Vol. 674 No. 1

Hospital Services: Motion.

I move:

That Dáil Éireann:

noting the conclusions of the Teamwork-Howarth Review of Acute Hospital Services in HSE Mid-West which recommended:

that the current staff complement of three A&E consultants in Limerick must be upgraded to eight in order to allow for a consultant delivered service (which have not been advertised or implemented);

135 additional new acute inpatient beds (which are not in place);

an increase in the number of ambulances (which have not been delivered);

a high dependency unit in Limerick Regional Hospital (for which planning permission has not yet been sought); and

the necessary upgrade of the A&E unit in Limerick Regional Hospital (which has not taken place);

and considering that:

currently between 15 and 30 people are regularly on trolleys for durations in excess of 24 hours in Limerick Regional Hospital;

the putative cost in the original draft of the report was €380 million and apparently only €6 million is available to implement the changes;

local GPs in the area have expressed serious concerns about A&E cover and patient safety if this plan goes ahead; and

the implementation of the HSE Teamwork-Howarth report is unlikely to take place in the current economic climate;

calls on the Government to:

maintain current A&E services at Ennis and Nenagh hospitals; and

proceed with the planned upgrade of Ennis and Nenagh hospitals.

I propose to share time with Deputies Noonan, O'Donnell, Crawford and Connaughton.

Is that agreed? Agreed.

This motion is self-explanatory and much of the rationale behind it is laid out clearly. While all that remains for me to do is to expand on the motion, I will first address the Government rebuttal, which "welcomes the conviction of the Royal College of Surgeons in Ireland that the reforms should continue in the Mid-West and elsewhere". This reference is very selective, however. In reply, the RCSI president stated, "While supporting this programme, this college remains extremely concerned about the provision of services in the major hospitals where accident and emergency departments continue to be overwhelmed on an ongoing basis and where patients who require elective surgical operations cannot be adequately managed within the health service in a timely and predictable manner". Clearly, the accident and emergency unit in Limerick falls into this category.

Furthermore, the Government rebuttal refers to CT scanners which have been present but not operational in Ennis and Nenagh hospitals for well over a year. The rest of the rebuttal welcomes and supports various intentions but does not provide timelines, which is at the core of our problem.

Yet again, the HSE and the Minister for Health and Children, backed up by a Fianna Fáil and Green Party Government, are ignoring their own report, the Howarth-Teamwork report, Review of Acute Hospital Services in HSE Mid-West. The report identified a number of issues that had to be addressed in order to achieve their end goal, which is the reconfiguration of the hospitals, with the centralisation of surgery and acute medical services in Limerick Regional Hospital.

The first area they examined was the accident and emergency department of Limerick Regional Hospital. A number of issues arose out of this. First, they acknowledged the unit needs serious upgrading as it is regularly overcrowded, with as many as 15 to 30 people lying on trolleys for longer than 24 hours and a mean waiting time of somewhere between seven and eight hours for all patients. Into this cocktail, the Minister will add the patients of north Tipperary and Clare, which will result in further chaos and reduction of services, and is grossly unfair on the people of Clare, north Tipperary and Limerick.

Another facet of the accident and emergency unit is the staffing levels, particularly in regard to consultants. Currently, there are three very hard-working consultants in the accident and emergency department but this number does not allow for a consultant-delivered service so it remains a consultant-led service. To achieve the former and to achieve best practice, the report recommends that eight consultants in total be employed in accident and emergency.

Not one of these additional five consultants has been appointed. In fact, only two of the five posts have been approved. Although none of the jobs has been advertised, the word "approved" gives the impression that the posts will be filled imminently but this could not be further from being the case. There first must be approval of a post, then advertisement, the drawing up a panel, the interviewing of applicants and then, ultimately, the making of an appointment. It is then necessary to wait for the successful applicant to become available. The process can take anything up to 18 months.

One of the main reasons for the congestion in accident and emergency in Limerick is lack of capacity within the regional hospital. The Teamwork report recognises this and recommends 135 additional beds prior to the reconfiguration of the service. Not one of these beds is in place. Instead, we are given a sop, with talk of reducing the average bed stay from 6.5 to 3.5 days, which will result in additional capacity. Yet, where is the evidence to support the suggestion this can happen? In order for this to be achieved, practices have to change within the hospital and the community, and there needs to be much greater support for the patient in the community. None of this has happened. I emphasise that none of the recommended 135 beds is in place.

Another area of concern in the Teamwork report is the necessity for further ambulances to service north Tipperary and the Clare region, including Ennis. None of these ambulances is in place. Furthermore, these ambulances are to be supplemented by emergency medical technicians or paramedics who will be able to give certain drugs at the roadside but will not be able to administer life-saving blood transfusions. The paramedic will travel in the ambulance with the patient if there is a serious life-threatening condition but with the current proposed spread of paramedics, there would not be somebody to take up the slack or to drive the paramedic's car from the scene of the accident.

The bottom line for patients in areas like Carrigaholt and Lorrha in Clare and north Tipperary is that they will be well outside the "golden hour" in terms of accessing the necessary life-saving treatment which has been proven in the past to have a major influence on outcome. There is a real need to supplement this until the road system is properly finished. The report referred to a helicopter but I have not heard mention of it since.

Another integral part of this plan is for a high-dependency unit of 40 beds to be built at Limerick Regional Hospital. Again, there is no sign of this. Planning permission has not even been applied for and from talking to the hospital doctors at Limerick Regional Hospital and St. John's, they feel there is a need for at least another 40 beds to which to transfer those patients.

Another area of deep concern relates to the local general practitioners, who were unanimously opposed to this move at a major meeting with the HSE. Not one GP out of 81 at that meeting was prepared to vote in favour of this plan as currently implemented. These are the doctors on the ground, in the community, who know the people and the real, practical difficulties they suffer. They are at one with their community in opposing this, not least because they have been in touch with their colleagues in the north east — in counties Monaghan, Cavan and Louth — where reconfiguration also took place and where a fiasco resulted. I am told this situation resulted in 17 people passing by Monaghan Hospital in an ambulance only to arrive too late at Cavan. To quote one of the participants in the recent "Prime Time" programme, a Clare man, "There is no point in having utopia if it is a corpse that arrives".

We have been accused of scaremongering but the facts are the facts. We have seen the extraordinary situation of Drogheda hospital having to close for seven hours because it just could not cope. We have seen the additional load on accident and emergency units in the region, including Beaumont Hospital, which had up to 50 people on trolleys a few weeks ago. We have heard one of the accident and emergency consultants talk of a 25% improvement when a patient is brought to a centre of excellence for multiple trauma. However, these studies relate in the main to helicopter medevac on the roadside to bring the patient to the centre. First, we do not have the helicopter and, second, will we seriously describe an overcrowded accident and emergency unit at Limerick Regional Hospital as a centre of excellence when it will have to deal with 54,000 more patients per year arriving from Nenagh, Ennis and St. John's hospitals?

This is just another instance of putting the cart before the horse. What really upsets people is that, underlying this, they see a trend — anything that will save money is implemented post haste but anything that will save lives or cost money will be put on the long finger into the distant future. That has been the history of this Government and this Minister.

In the original draft of this report, the cost of implementation was put at €380 million yet we are told there is only approximately €6 million to make it happen. Further, we have been advised by the Minister that the doctors in the hospital have been all bought into this and are enthusiastically supporting it. I have met all of those doctors. The two lead surgeons believe they will get the funding and trust the HSE to deliver but I am afraid nobody else does. Many of their colleagues are becoming increasingly concerned. At the outset, they were concerned by the lack of consultation on the Teamwork report but they are becoming more concerned with each passing day given the way it has been implemented and the ongoing lack of consultation.

Having taken all of the above into consideration, this comes down to an issue of trust of the people of Ireland, in particular the people of the mid-west, in our current Minister, the Government and their much-discredited agency, the HSE. We cannot trust a Minister and a Government which told us in January 2007 there would be no cutbacks, when they knew full well there would be. We cannot trust a Government and Minister which told us cutbacks would not hurt patients, when they clearly did. We cannot trust the Minister or the Government who promised the wonder of a vaccine against cancer for our children in August 2008 and which, three months later, turned their backs on those same children.

The Minister for Health and Children has displayed a pattern of behaviour which is very worrying. My words may seem harsh, but what else can one say when the Minister received letters from concerned doctors in Portlaoise dating back to 2002, and which were re-addressed to her in 2005, yet she did not take any appropriate actions. We saw what occurred as a consequence. There were 11 misdiagnoses of breast cancer. The files of 97 women were thrown into the corner of an office until a cohort was reached. That horrible ethos led to the same situation arising in the north east. In September 2007 the HSE knew a problem existed there and yet took no action until May 2008. It knew it was possible there were people walking around with lung tumours growing. In that instance, letters were written to the Minister complaining about the service, the lack of staff and the over-use of locums. However, nothing was done about it.

An article was published in The Sunday Times last weekend by Mr. Paul Gallagher who, through a freedom of information request, discovered that the consultants in Ennis General Hospital also wrote to the Minister highlighting deficiencies in the radiology service and stating it was not safe. Yet again, nothing was done. We are all familiar with the consequences in that case, which is now the subject of a HIQA inquiry following much public outcry, including comments from the family concerned. The Minister eventually agreed to the inquiry. What is emerging is a recurring pattern that borders on criminal negligence. There appears to be a refusal to listen to professionals in the field who have put their concerns in writing, a refusal to act in any appropriate fashion, and a refusal to address these issues.

Here we are again. Another report is before us, the thrust and principle of which have much merit, including the principle of centralising facilitates and trying to get the best for patients. However, the manner in which it is being implemented has no such merit. Everything this report seeks to do, including to improve safety and to reach goals, is being ignored and put on the long finger. This is not the way to proceed. The report does not have the support of the people or the professionals.

I appeal to the Minister, Deputy Harney, her Government colleagues, the Deputies who support her, especially the Ministers of State, Deputies Máire Hoctor and Tony Killeen, and Deputies Timmy Dooley and Michael Lowry to step up to the plate, to protect the people of the mid-west and to insist that the full recommendations of the report are implemented. Only then should the House consider the future of Nenagh General Hospital and Ennis General Hospital. I commend the motion to the House.

I support the motion and I wish to be associated with the arguments put forward by Deputy Reilly. The people of the mid-west are very fortunate to have such excellent medical practitioners, including consultants, doctors, nurses and paramedical staff. The service they provide is tremendous. I visited Limerick Regional Hospital this morning at 8.30 a.m. Everyone there went about their business, happily working and setting about the tasks of the day. They were able to separate their personal traumas, pension levies and family concerns from their day's work. They were up at work early in the morning and quite cheerful about it. I held a brief conversation with a consultant. He remarked on the uncertainty of the times and that the only remaining certainties concerning this Government were death and taxes, which is as good an epithet as one is likely to hear. I compliment the staff who provide a great service in the hospital in Limerick. Even if they are reconfigured, they will continue to do so.

It is very easy to agree with the objectives of this report. Who would disagree with a report which is supposed to deliver on improved patient safety? Who would disagree with maximising clinical outputs, a programme to deliver better value for money, or an objective which purports to provide a high-quality service close to all patients' homes? It is not the objectives of this report with which one would disagree but its implementation, measured against the past experience of the Minister and the Department of Health and Children.

The modus operandi does not meet the needs of the region. It is planned to centralise emergency services at the Mid-Western Regional Hospital in Limerick and to transfer to there all trauma cases from Ennis General Hospital, Nenagh General Hospital and St. John’s Hospital. It is planned to turn these hospitals into minor ailment facilities operating from 8 a.m. to 8 p.m. The theory and practice very quickly go their separate ways. They do so because the facilities are not in place in Limerick regional hospital to take the existing workload and certainly the facilities are not in place to take the workload which would arise from the transfer of cases from Ennis, Nenagh and St. John’s hospitals.

The Minister promised that the necessary facilities would be put in place. However, nobody believes the Minister and with good reason. The Minister has previously made promises on innumerable occasions concerning different aspects of the health service and its delivery throughout the country. However, the promises have not been fulfilled. Deputy Seymour Crawford will again illustrate the difficulties in the north east and Cavan-Monaghan. We will hear of the litany of pathetic cases, whereby some people we obliged to drive past Monaghan General Hospital to access the services required, but did not arrive on time. That is the experience of people in the regions when it comes to the integration of services. It is not a very attractive blueprint for the people of the mid-west who can see what occurred in the north east.

In these times of devastating cutbacks, when the pay and conditions of people in the public service are being trashed and when the fiscal situation continues to deteriorate, does anyone believe the Minister will produce €300 million to put the necessary programme in place to facilitate the new workload at Limerick regional hospital? It is not long ago since, for the sake €8 million, that the Minister reneged on a promise to vaccinate 12 year old girls, so that their lives would be saved at the age of 75 to 80. The Minister could not deliver on a promise of €8 million. Does anyone believe it is credible that she will now deliver on a promise to the people of the mid-west, to the people of Ennis and Nenagh, and to the many people in downtown Limerick who use the facilities at St. John's? Does anyone believe the Minister will deliver?

The only relevant figure in the Estimates for 2009 for this programme is a figure of approximately €6 million, but €300 million is required. I do not understand how this is supposed to add up, which is the problem we face. The report lists the necessary services, including an emergency operating theatre in Dooradoyle, of which there is no sign, the extension of the ambulance service and the deployment of advanced paramedics in the region. According to the report this service is under way. If the ambulances have been ordered, they certainly have not yet been delivered. The human resources situation involving ambulance drivers is not yet resolved. They have not even applied for planning permission for a new critical care block in Dooradoyle with ICU, HTU and CCU, although this is an essential component of the reconfiguration. New facilities in Ennis and Nenagh, a new theatre block in Nenagh, expansion of radiology services in Ennis, Nenagh and St. John's, upgrade facilities in Nenagh — these are dreams over the silvermines. This is not reality. Nobody believes the Minister will deliver them. That is the problem she faces with this programme.

In debating this issue over the past few weeks, Deputy Reilly has put forward a simple but profound proposition, that the Minister put the new facilities in place before closing the old ones. If she does that, people will vote with their feet and buy into them straightaway because the facilities outlined here would enhance patient safety and give better clinical outputs.

Various case assessments have been made, and an assessment of outputs of patients who went through accident and emergency services in Nenagh and Ennis. In some cases the outcomes could have been better but there is no guarantee that the outcomes will improve by taking the patients into Limerick in an ambulance, to lie in the accident and emergency unit for five or six hours before receiving attention.

There is a sting in the tail of this report because we have highlighted accident and emergency services but, on the first page of the statement I received, the HSE states accident and emergency surgery and critical care services need to be reconfigured as soon as possible, followed by medicine in the longer term. If one has the patience to read to the end of the report, one can see many plans for the reconfiguration of medical facilities which turn Ennis and Nenagh into medical outposts.

I support the motion proposed by our health spokesman, Deputy Reilly. The cart is being put before the horse. The Minister is introducing changes to accident and emergency services on 1 April and to surgical services on 1 July, although the approved services are not available in Limerick Regional Hospital.

St. John's Hospital is in my constituency, in the heart of the city. It is the only accident and emergency service based in the city. Barrington's was the main provider of accident and emergency services in Limerick until a Fianna Fáil Government closed it in 1988. St. John's took on that role and has done a terrific job. The report mentions that the service in St. John's, along with those in Nenagh and Ennis, will be nurse-led. I welcome the commitment by Mr. Paul Burke, who is co-ordinating the reorganisation of the acute service in the mid-west, that it will continue to be doctor-led. That is critical for St. John's. I hope the Minister will give that commitment in writing to Mr. Burke. There are three doctors in the accident and emergency unit in St. John's, four nurses and two administrators. I am worried that if the service is doctor-led, the medical skills will be lacking to assess a patient with an acute difficulty.

The Teamwork-Howarth report mentions increasing the throughput of patients in the accident and emergency unit of St. John's hospital from 19,000 to 30,000 annually. St. John's is open five days a week from 8 a.m. to 8 p.m. Does the Minister propose to make that a seven-day a week service? She proposes sending patients directly to the accident and emergency services in Limerick Regional, where the service is already overstretched. The average waiting time for a patient in the accident and emergency unit in Limerick Regional is seven to eight hours. I cannot understand how bringing in extra patients will improve the quality of care. That is why it is critical that the accident and emergency services are maintained in Ennis, Nenagh and St. John's and that the hospitals are upgraded.

According to the original Teamwork-Howarth report, €47 million would be spent in St. John's. That reference has disappeared from the published version of the report. Will that €47 million investment be honoured? The hospital needs new buildings and upgrading. Will the Minister provide the staffing resources to activate the much-needed CT scanner that has sat idle in the hospital for the past two years? The ground floor of St. John's has been closed for a long time. It was traditionally closed for the summer months for budgetary reasons but it has remained closed for a longer period. Does the Minister propose to provide funding to open it?

There are excellent medical and consultant staff in St. John's and Limerick Regional and in the hospitals in Nenagh and Ennis. St. John's and Limerick Regional interact in respect of consultants and appointments. I would not like to see the elective surgical work that can be carried out in St. John's moved automatically to Limerick Regional. That would worry medical staff and needs to be clarified.

Staff in St. John's say they were not properly consulted in the preparation of the Teamwork-Howarth report. The consultants visited them for a few hours. These people are at the coalface and should have been consulted. Furthermore, they were not consulted before the report was published. We met many of these people during Deputy Reilly's recent visit to St. John's and Limerick Regional. It is critical that the HSE engage in meaningful discussions with the staff and management of St. John's. We want to retain a functioning service and accident and emergency unit.

Will the Minister say whether she will give a commitment in writing to providing a doctor-led accident and emergency service in St. John's? Will she say whether in increasing the throughput of patients from 19,000 to 30,000 patients, the service will increase from five to seven days? Will she say whether she is providing the resources to operate the CT scanner in St. John's? Will she put resources in place to enable the ground floor in St. John's to be opened? Will she put in place the €47 million proposed in the original report for St. John's? Will she set a timescale for the provision of the extra facilities, staff and resources in Limerick Regional, for example, that the number of accident and emergency consultants increase to eight, the addition of 135 new acute beds, the increase in the number of ambulances, the high dependency unit and the upgrade of the accident and emergency unit in Limerick regional? I also call on her to ensure that the accident and emergency departments in St. John's Hospital, Nenagh General Hospital and Ennis General Hospital are left as they are, and that nothing happens until the services in the Mid-Western Regional Hospital in Limerick are upgraded.

I thank Deputy Reilly for tabling this motion. I feel very different tonight because I have a number of colleagues around me. So often in the past few years, I was a lone voice when I spoke about this issue in regard to Monaghan General Hospital. As Deputy Noonan and Deputy Reilly pointed out, we in the Cavan-Monaghan region have come through much of this. Seventeen people may not have died if Monaghan General Hospital had not been off call at the time of those deaths. Unfortunately, we are soon heading back to that kind of situation. When 41 doctors advise that they are worried about this, yet we are told at the same time that everything is fine, then one wonders where are the structures that allow for discussions to take place.

One of my colleagues on the Government side asked the Minister of the day why there was such an undue haste about the issue. Another of my colleagues on the Government side, Deputy O'Hanlon, clearly stated that what is left in Monaghan General Hospital is safe. Unfortunately, that does not seem to be the case now. What is often promised is not delivered, and even though we have been told over the past few months that things would be ready in a matter of weeks, they are still not ready or tested.

I remember when the maternity unit was taken out of Monaghan. I did not object to it at the time, because I could understand the rationale behind it. We would be catered for in Cavan and in Our Lady of Lourdes Hospital, which is supposed to be the specialist maternity hospital for the region. Yet the Neary issue has caused tremendous trouble to many people. As some people were on the wrong side of a particular date, they still have not been compensated. In more recent times, the wife of a good friend of mine lost her life, as did her child. The reason given for their deaths was pressure on the system. The people involved could not deal with what was happening.

I ask the Minister to take all these things into account. The issue is about saving money. One cannot think that this is about saving money or lives when we look at the history of Monaghan. I do not know where the money being saved is going. Close to €6 million was spent on two wards in Monaghan, and these will now be completely restructured. A CT scanner and beds are lying in storage outside Monaghan town, for which rent is being paid. There is no effort to save money or otherwise. I was in Monaghan General Hospital late last night visiting a friend, and I noticed that staff are in a quandary as they do not know what the future holds. I was in Cavan a week ago, and I could see how difficult the situation has become. Our experience is that Cavan and Monaghan can no longer cope. I warn my colleagues that the same situation will occur in Nenagh and Ennis.

Let nobody be in any doubt that this is a Fianna Fáil Government supported policy. The Minister of State, Deputy Moloney, on behalf of the Minister for Health and Children, made it clear in his speech that it is Government policy to repeat what it is doing in Monaghan in both Ennis and Nenagh.

I support Deputy Reilly on this issue. I am not from the region concerned, but I am close to it. Why does the Minister think that the people in Ennis and Nenagh are scared at the moment? Why does she think that ordinary law-abiding people will come out in their thousands in opposition to this? These people also believe in centres of excellence, as any right-thinking person would do. However, they genuinely believe from experience that something will happen in the regional hospital in Limerick, and nothing will happen in Nenagh and Ennis.

There is a similar proposal for University College Hospital Galway and the west. How would the Minister expect the people of Tuam to react to guarantees given by her Government over ten years that the community hospital in Tuam would be built? As far as I can see, things are getting worse, yet this hospital was supposed to complement UCHG. Certain things would be done there that could be carried out within 20 miles of the hospital, so that people would not have to be brought in by ambulance.

The Teamwork report could not have been more clear when it stated that no acute service will be withdrawn from the current general hospitals until the regional centre of excellence is resourced. The Minister has been a good few years in her current job, for which she is well paid. While the goal of creating centres of excellence is shared by everybody, I cannot understand her methods of bringing people towards that goal. Is she gone to the stage where she feels she must act like a dictator? Does she feel that whether the people come with her or not, she is right all the time and that this will have to happen? People have to be made understand that this is being done in their best interests, but if the people of Nenagh, Ennis or west Clare are asked whether this is the case, they will say that it could not be further from the truth. They believe that there will be a downgrading in their areas, and there will be no way back when it happens.

Even though the Minister has broken many promises, she should at least ensure that she does things locally. I guarantee her that if this happens in Nenagh, Ennis and elsewhere, she will have little trouble with the centres of excellence. We were talking with the president of the IMO last week on the health committee, and about the importance of primary medicine at a local level. He threw his hands up in the air and told us that we are making very little progress. How can the Minister expect people to believe that the likes of the Mid-Western Hospital in Limerick will not become a dumping ground for all these cases, and that they will not be able to control it?

I would like to share time with Deputies Dooley and Collins.

Is that agreed? Agreed.

I am sure Deputy Dooley will be here.

I move amendment No. 1:

To delete all words after "Dáil Éireann" and substitute the following:

"—strongly endorses the Government's commitment to patient safety, quality and fairness as the priorities in the delivery of health services throughout the country;

supports the Government's view that fairness to patients throughout the country requires that all patients should have access to the appropriate care in the appropriate place at the appropriate time, provided by the appropriate person;

recognises that the plan to reorganise hospital services in the Mid-West is evidence-led and in accordance with the principles of patient safety, quality assurance and fairness;

notes and welcomes the conviction of the Royal College of Surgeons in Ireland that the reforms should continue in the Mid-West and elsewhere;

welcomes the clinical leadership in the Mid-West region in the project to deliver better services to patients;

urges everyone in the health service and public representatives in the region to work together to put patient care first above all other interests;

welcomes the HSE's commitment that Ennis, Nenagh and St. John's Hospitals will deliver additional day surgery and diagnostic services, including CT scanning and that many patients from Clare and North Tipperary who currently have to travel to Limerick will now be able to access these services in their local hospitals;

welcomes the additional specialist services such as dermatology, neurology and rheumatology which will be available in Ennis and Nenagh Hospitals;

supports the HSE's plans to appoint eight additional hospital consultants to enable the delivery of these new services and specialties at Ennis and Nenagh Hospitals;

welcomes the HSE's intention to enhance the ambulance service in the Mid-West through the deployment of twelve advanced paramedics and increased out-of-hours ambulance cover;

supports the HSE's intention to develop a regional critical care service involving the provision of a dedicated new critical care block which will have a total of 40 specialist intensive care, high dependency and coronary care beds and a new emergency theatre;

recognises the necessity to make capital investment in all four hospitals in the region to support the reconfiguration plans; and

welcomes the significantly reduced reliance on locum positions to provide services and their replacement with full-time consultant staff for the region which will result from the reconfiguration programme."

I would like to begin by asking the Leas-Cheann Comhairle to clarify something. In his contribution, Deputy Reilly referred to the issue of me being accused of criminal negligence. I ask Deputy Reilly to reflect on that. I ask the Leas-Cheann Comhairle for his co-operation in that regard. I can take political accusations, but I am not going to accept that.

Will Deputy Reilly reflect on it?

The Official Report will show that I said it "borders on criminal negligence".

The Minister of State is some man to talk about weasel words.

He knows all about weasel words.

If Deputy Reilly is not man enough to withdraw what he said, that reflects more on him than it does on me.

In his contribution, Deputy Crawford accused me of acting with "undue haste". It is worth quoting something that was said in this House more than 30 years ago, after the publication of the FitzGerald report, which recommended the kind of approach that is now being adopted. The then Minister for Health, Brendan Corish, said that there could be "no more delays or equivocation" as it was not "medically feasible" to continue to do what the State was doing. Almost 40 years on, we are still having the same debate.

The Minister has a good researcher.

The reorganisation of our hospital services around patient safety has always been put on the political conveyer belt. In his contribution, Deputy Reilly invited the Ministers of State, Deputies Hoctor and Killeen, as well as Deputies Dooley and Lowry — I do not think Deputy Collins was mentioned — to put their people before their party, or words to that effect.

There was a time when the Minister was good at doing the same thing.

I will deal with the issues raised by Deputy Connaughton.

The Deputies in question were elected by the people of the mid-west.

The only issue at stake during the reorganisation of services in the mid-west is patient safety, rather than money.

The same thing applies in Monaghan.

That is the dynamic that is driving reform. That is why the surgeons in the mid-west region support this reform. We are being asked to keep open the accident and emergency departments in Nenagh and Ennis even though there is no emergency consultant in either hospital.

That is the Minister's fault.

The accident and emergency unit in Nenagh deals with an average of six or seven patients each night and the equivalent unit in Ennis deals with an average of nine patients each night. Can Deputy Reilly, as a doctor, stand over that? The units are not staffed by doctors who are trained in emergency medicine. The staff of the units do not even report to emergency consultants, surgeon consultants or physician consultants.

Is the Minister casting aspersions on doctors in Nenagh?

I am simply saying they do not have specialist training.

The Deputies on the Opposition benches were allowed to make a substantial case without interruption. I ask them to allow the Minister to make her contribution in similar fashion.

She should apologise to the doctors in Nenagh.

The Leas-Cheann Comhairle should ask her to be relevant.

I did not devise this reform in my Department with my officials, or in conjunction with the HSE. This reform is being driven by medical evidence of what is in the best interests of delivering good outcomes for patients.

I remind Deputy Reilly, who may wish to challenge that assertion, that I can quote from many reports, including a World Health Organisation report, in support of it. When Deputy Reilly and I participated in a discussion on RTE the other night, we watched a film clip in which Dr. O'Donnell spoke about an increase of 25% in mortality rates. The World Health Organisation has estimated that the increase might be as high as 50%. Is there any Member of this House who would not bring his or her sick daughter, son, mother, father, brother or sister to the hospital that offered that person the best chance of recovery?

I agree, but the problem is getting to that hospital.

I do not believe there is a single Deputy in this House who would not take his or her loved one to such a hospital.

We used to have such a hospital in north Tipperary.

As Minister for Health and Children, I am part of a Government that has a responsibility——

Would the Minister like to have to bring such a person 80 miles?

I listened to the Deputy.

I ask Deputies to allow the Minister to make her contribution.

We have a responsibility to make sure we do not continue with a status quo that does not give patients a chance to enjoy the best possible outcomes, particularly in respect of surgical procedures. By international standards, we have enough people with specialist knowledge in anaesthetics and surgery to deliver emergency surgery in the mid-west region. There are more than 400 hospital doctors and more than 1,400 nurses in the region. We cannot deliver the best service there if it is fragmented across four hospitals. Just 28 surgical procedures took place at Ennis General Hospital during the night over a six-month period. The relevant figure in Nenagh General Hospital was 12 and in St. John’s Hospital was 21. Between the three hospitals, there were 60 surgical procedures during the night over the six months in question. We all know that doctors’ skills cannot be maintained, and good patient outcomes cannot be delivered, if there is low-volume activity in high-volume specialties. I do not say that merely on the basis of evidence from Ireland. What we are seeking to do in Ireland is being put into practice in virtually every country in the world that I have examined. I have spoken to my ministerial colleagues across Europe, who took these steps many years ago. It has also been done in Northern Ireland.

They put in the services first.

We are simply trying to give patients in the mid-west the best chance to enjoy good outcomes when they need to avail of surgery or emergency medicine.

The Minister should first put in place the services.

Notwithstanding Deputy O'Donnell's contribution, I note that the Fine Gael motion does not mention keeping emergency services in St. John's Hospital, or extending them to seven days. I understand that the HSE is in discussions with the hospital authorities on that matter.

That is good to hear.

That was not referred to in the motion. Deputy Reilly mentioned the reference to 135 beds in the Teamwork-Howarth report. The report said that 135 beds would be needed if the specialist orthopaedic hospital in Croom and the stand-alone maternity hospital were to be closed, and we were not to have elective procedures in Ennis and Nenagh. As we are not doing those things, we do not need 135 beds. We will have elective procedures in Nenagh and Ennis, to where the doctors and surgeons will travel.

It will be day surgery only.

That was not envisaged in the Teamwork-Howarth report. We are not closing the stand-alone maternity hospital or the orthopaedic hospital in Croom. That is why the issue of the 135 beds does not arise. In the context of a debate on a matter as important as this — it was chosen as the subject of Fine Gael's Private Members' time — we should deal with the facts that are before us.

The issue of consultant manpower in the region was also raised. We are currently recruiting two radiologists and one pathologist, with a specialty in cancer, for the cancer programme in Limerick Regional Hospital. We will recruit two more emergency consultants, thereby increasing to five the number of such consultants. They will all work together. We will have three new radiologists, three pathologists, a dermatologist, a neurologist and rheumatologist. I want to talk about them because they are new to the region. They will provide services in Ennis for the patients of County Clare and in Nenagh for the patients of north Tipperary. At the moment, 700 patients per year come from County Tipperary to Limerick for diagnostic procedures, including CT scanning. A further 1,000 patients come from Ennis for such procedures. From the summer of this year, those procedures will be performed in the local hospitals in Ennis and Nenagh.

We were told that last year as well.

I assure the Deputy that the staffing implications are being dealt with. I think everybody will acknowledge that this reform is being headed by a clinician, Mr. Burke, who is well respected in the region. He is enthusiastic about the reform and is seeking to engage with his consultant colleagues and others in the region.

Have they got the money to do it?

Yes, he will have money to do it. I will deal with that in a moment. Even if no money were available in the morning, it would not be possible to maintain what we have in the region.

That is what they are afraid of.

The Minister has admitted that cuts will be made.

On Thursday of this week, we will outline the Government's response to the report of the patient safety commission. The commission, which was chaired by Dr. Madden, included patient safety advocates and experts from Ireland and overseas. The commission's report has been published, and Deputies are aware that it recommends the establishment of a system of accreditation or licensing in our acute hospitals. It will take us some time to draft that legislation. Even if the legislation could be implemented in the morning, many of the acute hospital services we provide could not be licensed or implemented as they do not live up to the requisite patient safety standards. That is a fact in Ireland and globally. We have to prepare for the challenge of putting a licensing and accreditation system at the heart of our acute hospital service, so that it is fundamentally organised on the basis of patient safety and good outcomes. When we took similar steps in our cancer service, that was opposed too. I am delighted to say that the reorganisation of breast services is ahead of schedule and will be completed by April of this year. There is almost unanimous buy-in, although not total buy-in. People who were initially sceptical and concerned, as we often are when change takes place, have become enthusiastic fans of what we are doing in the cancer area. They know it will improve outcomes for patients.

The numbers seeking the service in Galway is such that the system is bursting at the seams, while the service has not even arrived in Sligo.

I will deal now with capacity issues. Reference was made to the capacity of the accident and emergency department in Limerick Regional Hospital. On approximately two or three occasions last year patients had to wait more than six hours in that department. That is a fact. As Deputy Reilly knows, patients are treated on trolleys all the time; sometimes the only treatment provided to a patient is while he or she is on a trolley. That is the case not only in hospitals in Ireland but in hospitals throughout the world. The fact that at any one time a given number of people are on a trolley does not prove any point the Deputy Reilly is trying to make.

The Minister should tell us about the pleasant experience they have on them.

The performance of the accident and emergency department in Limerick Regional Hospital is better than most. The hospital is challenged to provide services and that is the reason a unit with 40 critical care beds for high dependency patients will be provided.

No planning permission has been sought for it yet.

I am aware of that.

When will that unit be provided?

Planning permission will be sought shortly.

The answer is always shortly.

Will it be in place before 1 April?

No, of course the unit will not be in place before 1 April. The Deputy knows that.

I know that but I am——

Equally, you must know——

The Minister should address her remarks through the Chair.

Through the Chair, the Deputy must know what is happening here is urgent.

On reading one of this morning's newspapers — I believe it was the Irish Independent — I note Deputy Reilly was quoted as saying that the salaries being paid by way of overtime earnings to non-consultant hospital doctors in the mid-west is outrageous. The reason it is outrageous, to use his phraseology, is because of the way we organise services. We have people on call in four hospitals in that region at night to deal with a very low level of activity in three of those hospitals. Not only does it not make sense from a financial point of view, it does not deliver high patient safety outcomes for the patients who visit these hospitals. This has nothing to do with the doctors or the staff, it has to do with the manner in which——-

Would the Minister care to cite the rest of the quote?

——we have sought to organise services.

Deputy Reilly talked about the letters I get from doctors. I get letters advising me that this and that is outrageous and asking if they could only have a little bit more here and there. That is what we have done for the past 12 to 14 years. We have multiplied nearly fivefold the amount of money going into our acute hospital services.

Senior consultants have expressed concern, not outrage.

Given the failure to reorganise how and where we do things, we are not getting the outcomes or the value for money service we deserve.

We will not get it by putting the cart before the horse.

The most important thing for patients is to be treated in the right place at the right time by the right people.

That is a fact. If somebody is involved in a road accident, the place that person should be stabilised is on the roadside. That is the international evidence. We have trained up to 12 paramedics, six for each county. We have already procured two specialist vehicles, which Deputy Reilly does not acknowledge, one for each county.

In Tipperary at night there is one call out. We have 12 paramedics in training, we have recruited 12 additional ambulance crew and I accept there are industrial relations issues. International evidence suggests that the best place to stabilise a traffic accident patient is on the roadside. The golden hour or two hour rule in terms of receiving treatment is not about getting to a place called a hospital. An unfortunate accident occurred in Deputy Connaughton's area last night and, tragically, one person died at the scene and the other person died in hospital. Half of all the people who die everyday in Ireland die in hospital. It is not a question of just going to a hospital, it is about getting the people in a specialist centre as quickly as possible.

The people involved in the accident to which the Minister refers were brought to the hospital in Ballinasloe.

In regard to trauma cases, protocols are already in place in Ennis and Nenagh general hospitals to take those patients to Limerick Regional Hospital. That is the current arrangement. Those patients are supposed to be taken to Limerick and are not supposed to be taken to either Nenagh or Ennis.

Hospital services and the re-organisation of them have always been a challenge for us in this country. If we were starting to put in place a hospital infrastructure today, we would never build 35 acute hospitals around the country. We know that trying to get specialists, not only domestically but internationally, is a challenge. Those specialists work in a an extraordinary fragmented fashion. We have 4,800 junior hospital doctors and 2,100 consultants, therefore, we have many doctors working in hospitals. Many of them deal with very low numbers of patients. To allocate more staff to a system that is not properly organised around patient safety in order to deliver good outcomes would not make any sense, no matter who writes the letters.

I met a group of people from Ennis. The HIQA report will be published soon and we will see what it has to say about how we organise services. We live in an environment where we have a new organisation independent of the provider of services, funded by the taxpayer to set and monitor standards and to carry out inquires where it is considered there is a risk to the patient's care or welfare. That is what that organisation has been doing. For the first time in the past few years, we have had inquiries into wrongdoings, which have been very revealing. We can either bury those reports or pretend more of the same will get us over the findings of a report or we can change things. That is what we are seeking to do.

The president of the Royal College of Surgeons in Ireland was clear when he said we want critically ill surgical patients to be brought to centres that are appropriately equipped and staffed where there is a sufficient volume of this kind of activity to sustain the necessary levels of skills. He went on to say, it is precisely at these times that changes can be made with sensible costings rather than the over-exuberant plans and unrealistic budgeting that is sometimes mentioned. He clearly indicated, contrary to Deputy Reilly's speech, that, as president of the Royal College of Surgeons in Ireland, the training body for surgeons in Ireland, the reforms in the mid-west are appropriate as far as he is concerned.

Patient safety is not only about organising services differently in our hospitals, it also involves how we regulate professions working in the health care area. We recently modernised how we regulate medical practitioners. We have a lay majority in that respect. We have a different procedure as far as fitness to practice is concerned where hearings can be held in public other than on an exceptional basis, where doctors are mandated by law to maintain their competence. Many of those provisions, particularly the lay majority one, was opposed by the Opposition.

The same position applies to the Pharmaceutical Society of Ireland where there is also a lay majority. For the first time in more than 100 years we have an appropriate regime in regard to the regulation of the pharmacy profession. Shortly we will have a new nurses Bill, subsequently a dentists Bill and so on.

Patient safety is about the organisation of services, but it also about the regulation of the professions. In particular, it is about ensuring that those who work in medicine maintain their skill base. We know in our heart — Deputy Reilly, as a doctor, in particular, knows this — that one cannot maintain one's skill in an accident and emergency department, particularly if one is not a consultant with specialty training, and certainly if one is only dealing with six, eight or nine patients a night. Nobody can maintain or even acquire a skill in that kind of environment. We must learn from the evidence and be courageous enough to act on it. The Government knows this and that is why it is so enthusiastic for the reform. It also knows reform will be difficult and many people will be worried. The reason they will be worried is that politicians are telling them that they are going to die.

That also happened in the case of the hospital in Portlaoise many years ago.

They would know of the Minister's broken promises. They have seen what has happened in the north east.

Relations of politicians have also told them they are going to die.

Allow the Minister to conclude.

I accept that GPs will be challenged because if there is no accident and emergency out of hours service, there will be some extra work.

Does the Minister believe they only act in their own self interest as well?

No, in the case of Ennis——

It is a case of everybody being wrong, except the Minister.

——there will be——

(Interruptions).

——and the HSE is in discussion with the GPs.

What about services in Nenagh General hospital?

(Interruptions).

I can understand a GP being concerned if the accident and emergency department in a hospital is to close. Of course, they would be concerned. We all have our own concerns. Discussions are taking place with the general practitioners.

In regard to senior medics, particularly the surgeons working in the mid-west, I do not know to whom Deputy Noonan spoke this morning. He seemed to have a Fine Gael perspective on the world. No Government has reduced tax more, as that consultant should know, than the parties that have been in Government for the past 12 years. Therefore, I do not understand why he thought we did not reduce tax. However, Deputy Noonan presumably has his own friends who talk about death and taxes, but I have spoken to many consultants not only in the mid-west but throughout the country and I know that many people working in medicine in Ireland are enthusiastic about the reform——

What about the resources?

That is the problem.

——-and want to us see us , the elected us representatives, having the courage to see it through.

Hear, hear. Well done, Minister.

I welcome this opportunity to discuss the issue of reconfiguration of medical services in the mid-west region. Health is an emotive issue and the advent of change generates fear and uncertainty in the minds of the public at large. While that fear may be well-founded in some cases, the efforts by some vested interests to mislead and misguide is unfortunate and unnecessary.

The current position on the delivery of health services in the mid-west, and Clare in particular, is unacceptable. Patients are confronted with unnecessary risk on a daily basis. A number of cases have been highlighted in the media which have created a bad impression of Ennis. That has been difficult for those people and their families and the outcome was not acceptable. Notwithstanding that, it is my understanding that similar cases happen throughout the smaller hospital network and there is a requirement to address that.

According to Dr. Cathal O'Donnell, an accident and emergency consultant in the region, the chance of a better outcome for the patient can be increased by up to 25%, based on existing case data. He has staked his reputation on this claim. He has also stated on record that mortality rates in the region will reduce as this reconfiguration is implemented.

The Minister already quoted Professor Frank Keane, president of the Royal College of Surgeons in Ireland. In a letter to The Irish Times in January this year, he stated:

I would like to reaffirm that the Royal College of Surgeons in Ireland is convinced that the reform should continue in the mid-west and elsewhere where these changes are necessary and, in many cases, long overdue. The Royal College of Surgeons in Ireland's motive is first and foremost to achieve better and safer patient care. We want critically ill surgical patients to be brought to the centres that are appropriately equipped and staffed and where there is sufficient volume of this kind of activity to sustain the necessary levels of skills to manage these patients. Timing is often an issue and therefore patient transfer from hospital to hospital should be kept to a minimum.

That complies with international best practice which seems to suggest, as the Minister stated, that stabilisation should take place at the earliest possible time in the case of a road traffic accident on the roadside and, in the case of another trauma, at the particular site of that event.

These are just two of the many clinicians who have called for, and who support, the proposals contained in the programme of service delivery reconfiguration in the region.

As a public representative with no medical training, other than being the son of a well-qualified but retired nurse, it is incumbent on me to listen and heed the advice of such eminent medics. Regardless of my hunches or any desire to be politically expedient, I cannot, in good conscience, ignore the advice of these professionals who have taken an oath which places upon them a burden to protect their patients. Patient safety, reduced mortality and better outcomes are the cornerstones of this reconfiguration.

Tell that to the people in County Clare.

I tell them and I have no problem with that. I am prepared to put the facts before the people and to accept the advice of the senior clinicians in the region. There are other people running around this country who are not prepared to back up what they say with any level of evidence other than "dúirt bean liom go ndúirt bean léi". That does not work for me and it does not work for the patients in County Clare. I will be surprised if it works for the patients in the Dingle Peninsula whom the Deputy represents.

Carry that out to County Clare.

What about Deputy Dooley's pre-election commitment?

It is incumbent on all of us to ensure these changes are made without delay.

(Interruptions).

Allow the Deputy speak.

If these changes are to be successful, they should, and must, be supported by investment in the supporting infrastructure and in bed capacity, upgraded facilities and improved and enhanced ambulance cover. I appeal to the Minister and her Department——

Do not do it, Tadhg.

—— to lead this change through investment. The geographical spread of County Clare, as I am sure Deputy Carey will agree when he speaks later, will require extra ambulances and extra ambulance personal. It will require advanced paramedics. There are particular geographical matters between east and west Clare. East Clare currently has a period from 7 p.m. to 12 a.m. without ambulance cover and we must address that. We must address the issue of west Clare. I know the Minister has frequented Loop Head and she will know it is 80 miles from Limerick. The fact that ambulances will be out of the county for longer periods of time requires that investment.

That is the golden hour. One cannot get from Loop Head to Limerick in an hour.

The proposed changes in emergency department cover from 8 p.m. to 8 a.m. at Ennis Hospital need further clarification and consideration. Engagement with Shannon Doc services is necessary to provide the people of County Clare with access to appropriate services on the hospital site. I believe there is need for an extra eight consultants and 12 advanced paramedics and also for that critical care block required at Limerick Regional Hospital. Capital investment in Ennis is long overdue. Unfortunately, it has not been advanced as quickly as all of us would have liked.

We cannot put the cart before the horse. I know the Minister is committed to ensuring that support is put in place to allow the reconfiguration to proceed without delay in order that patients in the mid west are given the best possible chance for a positive outcome. Collectively, we can all reduce unnecessary deaths.

We must remember the context of any debate in this House in respect of the health service. All parties, with the exception of Sinn Féin, from the 1960s to the 1990s——

That is a cheap shot when no member of the party is present.

——contributed to the demise of the health services. If we are honest we must ask what was the result. We had deficits in funding, infrastructure, human resources and strategy. Everything has had to play catch-up in the past 12 to 15 years. We must acknowledge the levels of funding now available. We have invested in our infrastructures. Hospitals are being built and improved. Our human resources are being improved. We are engaging more consultants, doctors and nurses, all frontline staff of the kind that everybody wants to see. We have a redundancy programme coming down the line for the administration staff that everybody has a problem with, whom people seem to want to lose.

Let us keep this in context. I welcome the recent coverage and debate we have had in respect of reconfiguration in the mid west. It was refreshing to see an input from independent people who work on the frontline. That was the first time in a long while that we have not had the entire debate crowded by politicians, including all of us in this House, thereby letting it descend into a political slagging match.

These are the frontline people who are charged with the delivery of the service and they have staked their reputations on that. Let us listen to them because they are qualified, independent and they know their work. I am certainly happy to buy into what they say. I mention, in particular, Paul Burke and Cathal O'Donnell.

I can understand the concern expressed by people in counties Clare and Tipperary. However, there is a change. For the people in those counties to whom I speak — in my party we do not confine ourselves merely to our own constituencies — in Tipperary, Nenagh and Ennis——

We will allow the Deputy pass through.

—— there will be additional specialist services such as dermatology, neurology and rheumatology. There are plans to appoint eight——

The Deputy can get his corns and bunions done there.

——additional hospital consultants. It is equally important to point out that Cathal O'Donnell and Paul Burke have a shared responsibility for the region, not only for the accident and emergency department in my local hospital, namely, the regional hospital.

For Limerick Regional Hospital and its accident and emergency department, I welcome the fact that this initiative will deliver a new emergency operating theatre, an expanded ambulance service and a critical care block that will bring in up to 40 beds when it is built. I am sure this will be delivered.

Deputies

When?

It will be built but the Deputies do not wish to move forward at all. They just want to look backwards.

There is not even car space there, for God's sake.

We will move it forward.

(Interruptions).

Allow Deputy Collins to make his contribution.

There will be an intensive care unit with an enhanced service and there will be a high dependency unit.

With regard to the roll out of this plan it is also important to remember——

It is a hospital.

—— that the primary care centre——

(Interruptions).

Allow Deputy Collins make his contribution.

I thank the Leas-Cheann Comhairle.

Let him at it.

The roll-out of primary care centre infrastructure is at an advanced stage in my constituency. I am glad to know this, as most people would be, with regard to their constituencies. To name a few, places such as Croom, Ballylanders, Caherconlish, and Cappaghmore that Deputy O'Donnell knows very well, are at a very advanced stage. The roll out of BreastCheck is also well received within the constituency.

That is what I worked hard for.

Deputy O'Sullivan mentioned general practitioners. This is not a criticism but I would like to see more investment in GP training and more places for GP trainees in the mid west. We have had a number of female GPs who, due to life responsibilities and family circumstances, cannot work on a full-time basis and we need more training places.

Any debate about the HSE showers that agency with negativity, which reflects on its staff. For my part, I wish to thank the staff of the HSE in the mid west for their service and dedication, for their professionalism and for the approach they take to their jobs on an everyday basis in difficult circumstances. I do not think it is fair there should be negative reflection on them.

The Fine Gael motion, as tabled, states that "regularly" 15 to 30 people are on trolleys. That is a very liberal use of the word "regularly". I was in the accident and emergency department a couple of days ago and did not see anybody on trolleys. I was in the hospital a week ago and did not see anybody on trolleys. I had occasion, as I told Deputy Reilly outside the House——

The Deputy is in the VHI. He went in a different door.

I had occasion to visit the accident and emergency department during the Christmas period.

That is why. He went in a different door.

I shall tell Deputy Sheahan which door I used. I went in the door that led to the accident and emergency department and presented myself. There were 15 people ahead of me and I was No. 16. They were all seen within 25 minutes, I was seen within half an hour and nobody was on a trolley. I do not know how regular, or how liberal, is the use of that word "regular" but I believe it is abused.

That is a unique story.

With the permission of the House, I wish to share time with Deputies Caoimhghín Ó Caoláin and Seán Sherlock. The problem with this matter is one of trust. The Minister put forward a fine, spirited argument in this House about why what she was doing was what she felt to be right, but the whole system is predicated on services being in place in the Mid-Western Regional Hospital and in the community that are not in place. When I asked the Minister when the critical care unit would be available in that hospital she was not able to tell me. She is well able to tell us when surgical activities and night time accident and emergency services will be closed in Ennis and Nenagh, but not when the facilities that are meant to be in place, and which the Teamwork report says are a predicate to the changes, will be in place. It is a problem of trust. Unfortunately, there is no trust in the mid-west that the reconfiguration plan will be anything other than a money saving exercise which will hurt patients.

I listened to Deputy Crawford earlier in the debate. I respect him very much. He does not exaggerate but is a very responsible Deputy. He said 17 people in Monaghan may not have died if what happened in the north east had not happened.

He is not a doctor.

It is the doctors' opinion, and the Minister knows that.

It was reported by the local GPs.

How does the Minister know? She is not a doctor.

I take the advice of doctors.

So does Deputy Crawford.

While the Minister talks a very good talk, the reality of what happened in the north east is there for us to see. We must see that exactly the same is coming down the tracks for us in the mid-west if we take this on trust, particularly in the context of the financial situation. Last week a HSE west meeting was told that a further €10 million will be taken from the acute hospital budget in the mid-west on top of the €400 million that was taken off at the end of last year after the service plan had been published. That is the reality of the cuts coming down the tracks. How are we supposed to believe the Minister? That is the problem.

Dr. Paul Burke and his colleagues are very genuine people who believe what they are doing is right, but there are many GPs in the mid-west, who are also highly trained doctors and who know their patients very well, and they are unanimously against this proposal. I have spoken to many who work in the hospitals in the mid-west who are extremely worried about this proposal and, above all, the patients and the public are extremely worried about it. I attended the meeting in Nenagh recently and intend to attend the protest on 21 February in Nenagh. I assume there will also be protests in Ennis. I listened to those people. There were so many people there that hundreds of them were out in the rain because they could not fit into the venue. It was a huge meeting of ordinary people who live in north Tipperary — doctors, nurses, patients of the hospital and their relatives. They are genuinely fearful about what is being proposed.

My colleague, Senator Kelly, said people in the mid-west should be very afraid and, unfortunately, he is right because the theory is great but, unfortunately, we cannot trust the practice. The people who would otherwise go to Nenagh and Ennis will all descend on a regional hospital that is already overstretched and overcrowded. We hope St. John's is safe, but we are not quite sure and want undertakings in that regard. Neither the Minister nor the HSE has been able to give us any commitment that the money will be spent on what is identified in the plan as needed.

If we were to accept this on trust we would need our heads examined. The plan is supposed to be predicated on more comprehensive primary and community care, long-stay beds, diagnostics, day-care beds, a medical assessment unit, a critical care unit in Limerick, more ambulances and more ambulance personnel. These are all good things but the problem is that there is no money in the kitty to provide them.

They already have the ambulances and the personnel.

The Minister has already told us there are IR problems and we have no guarantee they will be in place at the time.

We have them. They are in place.

The Minister should be honest.

The Minister can bamboozle sectors of the commentariat and the 1% of the population who, unfortunately, vote for her party. She has done much talking about, for example, fixing the national crisis of accident and emergency overcrowding, but there are more people on trolleys now and in the last year than there were during the so-called crisis three years ago.

That is not true.

She talked about providing extra hospital beds through co-location, but not a single extra bed has been provided in that way. She talked about rolling out the HPV vaccine for 12 year old girls next year but she has gone back on that. She talks a very good talk but, unfortunately, she does not deliver. The Minister and the HSE promised that specific actions to improve overcrowding in the accident and emergency unit in the Mid-Western Regional Hospital would be provided if it went along with her plans three years ago, and it did. The hospital was at the top of the list and was supposed to get extra consultants as a reward, but they were never delivered.

It is getting them.

It did not get them when they were promised. Again, we are offered more consultants but it is always in the future. However, they are not in place, so how are we supposed to believe the Minister?

The crowd that turned out in Nenagh knew the issues very well. They know we need a major specialist centre. I have no problem with the Minister's plan and agree that people with severe trauma due to, for example, road traffic accidents, no matter where in the region they come from, should be stabilised at the side of the road and taken to the Mid-Western Regional Hospital in Limerick. That is true and I have no problem with it. However, that is only a tiny minority of patients who use the hospital services in the mid-west. People feel very strongly, and I agree with them, that hospitals the size of Nenagh, Ennis or St. John's have much to contribute to people with more common conditions, who need surgical procedures closer to home or who need a more straightforward access to their hospital than they can get through the channel of the accident and emergency unit in the Mid-Western Regional Hospital. Those people are also stakeholders and are entitled to be involved in the debate. That is why my colleague, Senator Kelly, and I published the Teamwork report when we received it. We had planned to publish it, as the Minister knows, on a Monday when we released our press release. The HSE and the Minister rushed to publish it so they could have——

Rushed? We were criticised for the fact that we would not publish it.

Exactly. The Minister published it only because we were about to do so.

The Deputy criticised us because we were engaging with the stakeholders.

The Minister did not. That is the point.

She engaged with approximately 1% of the stakeholders, the consultant doctors who work in the hospitals.

What about all the other stakeholders? What about the patients and the public? We live in a democracy. What about the GPs? The Minister is very selective in who she considers to be stakeholders.

We have discussed it with the GPs.

Is there any reason patients from Kilbaha or the upper end of north Tipperary should have to come to the Mid-Western Regional Hospital in Limerick? Is it not possible, for example, for the consultants in Limerick to supervise the accident and emergency departments in Ennis, Nenagh and St. John's and be responsible for what goes on in them without having to centralise everything in Limerick? That should be examined.

That will happen between 8 a.m. and 8 p.m. as the Deputy knows. At night it is impossible.

I see no reason it should not also happen at night. There is a major lack of trust about what the Minister plans to do. I would like to quote from the report:

The overriding principle will be that no services will be withdrawn from the current general hospitals prior to the build-up of new, alternative services, i.e. that the Regional Hospital will be resourced, developed and working to recognised to international, best-practice standards.

Will the Minister stand over that? From what she has said already tonight she will not because she has already told us those services will not be in place when she removes the services in Ennis and Nenagh.

We are again being given a cart-before-the-horse situation where services will be withdrawn from hospitals that provide them with the promise that services will be in place in the Mid-West Regional Hospital. I will again quote from the HSE west report given to representatives last week:

2009 will be a very challenging year in providing the existing level of services with significantly reduced resources requiring ongoing monitoring of the budget situation. Where adverse budget variances are identified [that is lovely HSE speak] measures which may have implications for the level of service provided will need to be taken swiftly to ensure a break-even position by year-end.

It will all be driven by money. We have no confidence that the Minister will implement the required services. There is a need for a debate on the role of secondary hospitals in this country. We have not had that debate. They have an important role, as do tertiary and larger hospitals and the community. We have not had that debate because the Minister will not engage with any stakeholders except the very few who agree with her.

I thank Deputy O'Sullivan for sharing time.

My colleague, Sinn Féin councillor Seamus Morris of Nenagh Town Council, has told me that a sign was recently put up outside Nenagh General Hospital, directing children and pregnant women away from the hospital. It is the first time any such sign has appeared in that location and it is ominous for the people of north Tipperary. As the Minister knows, this is a feeling all too familiar to the people of my home county of Monaghan, where exactly the same signage has been in place since March 2001. While that sign was going up in Nenagh to turn away women and children, where was the Minister? She was walking a red carpet rolled out by her friend Ulick McEvaddy at his private, for-profit Vista health unit in Naas. This so-called health campus was built as a business venture by Mr. McEvaddy who, as we recall well, in 1999 hosted both the Minister herself and the former Minister for Finance and fellow Kildare man Charlie McCreevy in his luxury villa in the south of France. It is no wonder Mr. McEvaddy and his likes are the beneficiaries of massive tax breaks courtesy of this Government's health privatisation agenda.

By the way, there was no tax break for it.

Indeed there was. Is the Minister saying that is absolutely the position?

Yes. I am certain.

Is she saying that if we place the pertinent questions we will find that Mr. McEvaddy is not a beneficiary of public moneys under any guise whatsoever?

This facility is not a hospital and does not benefit from tax breaks.

I remind the Minister this is not Question Time.

We will test the Minister. I assure her we will do so.

The Deputy can.

The Kildare Nationalist, reporting on the Minister's visit to Naas, mentioned that she spoke of the importance of investment in health care. It went on to state: "However, she was not able to comment on the current beds crisis at Naas General Hospital." I bet she was not.

Hand in hand with privatisation goes the disastrous centralisation of our public hospitals. Monaghan has been the blueprint for the centralisation of hospital services in this State. We now face the threat of the axing in 2009 of all inpatient acute care in Monaghan General Hospital. Monaghan's average of 3,000 acute medical admissions per year will have to be catered for predominantly by Cavan General Hospital, which is already severely overstretched. The outlook for Ennis, Nenagh and other smaller hospitals is similar if the plans of the Government and the HSE go ahead. It will mean loss of services, long distances to travel for patients and further pressure on other hospitals without the provision of additional beds and staff to meet the need.

Nenagh hospital has set a high standard of service for smaller hospitals, and its close relationship with local GPs in terms of access and admission is an example that should be followed. A report on Nenagh hospital in 2006 found that 97% of cases sent to the hospital were safely treated and only 3% required transfer to Limerick. GPs in Clare, north Tipperary, Cavan and Monaghan have all come out strongly against the HSE plans in recent weeks. However, the Government and the HSE, as I had occasion to hear clearly only last Thursday when I met the Minister and Professor Drumm, in pursuing their centralisation and privatisation agenda, are working against the interests of patients and against the advice of front line health care providers.

The HSE report on accident and emergency services in the mid-west was jointly authored by Teamwork, the British-based management consultants whose recommendations form the basis for the current policy of slashing services at local hospitals and over-centralising services in already overstretched regional hospitals. The report on the mid-west is no different and would see accident and emergency services taken from Ennis and Nenagh, leading to the downgrading of those hospitals and their eventual conversion to glorified day care centres. Make no mistake about it, that is exactly what will happen. We are almost at that stage at Monaghan General Hospital, as the Minister knows too well, where the HSE and Government propose to end all acute inpatient services in the early part of this year.

In speaking on this motion and against the Government amendment I wish to make it very clear that I am opposed to the plans arising from the Teamwork-Howarth report, Review of Acute Hospital Services in HSE Mid-west, which provide for centralisation in Limerick. Lest there be any misunderstanding, Sinn Féin does not support a position which says that if all these contingencies are put in place then centralisation will be acceptable. It will not be acceptable, full stop and end of story. Among the recommendations of the Teamwork-Howarth report are, lest we forget, no provision of critical care at the local centre; the removal of acute services in small and medium-sized hospitals; all inpatient beds in Ennis, Nenagh, St. John's, St. Munchin's and St. Nessan's hospitals to close; and asset-stripping, namely the potential sell-off of St. Munchin's maternity hospital and St. Nessan's orthopaedic hospital, Croom. These plans are not acceptable. They are clearly running in parallel with similar plans in my own region and are equally against the interests of patients and of our public health service in general.

The Ennis General Hospital Development Committee has stated that the removal of acute surgical facilities from Ennis, as opposed to the proper resourcing of the casualty unit and associated services, will increase the risk to lives in Clare. They point out that the danger is further heightened for the 44,000 people who will have to undertake a journey to Limerick of between one hour and one hour 45 minutes from the scene of an accident, after a possible 45 minute ambulance response time. The Clare Champion reported on 6 February that it had obtained a HSE document showing there are an average of 50 medical patients occupying surgical beds in Limerick Regional Hospital every day, resulting in cancellations of planned surgery, overcrowding in the accident and emergency unit and longer hospital stays for certain patients. This is the hospital into which the Government and the HSE wish to centralise all emergency patients from Clare and north Tipperary. It just will not fit, exactly as the situation in Monaghan and Cavan will not fit. No matter how often we try to impress that on the Minister, she remains dogged in her determination to move ahead with her foolhardy plans.

It is grimly appropriate, while we make mention of foolhardiness, that April fools' day is the target date for the closure of the accident and emergency units in Ennis and Nenagh. Surgery is to follow some three months later. GPs in both Clare and north Tipperary are opposing plans for them to provide out-of-hours casualty services in both hospitals. Consultant geriatrician Dr. Christine O'Malley has expressed her serious concern about the prospect of losing the services of general surgeons from Nenagh. She said:

I have never worked without having surgeons on stand-by in the hospital. I am concerned that GPs are being asked to work above their level of competence. Every health professional has to be confident they are working within their level of competence when it comes to the treatment of patients.

Limerick Regional Hospital can't meet its own requirements at the moment. The HSE is devising a plan without looking at the situation on the ground. Consultants refer patients who need a bed in Limerick on a daily basis and are regularly told there is no bed for them due to overcrowding and the fact that there can be up to 30 people on trolleys.

We are determined in Monaghan, and, I hope, in Cavan, to resist the plan to effectively close Monaghan General Hospital — certainly to remove acute medical services from that hospital to Cavan — over the next number of weeks. I commend the people of Clare and north Tipperary on their support for their local hospitals and their determination to sustain the vital services they provide. That, at the end of the day, is the most important element in terms of health care provision and the provision of acute hospital services, not only when we need it but — make no mistake about it — even when we do not, for the peace of mind, assurance and confidence to face what each day brings.

Debate adjourned.
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