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Dáil Éireann debate -
Tuesday, 14 Dec 2010

Vol. 725 No. 1

Adjournment Debate

Health Services

I am grateful for the opportunity to raise the important issue of the reorganisation and restriction of emergency services at Connolly Hospital, Blanchardstown, Dublin 15. The hospital is situated beside the M50 and it serves a vast hinterland, including most of Dublin 15 and north county Dublin up to the Ashbourne Road, the Navan Road, Finglas, Cabra in the city and large tracts of counties Meath and Kildare. The hospital is at the centre of Ireland's key population growth over the past 15 years. People from all over the region have come to depend on the hospital for primary medical care and staff at all levels have striven to develop the hospital over the years in face of different and constant pressures.

The hospital was starved by the Minister for Health and Children of critically important investment in infrastructure such as modern diagnostic equipment, which is taken for granted in hospitals the world over. I have waged a long campaign to secure an MRI scanner for the hospital. However, that type of up-to-date diagnostic equipment was referred by a ministerial order of the Minister, Deputy Mary Harney, to the private hospital that was due to be co-located in the grounds. Like the Celtic tiger economy and the bubble, that co-located hospital has vanished into the mist.

The issue about the hospital that most concerns local people and those in the Blanchardstown hinterland is the suggestion that 24-hour accident and emergency cover is to be withdrawn and consolidated within other hospitals. In particular, there have been suggestions about a partnership between Beaumont Hospital and the Royal College of Surgeons in Ireland teaching centre of excellence which would mean a shift to Beaumont Hospital being the primary hospital in the new arrangement. According to a memorandum circulated to staff at James Connolly Memorial Hospital on 29 November last, the HSE intends to progress a full impact assessment, cost-benefit analysis, detailed planning and initial engagement regarding the phased reduction in 24-hour emergency departments in north Dublin from the current three sites to two sites. The three sites are James Connolly Memorial Hospital, the Mater Hospital and Beaumont Hospital.

Given the critical position of the James Connolly Memorial Hospital on the M50 and the fact that, unfortunately, gunshot injuries are a large issue in west Dublin and the hospital has developed a specialisation in this area which is recognised throughout Europe and the world and that these incidents tend to happen at night, what is happening in this review is worrying people in the area. The HSE memorandum states clearly that no decisions have been made with regard to the emergency service in James Connolly Memorial Hospital. I received a reply from the public affairs division of the HSE which indicated that the HSE is merely considering these issues at present.

While the notion of a co-located campus definitely has the possibility of introducing many savings, nonetheless certain key services are important. How advanced is this process? When is a final decision expected to be made? Will hospital staff and local people be consulted about the changes or are they to be presented with a fait accompli? Will the Minister publish the capacity study completed this year on the development of emergency services based at James Connolly Memorial Hospital? When they are completed will the Minister publish the impact assessment and the cost-benefit analysis for any new arrangements? Can the Minister give a commitment that the people who depend on the emergency services based at James Connolly Memorial Hospital will not suffer any diminution in these services that would put lives or the quality of patient care at risk in any way?

The staff in the hospital have been extremely co-operative with the change management process that is currently ongoing. As I said, the hospital serves a very large hinterland, including large parts of Dublin 7 and Finglas, the Dublin 15 area, north Dublin through to the Ashbourne Road and very large areas of both Meath and Kildare given what has happened to hospitals in Meath. People and the staff in James Connolly Memorial Hospital, where there is an exceptionally positive environment, deserve a considered response from the Minister.

I will make every effort to give a considered response and to answer the questions posed by the Deputy. I apologise for the fact that my colleague, Deputy Mary Harney, cannot be here to respond.

The HSE has recently been considering how best to reform the way services are provided in Dublin North while reducing costs, maintaining a clear focus on patient safety, allowing people to be treated in more effective ways and protecting access to appropriate services. The way in which accident and emergency services are delivered in the region has recently been considered by the HSE in this regard. No decisions relating to the potential impact on any of the sites, including at James Connolly Memorial Hospital, have been made.

International trends point toward the provision of fewer emergency departments, based within larger hospitals that are focused on acute care services. There are potential advantages to having hospitals that specialise in elective, non-emergency care. Having protected beds for non-emergency care can eliminate the cancellation of procedures and operations which frequently occur when emergency patients have to be admitted to the beds. Reduced cancellations means that medical staff can schedule more patients, confident in the knowledge that beds will be available as planned. This allows the emergency hospital to focus primarily on acute care and so provide a better care experience to emergency patients.

However, such advantages must be weighed against the needs of the local population. The HSE intends to undertake a full impact assessment and cost-benefit analysis of any change to emergency department services. This will require detailed planning and engagement with a wide range of interested parties. The HSE has stressed that this project is at a very early stage and no decisions have yet been taken on the future of any particular service.

I do not have the specific information sought by the Deputy. I will respond to her within a few days.

Does the Minister have an indication of the timeframe?

No, because the HSE response is that it is at a very early stage. I will respond to the Deputy with the specific detail as quickly as possible.

Hospital Services

I thank the Ceann Comhairle for giving me and Deputies Breen and Dooley the opportunity to raise this important issue.

As late as last May at a Western Regional Health Forum meeting, the HSE stated that there was to be no change to the services currently offered at Ennis General Hospital. The re-organisation of acute services in the mid-west came about as a result of both the Teamwork and the Health Information and Quality Authority, HIQA, reports into the breast cancer misdiagnoses of the late Ms Ann Moriarty and the late Ms Edel Kelly. At the launch of the HIQA report, Dr. Alan McKinney, a member of the HIQA Ennis investigation team, stated: "Before transferring a hospital service, it must be ensured there is a safer, better alternative available. There is no point making things worse than they are now". However, hospital services are being closed on the cheap without adequate resources being provided in the major centres or so-called centres of excellence, in this case in Limerick. This questionable practice presents us with the dangerous scenario of ultimately ending up with nothing at both county and regional level and endangering the patient, according to Dr. McKinney's hypothesis.

What has the Minister done about the major capital works outlined in the Teamwork report with regard to Limerick Regional Hospital? She has done very little. Why are there regularly up to 50 patients on trolleys in Limerick Regional Hospital? Why must patients wait for months for MRI scans in that hospital? Where is the better cardiac service for Limerick? Is there a 24-hour emergence cath lab service in Limerick Regional Hospital? There is not. Why strip the service in County Clare and replace it with nothing?

Prior to accident and emergency services reconfiguration in April 2009, I vividly recall the Minister for Health and Children and the HSE ploughing ahead with their strategy without even putting in place a proper ambulance service for the people of County Clare. They were happy to pursue this course until Dr. Paul Burke appeared on a "Prime Time Investigates" programme and outlined the reality. That is the level of commitment displayed to date — try to do things on the cheap, unless one is questioned.

The reconfiguration process has been ongoing for more than 18 months. It is time to have an independent evaluation of the process.

I am asking that HIQA officials be called in to evaluate where we are on reconfiguration. Has the Government delivered on patient care? I do not think it has. It has delivered on saving money, but it has not delivered on the patients.

I also wish to thank the Ceann Comhairle for facilitating the Clare Deputies in what is an important issue for us. I welcome the opportunity to contribute to this debate tonight. Concern has been raised with me and other public representatives in the past number of days regarding the possible downgrading of cardiac services at Ennis General Hospital. As the Minister of State here tonight is aware, Ennis General Hospital has seen significant change in services provided in recent years. It has been always based on patient safety and the quality assured service that should be delivered at any particular time. The core of this whole reconfiguration process has been the necessity to ensure the service is quality assured and is in the best interests of the patient.

The transfer of acute surgery to the Mid-Western Regional Hospital in Limerick was brought about by a number of misdiagnosed cases at Ennis that had tragic outcomes for patient safety and the quality of the service. All of us have recognised the importance of that. However, as part of that reconfiguration process, it had been always recognised that many services could be delivered at Ennis General Hospital in the best interests of patients and in a safe environment. In particular, it was recognised that Ennis would play an important role in the delivery of medical services, and that included some acute services. In my view, cardiology is one such medical service that can and should remain at Ennis. Nobody has put forward to me any case for moving the service.

I accept that interventional cardiology is by necessity delivered at a hospital such as the Mid-Western Regional Hospital in Limerick, where CAT labs and other enhanced technologies are available to provide that service. However, I see no reason the current service in Ennis should be in any way diminished or removed. It does not make sense from a cost point of view, from a patient safety point of view, or from any other point of view.

The Minister for Health and Children met with me and the Minister for Defence this evening. She gave us a fair hearing. She allowed us to put forward a very strong case for the retention of the service, and she recognised the necessity to continue to build on the services that are delivered in Ennis, so that the reconfiguration process can continue. It will not be possible for Limerick to manage the entire services of the region. It is just not physically possible to do it, and it is important that services are maintained in both Ennis and Nenagh, and enhanced rather than reduced. I look forward to what the Minister has to say this evening, given that she has had the opportunity to hear the three Clare Deputies this evening, and more particularly, given that she had a face to face meeting with the Minister for Defence and myself where we put forward the case on behalf of the people we all represent.

I welcome the opportunity to speak tonight on this important issue for County Clare. We all know that when the Government made the decision to reconfigure services to the Mid-Western Regional Hospital in Limerick, it signed the death warrant for the future of Ennis General Hospital as an acute medical hospital. I am delighted to see Deputy Dooley raise his concerns tonight, like the two of us on this side of the House. When the €14 million upgrading work started in the hospital earlier this year, I recall reading Deputy Dooley in the newspaper saying it was a vote of confidence for the retention of Ennis as an acute medical hospital. How could that be so? Ennis has been stripped of acute surgery. The 24 hour acute accident and emergency service is gone, as is intensive care. We are told that on 1 February, the cardiac services, including the high-dependency unit, will be transferred to the Mid-Western Regional Hospital as part of the HSE's plan to centralise cardiac services.

It is very easy to forget the €30 million promised by the former Taoiseach, Deputy Bertie Ahern, when he breezed into County Clare during the general election campaign in 2007. What happened the other €25 million? Did it disappear into a black hole?

The transfer of cardiology services was contained in the small print of the HSE's action plan for acute and community health services published in 2008 and supported by the Government. However, this was not supposed to happen until facilities at the Mid-Western Regional Hospital were put into place. This clearly has not happened. The sod has only just been turned on the new critical care unit. The CAT scan laboratory, which was supposed to operate at the hospital on a 24 hour basis, is operating from 9.00 a.m. to 5.00 p.m only. Clearly, the logic for centralising cardiac services depends very much on this system being put in place, so that a CAT scan can be read within two hours. Those of us who visit the Mid-Western Regional Hospital in Limerick can see it is like a building site at the moment, and there is a very serious shortage of parking spaces there. There is also a huge shortage of beds and severe crowding in the accident and emergency department. This evening, there were 24 patients waiting on trolleys in Limerick, while there were nine patients waiting in Ennis this afternoon. The ambulance personnel are doing an excellent job, but they will not be able to cope when this change comes into place without being given additional personnel and resources. They are already overstretched.

I understand that 1 February is the date set for the transfer of these services. The Minister for Defence, Deputy Killeen, and Deputy Dooley had a meeting this evening with the Minister for Health and Children. It looks like that may be put on hold until after the general election. Maybe that is being done so as not to hurt the Government Deputies in the constituency.

When will the 24 hour CAT scan laboratory be put in place at the Mid-Western Regional Hospital in Limerick? Galway already has the facility. What plans has the Minister in place for Ennis General Hospital? What is the future of inpatient services at the hospital? Will it be just a day surgical hospital? I fear that when the cardiac services at Ennis General Hospital are transferred to Limerick, it will be the nail in the coffin for acute services at Ennis. We want these questions answered tonight in the interests of patient safety, as we are all concerned about that in County Clare.

I am taking this Adjournment debate on behalf of the Minister for Health and Children.

Patient safety is central to the delivery of health services. People must have confidence in the care they receive and have the best possible outcomes. The way in which we deliver acute hospital services to our communities and their wider regions is changing.

The HSE has made significant progress in re-organising acute hospital and related services in the mid-west region since April 2009. While this has involved the relocation of some more complex services to the Mid-Western Regional Hospital at Dooradoyle, in the interests of patient safety and quality, Ennis General Hospital, as part of the regional hospital network, now undertakes an expanded range of day case surgery and diagnostic work. The Minister is anxious that the range of such services provided in Ennis General Hospital should continue to be expanded, so that people can have most of their health care needs met as close as possible to where they live.

All the cardiology services currently available in Ennis General Hospital will continue. The future of these services at Ennis General Hospital is secure and they will continue to be provided by a specialist cardiology team. In fact, these services will be expanded further, with the addition of cardiac failure clinics and cardiac rehabilitation services for patients who have had the acute phase of their illness managed in the Mid-Western Regional Hospital in Limerick.

In deciding on the best model for the provision of cardiac services in the region, the unanimous medical advice is to centralise acute cardiology to the Mid-Western Regional Hospital in Limerick. This is in line with the model being developed in the region, whereby services are organised on an integrated regional basis, delivered in a range of locations and settings. To facilitate this, a fourth cardiologist is being appointed. This will facilitate a separate cardiology rota, giving patients access to a cardiologist on a 24-hour basis for emergency cases in the region.

Interventional cardiology will be performed in the designated cardiac catheterisation laboratory in the Mid-Western Regional Hospital in Limerick, thereby enabling patients to receive the best possible care in the event of an acute cardiac episode. Six additional inpatient cardiology beds will be designated in the Mid-Western Regional Hospital to support this service. These developments will be brought on stream in the course of 2011, after the fourth cardiologist has taken up duty. General medical services will continue to be provided at Ennis, and the majority of medical patients, including respiratory patients, will continue to be treated at the hospital.

Ennis General Hospital has recently been a recipient of significant investment, with the installation of a CT scanner at a cost of €900,000, which became operational in 2009. In addition, an endoscopy suite for day medical procedures, at a total cost of €2.5 million, is under construction and is due to be completed by April 2011. The HSE has received planning permission for a new ward block containing 50 replacement beds. It is estimated that the construction of these facilities, which will cost €8 million, will be completed by the end of 2011.

The Minister and the HSE recognise the importance of Ennis General Hospital and the contribution it has made and will continue to make to the provision of hospital services in the region. Ennis General Hospital is a pivotal component in the provision of acute services in the mid-west. I assure the House on the Minister's behalf that there will be no reduction in the level of cardiology services provided at Ennis General Hospital and that it will continue to play an important role in the provision of health services to the population of the mid-west region.

I thank the Minister of State for that reply. Obviously, the pressure by Deputy Carey and myself this evening——

Sorry, Deputy, there is no provision for a reply on the Adjournment.

Pressure was put on our two local Deputies to deliver this service. I am happy with the reply.

Care of the Elderly

The Taoiseach today tried to minimise what was revealed in the "Prime Time Investigates" programme showing the neglect and abuse of older people by private home care providers under contract to the HSE. He spoke of four cases, as if it concerned only four older people. This is a total misrepresentation. The programme covered two major home care providers which were given the task of caring for a large number of older people. It also investigated the cases of a number of individual older people whose experience is clearly representative of others who have experienced the gross inadequacy of the home care being provided by some agencies and individuals in the State. People were justifiably appalled by these revelations, and the Taoiseach's response to them is totally inadequate. Among those appalled at the revelations are the many genuine and professional carers in both the public and private sector, who should be fully recognised and acknowledged.

An important first step in response to this scandal would be for the Government to admit that this has come about as a direct result of Government policy and HSE negligence. As far back as 2004, an evaluation of home care in the then Eastern Regional Health Authority area was carried out by Dr. Virpi Timonen. In his report, published by the ERHA itself, Dr. Timonen recommended that there should be more careful monitoring of the quality and adequacy of the services. His report highlighted the lack of national standards for any form of home care service. Dr. Timonen stated in his report:

Inadequacy of basic home help services, due to funding constraints, recruitment difficulties and lack of adequate structures, is causing a problem. Large numbers of older people in need of help experience problems accessing services. Lack of adequate day care and respite care services, and the uneven distribution of these services across the country, also poses a problem.

One of the main motives behind the introduction of the home care grants was responding to unmet care needs resulting from the absence or inadequacy of other services. The lack of comprehensive services, the uneven distribution of services and the structural problems identified in 2004 were not fixed. They have still not been fixed. Instead, Government and HSE policy has become increasingly reliant on putting public money into the private for-profit home care sector, which has now grown to some 150 companies across the State.

Is the Government proud of the fact that last week it reduced the minimum wage, putting more money in the pockets of the type of shark we saw on the "Prime Time Investigates" programme — people posing as care providers who exploit untrained and unqualified care workers, many of them immigrants, by paying minimum or below-minimum wages? In one case a person was illegally paid €4.88 per hour; another was paid €300 for a month's full-time work. This surely exposes the disgracefully low value placed on the work of caring for our older citizens. It is at one with the shameful decision in last week's budget to cut carer's allowance and carer's benefit by another €8 per week. There has been a total reduction of more than €16 per week in each benefit since 2009.

We should all be greatly concerned at the standard of care for older people in general and at some — but by no means all — of the people who have got involved in it as a profitable business rather than as a caring profession. We must ask what will be done to ensure that HIQA and the HSE have the ability and the resources to prevent such abuse either in nursing homes or in people's own homes.

To give but one example, the HSE has coerced all but a few of the residents of Loughloe House in Athlone to leave, despite their desire to remain and a community campaign to keep this public facility open for current and future residents. HIQA did not recommend that this facility close, but the HSE, pursuing Government policy, is determined that it will. Home care packages were offered to the residents as one of their options.

The home care scandal exposes the abject failure of this Government's policy of privatising health and personal social services. These private for-profit companies are receiving millions of euro every year from the HSE. Apart from the pittance paid to care staff, this public money is going into the pockets of the owners. Therefore, I call on the Government to take four steps as follows: it must put in place, without further delay and on a statutory basis, regulations for the home care sector; empower and provide the resources for HIQA to monitor compliance with these regulations; establish proper qualifications, pay and conditions for home care workers; and change Government policy from privatisation to direct provision of home care by the HSE.

I am responding on behalf of my colleague, the Minister of State, Deputy Áine Brady, who cannot be here this evening. I thank Deputy Ó Caoláin for raising the matter.

I am sure all Members of the House will join with me in expressing concern at the incidents highlighted in the "Prime Time Investigates" programme last night. The central focus of Government policy for older people who need care is that they should be able to receive high-quality care and they should be at the centre of all decisions regarding their care. The key element that must exist between the provider of care, whether public or private, and the recipient of that care is trust. This is fundamental to any service, but particularly health or personal social services, whose recipients are likely to be vulnerable. As an immediate response, the HSE is investigating the cases raised in last night's programme and is now reviewing all service delivery under its auspices to ensure that proper standards of care are being met. The executive will terminate contracts and change providers in cases in which this is necessary.

I emphasise, however, that in the vast majority of cases the HSE works in a close and beneficial partnership with high-quality home care providers in the non-State sectors. The HSE also has complaint mechanisms and an elder abuse network. In responding to referrals, the HSE provides a discreet and confidential service which may include counselling, mediation and anger management, as appropriate. Anyone who encounters elder abuse or inadequate care should report it to a GP, a HSE social worker, a public health nurse, a member of the Garda Síochána, or anyone they trust. The introduction of the nursing homes support scheme and the bringing into force of new regulatory standards for the long-term residential care sector demonstrates the priority the Government places on high-quality services for older people. Notwithstanding the severe financial pressures of recent times, there has been an expansion of the home care package initiative nationally through the provision of an additional €10 million in 2010 and a further €8 million in budget 2011. This year we protected the levels of other community-based supports for older people, such as home help, meals on wheels and day or respite care, and we also intend to do so in 2011.

With regard to the possible regulation of home care services, the July 2008 report of the Commission on Patient Safety and Quality Assurance recommended, among other things, the extension of any licensing systems in health care to the primary, community and continuing care sector. More recently, in July 2009, the Law Reform Commission published a consultation paper entitled Legal Aspects of Carers. This considers the legal issues surrounding home care and makes several provisional recommendations in the area of standards and regulations generally.

The Department of Health and Children accepts the need for a more standardised approach to the regulation of home care generally, whether by statutory or non-statutory providers. The HSE and the Department have progressed various improvements in home care provision overall during 2010, especially relating to the governance of services. These measures will be published and implemented in 2011 and include national guidelines and procedures for standardised implementation of the home care packages scheme, quality guidelines for home care support services for older people and national guidelines for the home help service. In addition, the HSE published its public procurement framework for home care services on 22 October last and is progressing this important measure, in conjunction with the other measures I have outlined, to ensure best provision to clients. Approved providers must meet and be monitored on a range of standards such as vetting, training, elder abuse protocols, supervision and client feedback.

As indicated to the House in a reply to a parliamentary question on 22 June last, the question of possible changes to legislation, including regulation and inspection, for the area of home care for older people generally is under consideration. The Department is examining the regulation of this sector in the overall context of the licensing of health care providers. Legislation is currently being prepared in this regard, taking into account the recommendations of the Commission on Patient Safety and the Law Reform Commission. The Government is determined to do everything possible to protect all older people in care. Our approach is to progress the various initiatives I have outlined, while examining the options and implications of introducing statutory regulation. I assure the House that the Department of Health and Children will work closely with relevant statutory and non-statutory organisations to take all measures necessary to ensure quality standards for all people receiving home care.