I welcome David Hanly, chairman of the National Task Force on Medical Staffing, Dr. Cillian Twomey of Cork University Hospital and Fergal Lynch, head of the Department's unit on the task force on medical staffing. I draw attention to the fact that while members of the committee have absolute privilege, this same privilege does not apply to witnesses. Members are reminded of the long standing practice where they should not comment on, criticise or make charges against a person outside the House, or an official by name, in such a way as to make him or her identifiable.
National Task Force on Medical Staffing: Presentation.
Mr. David Hanly
Thank you for inviting me to speak to you this morning. Dr. Cillian Twomey, a member of the task force, and Fergal Lynch from the Department of Health and Children, who led the task force's secretariat, accompany me. By now I anticipate members will be familiar with the main elements of our report. In the time available to me I propose to highlight some of the key aspects that I feel will be of particular interest to the committee.
The task force was set up by the Minister in February 2002 to prepare an implementation plan for reducing the working hours of junior doctors, to plan for the development of a consultant provided service and to address the implications for medical education and training. We were also asked to advise the Minister on how acute hospital services should be structured in the future. We chose two regions for detailed study, namely, those of the East Coast Area Health Board and Mid-Western Health Board.
We took the view that a fundamental element to any of our proposals is that they aim to improve patient care. Effective patient care and patient access to safe hospital services were our key concerns. We agreed that we had to produce an honest, objective report and to do that we had to put aside any considerations of the political implications, the industrial relations issues and any vested interests or personal concerns of all the members of the task force. This we did. We took a blank sheet of paper approach with all of the consultants, junior doctors, senior management, nursing and health and social care professional staff in the two regions with whom we met - over 600 people in all. We put the following question to them: "If you had a free hand, with no existing infrastructure, no political or industrial relations considerations, and a population and a geographic area the size of this region, what would you advise the Minister to do in relation to hospital services?"
The only givens in this exercise were that any proposals must comply with the EC working time directive and be in the best interests of patients. Our report is based on the results of that process. It is the distilled wisdom of all those we met. It is further informed by the many submissions we received and the international research that we carried out. In developing our final proposals, we took account of all existing services and examined how closely the ideal situation could be matched with the reality of current services.
A driving force for all of this is the EC working time directive. It is now the law and must be complied with and will apply across the EU from 1 August 2004. From that date, non-consultant hospital doctors - junior doctors - must work no more than an average of 58 hours per week. By 1 August 2009, this figure must reduce to a maximum of 48 hours per week. Currently, the average is 75 hours per week. This is not only unfair to junior doctors but also potentially unsafe for patients.
Our report recommends a series of initiatives aimed at meeting the most immediate objective, namely, reducing NCHD working hours to 58 per week by next August. These initiatives include replacing the current system of tiered on-call in which a number of doctors are on-call for the same patients at the same time, providing cross-cover between teams of doctors, changes to the rostering of junior doctors and enhancing the role of other health professionals such as nurses. We conclude in our report that major restructuring will be required to achieve a 48 hour week and that this will take some time to implement.
A consistent recommendation of previous expert reports is that we should have a consultant provided service rather than one that is consultant led.
In our report we acknowledge that while some consultants already operate a consultant provided service, this is not the norm. The move to a consultant provided service will mean that consultants will work as part of a team to a greater extent than they do today. It would also mean more direct involvement by consultants in patient care and more timely and effective decisions. We propose that consultants should in future participate in rosters, including night and weekend work where required. They would also cover extended hours. By this we mean that hospital services should be available outside the traditional nine to five, Monday to Friday, model which applies today.
We recommend that diagnostics, outpatients and theatres should function for longer hours, say, 8 a.m. to 8 p.m. or 7 a.m. to l p.m. and perhaps at weekends depending on the need. We must give a better service to patients and we must make better use of these high cost facilities. Medicine is, after all, a 24 hour a day, seven day a week business.
To put all of this in place, we must also radically change the ratio of consultants to doctors in training. The ratio of one consultant to 2.3 junior doctors today is the wrong way around and must be reversed. We recommend doubling the number of consultants, from 1,700 to 3,600 ten years from now. We also propose a corresponding phased reduction in the number of junior doctors, giving us a far better ratio of consultants to NCHDs.
There will be particular challenges in training junior doctors within a 48 hour working week. Moving to a consultant provided service will also have significant implications for the delivery and organisation of medical education and training. We propose that all junior doctors should be in training posts and that a range of training functions that currently come under the remit of a large number of agencies must be drawn together. Whatever the exact shape of future training structures, the task force believes that we must do everything possible to ensure that these functions form a key part of the new structures. Training must be protected from service pressures.
In order to achieve a consultant provided service, comply with the European working time directive and deliver high quality medical education and training, we needed to look at how our acute hospital services are structured. Among the principles we adopted were regional specialty self-sufficiency and providing safe high quality services as close as possible to the patient. Each region should have the full range of specialist services appropriate to that population that can be safely and efficiently delivered. People should not have to travel to Dublin, Cork or Galway unless it is for a service that by virtue of the volume of cases can only be provided on a supra-regional or national basis, such as neurosurgery or renal transplant.
A key factor in determining where services can be provided is workload, namely, volume of cases. This is particularly important in the context of physicians and surgeons maintaining their skills. If one is only required to perform one appendix operation per month, one is less likely to be as good at it as someone who is doing three or four per week. We were also aware that care provided by groups of doctors working in multi-disciplinary teams results in better outcomes for patients. In the future, any hospital providing acute 24 hour a day, seven day a week care will need an absolute minimum of seven consultants each in medicine, surgery and anaesthesia to allow its medical staff to comply with the European working time directive. However, when you add in the other important services to support these, such as radiology, pathology and so on, one needs 45 to 50 full-time consultants. Many smaller hospitals do not have the population base and the workload to keep 45 to 50 full-time consultants busy and skilled.
We can no longer depend on any doctors - consultants or NCHDs - working lengthy hours to maintain some services in smaller hospitals. This does not mean downgrading their services, but it has important implications for the type of services that smaller hospitals can safely and legally provide. The task force recommends a comprehensive range of hospital services provided in each region through a fully integrated network of hospitals serving the whole region. In the regions studied, this will mean one major hospital and a number of smaller hospitals in an integrated network.
The role of the major hospital is that it should have the full range of specialist services with an adequate number of consultants in each specialty to service the whole region. The role of the local hospital is key in this integrated network. Far from being downgraded, as some people have been saying, we propose that each local hospital should have an enhanced range of specialist services and should be an important part of the integrated regional service. Not only would a lot more of the day-to-day routine work be done locally, such as outpatient clinics, day case medical and surgical procedures and a minor injuries and illness unit, but some less acute work should be transferred from the major hospital to speed up access. Local hospitals could, for example, provide some services for the whole region, again as part of an integrated network. Local hospitals would also provide a range of other very important services to the local community and create vital links with primary, community and continuing care services. What local hospitals should not do is complex medical or surgical cases that require intensive 24-7 medical care. For reasons of volume and safety, this type of work is best provided in major hospitals.
For the same reasons, there should not be a full-scale accident and emergency service in local hospitals. The minor injury and illness units proposed for local hospitals can cater safely for a high proportion of cases presenting to any accident and emergency departments. Between 60% and 70% of those attending accident and emergency departments require non-urgent care, and only 5% to 10% of patients arriving there have major trauma. Minor injury and illness units would therefore cater for a high proportion of all existing cases.
Ultimately the type of patients staying overnight means there would not be a need for doctors on duty in the evening and at weekends. Many patients would be discharged the same day following, for example, medical or surgical procedures. This change will take some time to implement and would have to be phased in over time. A vital element to implementing this plan will be an upgraded ambulance service. Time is a crucial factor in medical emergencies. Our report stresses the importance of well trained emergency medical technicians who can provide immediate life saving treatment to patients before they reach hospital. The focus then is not on taking the patient to the nearest local hospital but on giving life saving treatment immediately and getting the patient to the hospital best equipped for their condition. Training and resourcing of ambulance services is an essential feature of meeting this requirement.
The other key elements of our report include an integrated management structure for each network of hospitals, an examination of the role that assistant grades can play in delivering services and a discussion of the implications for other health professionals of our proposals. I must emphasise that the guiding principle of our work is what is best for patients. We strongly believe that what we have proposed will greatly improve the quality of care for patients. Taking account of the requirements of the European working time directive, the importance of developing a consultant provided service and the need to reorganise acute hospital services, we believe that it is the best way forward.
I thank Mr. Hanly for his presentation. The assumption in the report that 60% to 70% of people presenting at accident and emergency units do so with minor injuries or emergencies bothers me. Over the years we have examined how unnecessary it is for so many people to clog up the system by appearing at accident and emergency units. The report is forward looking in its recommendations but it seems to accept that, in terms of primary care, GPs and others will present unnecessarily at accident and emergency and, therefore, continue a system that clogs up services. We should aim to get rid of that so people can be dealt with in centres of excellence provided under primary care.
Mr. Hanly
It was not part of our brief to look at general practice; there is another task force dealing with that issue. We were, however, conscious that there are needs within general practice, that there should be more general practitioners in the system and that there should be greater integration between primary care and the hospital services system. We were conscious of it but did not have it as part of our brief to make specific recommendations in primary care.
There was a report on attendance at accident and emergency departments nationwide produced by Comhairle na nOspidéal a year or two ago and it looked at the total attendances of patients to these departments. Nationally the current percentage of attendees who require hospital admittance from the moment of attendance at A&E is 25%, with 75% of those who attended not needing to be admitted to hospital. They may have required medical attention but one must realise that more patients are attending accident and emergency departments because of a deficit of access to traditional services such as outpatient clinics. If there are not enough consultants in a particular specialty; the waiting time to attend that consultant for a particular problem will be lengthy.
It is also related to differing practices in urban and rural communities, where the accident and emergency department has become the first port of call for people with illness needs. In our study of the two pilot regions, the percentage of attendees to the smaller hospitals who needed to be admitted to hospital was even less, between 11% and 17%.
Our report advocates a more comprehensive, multi-specialty, regionally enhanced service so that many of the patients who currently attend A&E departments will more rightly be referred to appropriate outpatient clinics and be seen more quickly because there will be more doctors to see them. There will still be a requirement for patients with minor injuries to attend accident and emergency units, which we refer to in the report as minor injury and treatment units, and they will continue to attend those hospitals with those requirements and will be dealt with by the staff in those units.
If the historical shrinkage of acute beds, the agreed requirement for 3,000 additional beds and the deficit of consultant speciality provision, which is unequal and unfair, are addressed as outlined in the report, there will be an enhanced service to patients and many of those who now go to A&E will not go there; they will go directly to the appropriate source of opinion, intervention and treatment.
I welcome the delegation. I feel guilty because I know members of the task force were taken aback by the extent of the opposition to the report on the part of the Opposition parties. I am conscious of the time that was devoted to it and when I criticised aspects of it, in no way did I question the motivation of those involved or underestimate the task they faced. Everyone recognises the welcome aspects of the report, such as the consultant led service and the education and training recommendations.
Could the Deputy ask questions of the delegation?
The Chairman always says that but I will take my five minutes. I can hardly draw breath without the Chairman complaining. I value the training recommendations and recognise the need for and value of the concentration of specialties in the regions.
The problems arise, however, with the limited locations for A&E services. I spoke to members of the task force who have argued the point but I do not accept intellectually or intuitively the argument about the closing of so many A&E units. The public do not want or expect an accident and emergency unit at every crossroads but they do want reasonable access and they do not feel that what is being recommended is attainable and I am not sure if it is desirable socially or medically. The public are not fools, they know there are trade-offs between convenience and quality but when they reject the closure of the local accident and emergency department, they are making a judgment about what they want and value and it would be foolish to ignore it.
I understand this is a clinical report with different priorities but the health service was looked at as if it was a blank sheet. There is always a temptation not to start from what exists but the reality is that we must, the health service must be kept going while we are in transition. The report gives a vision of a Utopia without giving a map to get there. The transition was the motivation for the opposition to and criticism of the report. The ability to implement the recommendations is of critical concern, particularly for the implementation group.
Mr. Hanly
We will be involved with the implementation group but our job is to complete phase two of this report and I am heading that up - taking the report and rolling it out across the State and tweaking accordingly.
There will be huge cost involved in replacing the acute beds that will be lost in the smaller hospitals and transferred to major hospitals. There will also be physical costs for infrastructure, the manning of beds, access, ambulance and air ambulance services and road improvements, never mind consultants. Is it realistic to think the recommendations can be implemented given that we have already been told there will be no extra money in the first year?
The working time directive is the driving force behind all this change. Is the timescale for its introduction realistic? We read that before a process for negotiations between the IMO and the Health Service Employers Agency starts they are already shouting at one another in public. Is there any chance they will agree, even with goodwill, in the short time between now and next August? Within the pilot regions, even if it is possible to find the extra consultants in time, what chance is there of introducing the plan around the rest of the country?
The four short-term measures which the report says can be achieved cannot be implemented before next August because they all require renegotiation of contracts. If they could be implemented why was it not done years ago to improve the hours of the non-consultant hospital doctors? They would have been accomplished, for instance, in 2000 when the costly deal was done with the non-consultant hospital doctors in order to get them to work overtime. Now they want to be compensated for not working overtime. Would Mr. Hanly agree that each of those recommendations requires a new contract and cannot be achieved within the time allowed? If they are not achieved within the timeframe, smaller hospitals will die of neglect and the bigger hospitals will be in a permanent state of crisis, with patients on trolleys, or next August many smaller hospitals will close because there will be no cover available to them. Is that problem due to presenting late? I do not blame Mr. Hanly for that because what he is recommending now is more or less what he recommended in 2001 and nothing happened.
There are many good things in this report and I welcome the proposals for the increased number of consultants, the integrated regional approach and streamlining training. At present less than half of the medical undergraduates here are Irish. There is a direct incentive to universities to educate non-nationals and, while I have no problem with non-nationals, we are not growing enough of our own doctors to meet our needs. Even after a huge effort there is a shortfall of about 1,000 in the number of nurses. There has been no real significant change despite all that effort. A crisis is building up in general practice because there are too few GPs. Much of this report depends on a plentiful supply of highly skilled people.
Could Mr. Hanly respond to the argument against concentration of services which is now emerging? I have here an article from the British Medical Journal by Mr. Posnett, a health economist for York University. He writes about the kind of major hospital described in the report of 400 to 600 beds:
On the basis of available research evidence, bigger is not better: at present there is no reason to believe that further concentration in the provision of hospitals will lead to any automatic gains in efficiency or patient outcomes. Maybe the research base is inadequate, but the onus is on those who advocate the benefits of concentration to prove their case.
In the future, as general practitioners (through primary care groups) assume an increasingly influential role in planning the provision of health services, the perceived benefits of accessible local services may begin to turn the tide of professional opinion.
I am concerned that the essential proposal in this report may be based on an outdated model. How does Mr. Hanly respond to Mr. Posnett's research in terms of the efficiency of bigger units of major hospitals and the outcomes across the board, apart from specific outcomes in certain specialities, and the issue of patient access?
Would Mr. Hanly not accept that in my area, County Wicklow, which is in the front line now as the East Coast Health Board, is one of the target areas and that people living in Tinahely will not now be able to attend an A&E department in St. Colmcille's Hospital in Loughlinstown? In the long-term they will not be able to attend Wexford General Hospital. The only two A&E units they will be able to attend will be St. Vincent's Hospital in Dublin or Waterford hospital. That has serious implications for a part of my constituency which at the moment is suffering from a loss of GPs and access to St. Colmcille's. Mr. Hanly may say about 60% of people do not necessarily need to come to A&E but for those individuals it is not a matter of choice. It is where they go when they have an emergency. They are not being frivolous or misusing a resource. They go there because they need to go there. They may not need to be admitted but have a reason and a purpose in going. One does not undertake a long journey, even to St. Colmcille's, unless it is necessary. We need a response on that.
While Mr. Hanly is not responsible for implementation, has the Minister for Finance responded to the challenges Mr. Hanly has set him and the Minister for Health and Children in terms of infrastructural development and investment? Do we know whether there is any commitment at a time when acute beds are not even being opened in James Connolly Hospital in Blanchardstown because insufficient money was provided? We are not even using the resources we have. Is there any idea what view the Minister for Finance takes of this proposed investment? Is there not a genuine reason for the fear in local communities that the services will be reduced because that is in the report and its proposals will not be fully implemented and therefore the promised benefits will not accrue resulting in an overall loss at local level?
The report is based on the mid-west and the east coast areas. When does Mr. Hanly expect his next report covering the rest of the country to be available? If this report is implemented it will cost a great deal. Has Mr. Hanly made costings specifically as to what amount of money will be available? The success of the findings of the report is based on the availability of highly trained paramedical staff, particularly emergency technicians. Do we have that expertise in the areas available at the moment and, if not, are there plans afoot to have those staff trained and in place before any aspect of the report is implemented?
When I think of such things as surgery I have a slight doubt about the reduction in numbers of junior hospital doctors in the major centres. If we are going to utilise our very expensive facilities for longer hours, a surgeon is going to need assistants, etc. Has Mr. Hanly taken that into account on the assumption that if the number of consultants increases there will be a corresponding reduction in the number of JHDs? I am somewhat surprised at an examination of the role that "assistant grades" can play in delivering services. To what precisely does "assistant grades" refer - medics, nurses, paramedicals, or has that been taken any further?
Mr. Hanly
I shall try to pick up all of the various points. In relation to the questions raised by Deputy Mitchell, it is not our intention to close accident and emergency departments. They will continue to do a large proportion of the work they currently do.
The work to be done by nurses, from 9 a.m. to 5 p.m.?
Mr. Hanly
The departments will be nurse led and will do large parts of their work possibly between 8 a.m. and 8 p.m. It will have to be decided how long each department will stay open. That will depend on local conditions. The intention is that there will continue to be a nurse/practioner led accident and emergency service in each of the local hospitals on an extended hours basis. Precisely what that is will have to be worked out locally.
It is not the intention to make any of these changes until such time as everything is in place. One cannot simply take something out of one place and put it into another if one does not have the resources to deal with it there. All of this will have to be phased in on the basis of available facilities, people and the recruitment and organisation that needs to be done. It is not a matter of all this happening next Monday morning. It will not, cannot and should not work like that. This must be properly managed and implemented. That is what we have been saying.
The issue of a loss of acute beds was raised. Our report is predicated on the additional beds that have been agreed to in the national health strategy published two years ago. That called for an additional 3,000 beds. As a task force we met the committee, chaired by Dr. Mary Codd, which is looking into that. That committee will clearly have to be informed by the structures that our report is suggesting. We have made the assumption that those beds will be provided in the system and the question relates to where they will be provided. In the meantime, and indeed beyond that, what we are talking about is an integrated network of hospitals; not hospitals working independently and separately, but hospitals working together. The beds in the local hospitals will continue to be used for the kind of patients they now have and not for acute patients. The latter should move to the major centre where they have a multi-disclipinary team available while non-acute patients can be placed in the smaller hospitals. There will have to be a utilisation of the total number of beds in each region. It is not a question of closing beds at all. The beds will continue to be kept open.
What we are saying clearly in this report is that local hospitals should be enhanced with the kind of services that are appropriate for them. One might, for example, have a need for a consultation in rheumatology. Currently there is no rheumatologist in the whole of the mid-west and one has to go to Cork, Galway or Dublin, to which many patients come. A rheumatology service should be available not only in the mid-west, but in Nenagh and Ennis. There should be a team of rheumatologists, the number we have recommended being four. That is based on international norms for the number of rheumatologists per head of population, and there are norms for each of the specialties. We are saying that all the rheumatologists would be based in the network in the region. They would do their acute work in the major hospital and their outpatient and day procedure work in the local hospitals. That would apply to all the various specialties. They would do as much as possible on a day basis in the local hospitals and as close as possible to the patient. Each of the local hospitals would be doing a lot more work than it is doing today. What they would not be doing is serious acute work that is more correctly done in a multi-disciplinary major hospital.
The other question related to the European working time directive and whether the attempt to achieve these particular dates is realistic. Clearly it would have been better if all of this had happened a long time ago and I cannot say why it did not. We are where we are. There is a phasing in of these reductions in hours and the first step, the biggest single chunk of the work, is to get to a 58 hour working week by 1 August 2004. If we can go ahead with this plan rapidly, and do some of the things we have suggested in it, we can get very close to achieving that target if not actually achieving it. That achievement does, however, presuppose the resolution of those elements which must be negotiated between the various parties, the representative bodies on the medical side, the HSEA and indeed the other unions: this is not just about doctors, but about nurses and other allied professionals. They too will have to be negotiated with. We believe this is what should happen and that it is right for the Irish public and the health system. We should aim to get there. It is not in our hands to force people down a particular road or speed up these negotiations. We have to rely on other people to do that, but we should not back off from trying to produce a first class health service for the people of Ireland simply because it is going to be a hard road to travel. That was the position we took, saying that if we do not try we will never get there.
Another point made by Deputy Mitchell was that smaller hospitals would die of neglect in the meantime. That cannot happen because a service must still be provided, and one cannot move things from A to B unless the facilities and the people are in place in B, nor can one move things back from B to A unless the facilities are in place. It is going to be a long hard road but we ought to aim for a world class health service, and my personal view is that we should not back off from trying to achieve that because people deserve it.
I think I have covered most of the ground. I will move on to Deputy McManus's questions. The Deputy asked about the shortage of undergraduates in the system. As part of our terms of reference when we set out on this report in early 2002 we set up a medical education and training sub-committee under the chairmanship of Dr. Jane Buttimer. That group has not concluded its work. It produced an initial work which has formed part of our overall report. The reasons it was unable to conclude the second part is that it needed to know the results of our report before it could start estimating numbers and the real needs. The sub-committee is looking at the whole area of postgraduate and undergraduate training. We clearly need to give the young people of Ireland easier access to the education system, not just to allow for more medical staff but also for more nursing staff. There is a huge shortage of nurses, to which Deputy McManus alluded. It is my recollection that around 6,000 young people every year apply for a limited number of places, so it is not the case that people are not interested in taking on those posts. There is certainly huge interest in medicine. Our aim was to produce the report and say what we believe should be done, and we believe that there must be much more access to medical education and training for young Irish people. It is not in our power to produce the goods. That will ultimately be up to the Government. However, we have stressed that there must be radical change in medical education and training.
On the issue of the philosophy of concentration and the big is better concept, I do not disagree with you in the sense that big is not necessarily better. However, there are levels of size and one must reach an optimum. When one starts to go beyond that optimum size, perhaps building a 1,000 bed hospital somewhere, it is much more difficult to manage. Someone suggested during our various deliberations, obviously facetiously, that we build a 5,000 bed hospital in Athlone and improve all the roads.
Big is not necessarily better but one must have optimum sizes with a sufficient number of specialists in each category. The numbers vary from general surgery to rheumatology. The latter needs approximately one consultant per 80,000 people whereas for the former the figure is approximately one per 25,000 people. One clearly needs many more. To run a 24-7 service, one needs a minimum of seven consultants in each of the specialities one wishes to provide on that basis. We have done all the calculations and rosters, and the minimum number of people one needs to run such a service, including a full accident and emergency service, is between 45 and 50. One would need a general surgeon, a general physician, an anaesthetist, a radiologist, a pathologist and an orthopaedic surgeon if one were running a full-scale accident and emergency hospital. One would need a vascular surgeon for a full-scale accident and emergency department. Obviously one also needs a paediatrician.
The figure comes out at between 45 and 50 specialists. Many of the smaller hospitals, though not all, simply do not have the population and volume of work to justify having that number of people, and one will not get them since they will simply not come to work where they may become deskilled over time. There is an optimum size for hospitals, allowing them to accommodate the full range of specialities that one requires in any population group. The population group that we used was 350,000. We say that in the mid-west region, which currently has 109 consultants, there should be 304 serving the needs of all the people through a network of hospitals rather than just one. That is the basis. We are not suggesting that there be enormous hospitals but ones that can accommodate that size. At the risk that members might find it difficult to keep listening to me, I will pass over to Dr. Twomey again regarding a person who has a problem in Tinahely, needing access to an accident and emergency department, and whether that is Loughlinstown or St.Vincent's under our plan.
The current reality is that many patients, as we have said, attend accident and emergency departments without emergencies. I will deal specifically with emergencies. We would all like, in the event of our having an emergency, be it an accident, an acute coronary or whatever, to have the appropriate services to deal with it available to us as close as possible to where we live. Quite clearly, one cannot provide the entire panoply of requirements for emergency provision in every hospital in the country. To date, what has been happening is that patients are going into over 40 hospitals with varying staff levels. In some hospitals, there are 11 or 12 consultants and in others a much larger number.
In the mid-west region, which was one of our pilot areas, many of the patients who suffer major accidents are currently being triaged directly to the Mid-Western Regional Hospital as opposed to Ennis General Hospital or Nenagh Hospital since, when they are seen by the ambulance staff and emergency medical technicians at the scene, it is quite evident that they have broken a leg, and they have to go to where there are orthopaedic services available to deal with it. More importantly, it is now also known that if one takes in a medical emergency such as a coronary, the intervention prescribed at the scene is the single most important in ensuring the outcome of the event. There is now considerable evidence that the injection of thrombolytic therapy, which is medication to dissolve a clot at the time of the coronary, will significantly enhance the likelihood of that patient's survival.
An example of that has been undertaken in the North-Western Health Board area with Donegal general practitioners, who have been trained in the prescribing of such drugs and give them to patients at the scene, after which they are triaged to hospital. Similarly, in that context of cardiac emergencies, there are now machines which will tell one what the rhythm disturbance is and which button one must press for defibrillation purposes. That is critical to the patient's survival. It is our view that it is possible to train doctors, clearly, but also emergency medical technicians in the use of that equipment at an advanced rate.
Provided that service is developed around the country, something that is clearly needed, it then becomes important that the patient with the acute coronary, to continue the example, is then admitted to a hospital where the full range of appropriate services exists, including angiography and the possibility of stenting, or inserting a component into the damaged coronary vessel to make it patent. That does not currently exist for much of the country. It is a disgrace that the degree of specialist provision around the country is so unequal and unfair. Those are specialities which any region of 350,000 people ought to have. The only way one can construct and provide that is by appointing a sufficient number of specialists, in this instance cardiologists.
We were faced with the choice in our report of approving the appointment of additional consultants and distributing them throughout the existing network of hospitals without any change to how those hospitals function, which at one level might be politically attractive. However, it would not at all address the absolute requirement in law of meeting the European working time directive. Around the country there are currently doctors at consultant and non-consultant hospital doctor level working abnormal and totally unacceptable hours. That will continue unless we reconstruct and reconfigure our hospitals in compliance with the directive.
If one of us gets a coronary, he or she will want to be certain that the treatment offered is the best available as quickly as possible in the appropriate place. We suggest that, in the context of an acute coronary, that is immediate emergency treatment at the scene of the event, followed by admission to a properly staffed and equipped cardiological centre with not just cardiologists but radiologists, echo cardiographers and the whole range of services. This is an important point for the committee to note. If we did that within the existing construct of hospitals, it would require our appointing perhaps as many as 2,500 more NCHDs merely to construct rosters that would comply with the directive. There is currently one consultant for every 2.3 NCHDs. Our report advances that the ratio will go in the opposite direction from one to 0.6 over ten years.
Every single document on the health service during the past 20 years or more has said more senior doctors are needed and fewer NCHDs. Clearly our report has rejected, and rightly in my view, the idea of employing additional NCHDs to prop up the system. Half of that group currently are not in official training positions; they are providing a purely service function with no end in sight as to where they are going in their careers. It is unacceptable. I regard the directive as an opportunistic legal issue that has forced us to think outside the traditional box as to how we deliver our health system. We have an opportunity which will hugely increase the care to patients. That is the focus of our attention in the report. None of us has total ownership of care of patients but I assure the joint committee this report was written precisely with a view to improving patient care.
Mr. Hanly
Another question from Deputy McManus was about implementation and the views of the Minister for Finance. The Deputy will have to ask the Minister for Finance for his views.
We did invite him.
Mr. Hanly
On the question of our report and our task force, we had an assistant secretary from the Department of Finance on our steering group. He signed off on this report in so far as he fully understood the costs specifically related to it. The other costs which we did not attempt to put in were the capital cost, other than the 3,000 beds that we have assumed are already agreed under the national health strategy, and we did not attempt to cost the outcome of industrial relations negotiations. All the costs we have used are 2003 costs. We have factored in extended working hours, additional nursing and allied professional people in terms of numbers but at 2003 costs. We have not factored in what might be the outcome of negotiations. To the extent that we have been able to cost we have done it and to the extent that we have been able to get the Department of Finance to sign off we have done it. Beyond that it is a question the Minister for Finance needs to answer.
Perhaps I can move on to the rest of the questions. Deputy Devins asked when phase 2 would be done. I cannot give an absolute answer. It will be done as rapidly as possible. We are starting on it now; it will begin immediately. We would hope to complete it within the next nine or ten months or thereabouts but there will have to be much consultation in every region and we will have to go and look at each region. This is not a "one size fits all". We cannot simply say in this report this is the way it should be done, end of story, because there are areas around the country where geography and demographics are different from those of the mid-west and east coast areas. We have allowed for that in our report in so far as we have been saying that in some parts of the country there may be - and probably will be - a need for an additional general hospital which would be in the middle between the local hospital and the major hospital but, nevertheless, would be part of the integrated network of hospitals for those regions. I cannot speculate on where exactly they will be until such time as we have done the second phase. As I said, we are starting on it now and hopefully in will be completed within nine or ten months or thereabouts. We have covered the question on costs.
Dr. Twomey dealt with the emergency technicians issue to some degree. We have been speaking with the pre-hospital emergency care council who is responsible for looking at ambulance services throughout the country. Already it has advanced technician courses up and running. It needs to provide many more of these courses and at a faster rate. Obviously there is a question of funding to get those done. The changes we suggest in regard to accident and emergency cannot be made until such time as the emergency technicians are fully trained. There is also the issue of some small changes to the legislation in regard to what emergency technicians can do in the area of administering drugs and any other procedures they may not be allowed do at present. A fundamental part of the package is the emergency technicians.
On the question of the workload in the context of reducing the number of NCHDs, as suggested in the report, in each region there will be teams of specialists and each team will have a number of NCHDs. We suggest it should no longer be the case that every consultant has a team of people. Today there might be one consultant and three or four NCHDs working with that consultant and they would remain in that team. What we are saying is that the consultants themselves should be working in teams. Therefore, there would be a surgical team and, perhaps, an orthopaedic team. That team would have a number of doctors in training working with it. The exact numbers and how it will work will depend on training. In the training report there is the question of how one trains NCHDs in a 48 hour week as distinct from a 100 hour work week which some work at present. Training will have to be more structured and better organised. This is being done all over Europe as we speak. It is not as if it cannot be done and that there are no models. The numbers of NCHDs are based on that.
The Deputy asked also about assistant grades. There are a number of areas where assistant grades may be appropriate, for example, more care assistants to support nursing and operating theatre assistants. One particular orthopaedic surgeon said to us that it was a waste of time to have a junior doctor, who is training to be an orthopaedic surgeon, stand holding a clamp for an hour and a half while he did the particular procedure. He said that if he had a technician doing that work - that is happening in some hospitals - he would much prefer to teach the NCHD the actual procedures than that he should stand holding a clamp. There are many other areas like that. None of these things is an answer in itself. It is a combination of many things that will help reduce the hours of NCHDs down to 48 hours ultimately.
I was more interested inassistant grades as they apply at sub-consultant level. Has the delegation gone down thatroad?
Mr. Hanly
No. We have ruled that out of the report.
Will I get an opportunity to speak?
Yes.
I am anxious to do so because I have sat here listening for the past hour and a half.
I am concerned and that is the reason I want to give every member an opportunity to ask questions.
Some method will have to be devised about questions. Some members keep talking——
Thank you. If members continue talking we will not get through the questions.
I thank Mr. Hanly and his colleagues for coming in to address the joint committee. At the launch, and even today, Mr. Hanly was at pains to say the smaller hospitals are not being downgraded. Perhaps it is a case of "methinks he doth protest too much". I am aware from my colleagues in the Clare Greens that the perception there and in other areas is that smaller hospitals are being downgraded. Will Mr. Hanly and his colleagues agree it is of little comfort to those areas to say there will not be proper accident and emergency units but there will be a better ambulance service? From a perception point of view, is the delegation facing an uphill battle? It has been conceded today that centralisation does not necessarily result in better outcomes. Is it agreed that larger hospitals are more attractive to consultants because they offer a more varied case load and, perhaps, better equipment? Is that used as a carrot in negotiations?
I was in Germany a number of weeks ago when the issue of the junior doctors and the working time directive was being discussed. The first thing looked at were the financial implications which are quite horrendous and we have had very little discussion on that issue. I want to take up the points raised by previous speakers and ask what are the financial implications. Dr. Twomey said that under normal circumstances we would have had to employ 2,500 junior doctors just to keep pace. Is it realistic to say we can comply with this directive, keep standards as they are and comply by 1 August? Can we have specific details on the financial implications? With regard to the future, will it be more difficult to face down the local communities or the consultants? If Mr. Hanly was the Minister who would he prefer to face down?
We have a Minister for Finance who is increasingly sceptical with regard to the health service and the money needed for it. Has there been direct communication with that Department to see how implementable this is?
I too welcome Mr. Hanly and his team. I note the main concerns of their proposals are to improve patient care and to save hospital services. A group of patients neglected over past decades are patients in psychiatric hospitals. The report did not specifically refer to this group. What consultations did the team have with the psychiatric services and what percentage of the 600 people consulted were from the psychiatric service? Has the team any specific views on the conditions of the psychiatric services or on the need for improvement? Does it intend to bring psychiatric services in the psychiatric hospitals to an acceptable level - even to the present level of our general hospitals about which it is so concerned? Some of the psychiatric hospitals were built before 1845.
What timespan has been advised or suggested for the completion of the pilot project in the mid-west? I have a specific interest in the mid-west because I come from there. There must be some timescale for the finalising of that project which is obviously a test ground and prototype for the other projects. Surely the other projects cannot commence without the completion of the mid-west and the eastern health board projects.
I welcome Mr. Hanly and his team. With regard to the consultant provided rather than the consultant led approach, the aspiration is to have more consultants at the coalface. I know from consultants I know personally that those in smaller hospitals already deal one to one with all their patients. This is only a serious problem in most of our major hospitals where consultants have junior doctors working on their behalf. However, in smaller hospitals this approach is already in existence. I find it difficult to understand how this can be something the team is aspiring to when it already exists in the smaller hospitals.
The team took the criteria of no existing infrastructure with regard to the provision of an enhanced ambulance service. There is certainly no infrastructure in my constituency. If one travels from Roscommon to Galway it takes an hour and a half at the best of times. A consultant in Roscommon hospital has stated that this plan intends replacing a modern and efficient hospital with an ambulance. That is not acceptable.
Last night I attended an emotive and informative public meeting in Athlone regarding Portiuncula and Roscommon hospitals. Eminent doctors and consultants have accused their colleagues on this task force of acting shamelessly. They have implied that the task force was gerrymandered and representation from rural areas was marginalised. They feel the plan is anti-rural and anti-patient and that people will die. This has come from Dr. Hanly's colleagues.
I get a little confused. I accept the team is enthusiastic and is trying its best to implement these proposals. However, this is report No. 148 in five years, few of which have been implemented. This team acts with vigour but last night members of the Government party stood up and said that very few of these reports had been implemented and neither would this one. How does the team feel about that? Does it feel let down? While I want answers to these questions, I wish the team all the best.
A question I have been dying to ask is a little personal and Mr. Hanly may not wish to answer it. On becoming involved in this did he get a commitment from the Minister that the recommendation would be implemented? I am sure he does not want the hard work done by him and his team to be wasted by having the report left on a shelf.
I welcome Dr. Hanly and the team. They have strengthened my enthusiasm for this report by their presentation. They have proposed brave measures. Unlike Deputy Mitchell, I think this report is important. Its strength lies in the fact that we have a blank sheet. The report is above the influence of politics which should never interfere with medical care and it provides an optimum and ideal for us to deliver better services to patients. One thing that has emerged clearly is that patients are central in this report.
I would like clarification on whether local hospitals will increase in importance and whether traffic will be both ways. We must get rid of the notion that they are going to be irrelevant or die out. Does the team agree that the nomenclature around medical care is changing in the report? The notion of minor injury and illness units is a more accurate description of what actually passes for accident and emergency in smaller hospitals and is a better description for what we are getting. With regard to emergency medical technicians, is this a new role or new job description with which we will have to deal?
I have a final question for Mr. Lynch who, if I am correct, is head of implementation within the Department. Can I have a description of the Department's contribution going forward? What will happen with this report?
This report is all about living, not dying.
I am delighted to have the opportunity to speak as I have been waiting some time and would otherwise wonder why the people of Mayo elected me. I am here as a general practitioner and was a rural practitioner until I was elected. The reason I sought election was to address the needs of my area.
This report talks about saving lives. It is like the curate's egg - good in parts. However, it is rotten in other parts. This report is an example of what is to come and what may be applied in other areas. I will cut to the chase. I appreciate that we are talking about a consultant service; it is not a consultant service I know very well. There have been so many reports that have not been implemented and I wonder what chance there is of this report being implemented. Has Mr. Hanly been given an assurance that the money is there? The pace of Hanly will be the pace of the health strategy; 330 beds out of 3,000 promised. How will Mr. Hanly ensure that the consultants will have the contracts they need? There is trouble already from the IMO. How can he ensure that the consultant support staff contracts can be renegotiated?
In the case of the schools of medicine, there will be an interruption of supply for a number of years until such time as the postgraduate students are ready to go into medical school. I wonder where the beds are because they are not there. Where are the building projects to ensure that those extra beds will be accommodated? Where are the resources for the GPs who already are hard pressed? How will the GPs take up the slack when these local hospitals are downgraded? We should call a spade a spade because there is no other way of saying it. When I worked on the islands the health board did not care what happened on the islands as long as nobody complained. People are complaining now and there is somebody in Europe complaining. We are very good Europeans. What is happening about the GPs? The GPs are not under this embargo so nothing is done. I find that a very cynical attitude.
The Hanly report states: "The conclusion that the full range of emergency services can only be provided in major hospitals may raise concerns about access of patients to treatment in life-threatening situations.". That is very true. In my practice people are depending on a local hospital service. The report states: "Each region shall have a full range of specialist services appropriate to that population that can be safely and efficiently delivered. People should not have to travel to Dublin, Cork or Galway". But they do. If one applies the Hanly recommendations, Galway is where people in my area will have to go and that is the same distance as from here to——
The Deputy's area has not been examined.
If one applies the Hanly report, that is exactly what it says and let us call a spade a spade. There are neither proper roads nor helicopter emergency medical services. I take great issue with Dr. Twomey when he states that it is all up to the GP. It is not all up to the GP because the GPs are short-staffed at present. A person injured in a road traffic accident in my area would have to be brought to Galway. It is the same distance from the far end of Mayo to Galway as it is from Dublin to Galway. I ask Dr. Twomey to comment on a person injured in a road traffic accident with a bleeding spleen and even with medical help such as drips, who has no access to a helicopter emergency service or good roads. I remind him of the golden hour for treating injuries. What will happen to the injured person's kidneys while they are waiting for a service that will no longer be there?
Mr. Hanly's report deals with general hospitals. It states that if there are geographical problems they will be sorted out. If one reads the report one will see that the same comprehensive range of specialist services in major hospitals on a 24-hour, seven day basis will not be provided. There will be no maternity, no accident and emergency department, no urology department, no orthopaedics. Many years ago I started a campaign for orthopaedic services in Castlebar because the situation was similar to sending somebody with a fractured hip from Dublin to Galway for treatment. That is why I started that campaign. There was supposed to have been an orthopaedic unit in Mayo General Hospital. The first cross I had to bear was with the Institute of Orthopaedic Surgeons. The same issue of centralisation is driving the whole situation forward. Let us be realistic. There is no way this report will be implemented because the money is not there. Even if the money was there, where is the manpower, such as the consultants and the support staff, and where is the capacity?
Mr. Hanly has a supporter in me; I suppose that is a bit of help. Like everyone else I have seen so many of these reports come and go that I get very pessimistic about them. Dr. Twomey and I were on a committee at one time where the stumbling block was always Bantry and what was to be done with Bantry. There appear to be far more Bantrys now than there were.
Let us deal with a few practical matters. I am terribly disappointed that Mr. Hanly is not involved in the implementation of the report and I think this is a dreadful mistake. May I ask Mr. Lynch if one of the first recommendations in the report is already under way - that every hospital must have a rostering officer? There are already problems about rostering and if they are not already in place, when does the Department intend to insist on them being in place? We cannot have private arrangements being made between consultants and NCHDs.
I am a little dismayed that Mr. Hanly believes so much of the flak can be taken by nurses. There is a significant shortage of nurses even as it is. I agree with Deputy Fiona O'Malley that a considerable amount of what is described as accident and emergency treatment is now being given by nurses anyway so that is not a significant problem in my view. We could do something about the pre-hospital emergency care services by passing the required legislation so that thrombolytics and opiates could be used. That would make a significant difference in the treatment of those who require to be taken some distance.
I agree with the report that it is well worth examining the existing grades in both surgery and anaesthetics. I am pleased that service levels such as were in the UK were ruled out in the report because they were very unsatisfactory and led to great disappointment among those who took up such posts.
Deputy Neville is correct to stress the situation regarding the psychiatric services. Most seriously ill psychiatric patients are taken to A&E departments. I would like to have seen a little more integration than that suggested in the report.
I am pleased that Mr. Hanly's report has emphasised postgraduate medical education and training but I believe there should be some better form of communication between the Department of Education and Science where the Minister appears to have decided on a very different type of medical education than was ever here before where a form of apprenticeship is part of the education. It is the most expensive sort of education one could have for the medical profession. It is very nice to have doctors, dentists, radiographers, physiotherapists very well educated but the expense involved has not been taken into account.
If Hanly report No. 1 is still immobile by next August because nothing will happen before the local elections, what will be done about Hanly report No. 2?
I welcome Mr. Hanly and his team to the meeting. I continue to receive very mixed messages because I am told that the A&E departments will be closed in what are called the local hospitals and yet will be much busier than they are at present. If Mr. Hanly had been delivering the report by General John deChastelain I am sure everything would have worked because no matter what one wants to hear, it seems to be arguable from sections of this report.
The Hanly report model offers an economically viable framework in general terms to regions of significant population density but given the actual position in Ireland where, for example, in the North-Eastern Health Board region there is a population of 345,000, its recommendation of a centre of excellence per 350,000 to 500,000 population would leave no accident and emergency service outside of possibly Cavan town. In practical terms, a road traffic accident victim in Drogheda would have to travel the two hour journey on a very bad road system to Cavan General Hospital. I question if that is viable in medical terms. I cite the same example in the case of maternity services. A pregnant woman in Dundalk encountering a difficulty or emergency will be forced to travel across to Cavan which is on the other side of that health board area. We are all aware of the consequences following the death of baby Bronagh Livingstone. I wonder why we had a better medical service in many areas of medicine 40 years ago. It is fine to say that 60% to 70% of cases presenting at accident and emergency units are not that serious but what about the 30% to 40% of serious cases? That is an alarming number of people presenting with very serious issues. What happens to those in the local hospital?
When dealing with costs, Mr. Hanly, you should also deal with the cost of appointing consultants. It seems to cost €1.2 to €2 million to appoint a consultant because of the team surrounding him. How do you propose to deal with this considering your report proposes adding another 1,700 consultants to the system?
Mr. Hanly
Maybe I will just get that one out of the way. The current rule of thumb seems to be that if a consultant is appointed, it will cost €1.2 million or whatever is the figure they have at the moment. We are suggesting that such thinking has to go. When appointed, a consultant is appointed to do a particular job. Under what we are suggesting, a consultant would be appointed to be part of a team of consultants, which would have a number of doctors in training working for the team. However, each consultant would not have the long stream of NCHDs they currently have. There would be a specialist registrar, a registrar, a couple of senior house officers and an intern per consultant. In the new order we do not believe that is necessary and it should not be there. That is the answer to that particular question.
I will now go back to the first questions, which I believe came from Deputy Gormley. One of the things the Deputy was saying is that we have conceded that bigger hospitals are not good. That is not what I said.
No, I did not say that.
Mr. Hanly
That is the way I scribbled it down here.
I said that bigger hospitals do not necessarily lead to better outcomes. I believe Mr. Hanly conceded that to Deputy McManus.
Mr. Hanly
What I was referring to there was that the very large hospitals are more difficult to manage and so big is not necessarily better in that context. Certainly bigger hospitals where there are multi-disciplinary teams of people give better outcomes. There is a lot of evidence to support that.
I will address the financial implications in relation to junior doctors or non-consultant hospital doctors versus consultants. As the Deputy is no doubt aware a new agreement with NCHDs was established about three years ago. Since then they have been paid overtime for every hour they work. The average pay of a junior doctor is now around €110,000 a year. The pay of a consultant in the public service on average is around €150,000 per year. We have produced figures based on 2003 numbers and if the number of NCHDs is reduced and the number of consultants is increased, the actual financial implication is relatively small. That is not taking into account capital cost and all the other things we talked about. I am just talking about the pure pay element on 2003 figures and I am not taking into account whatever may come out of negotiations with these various groups.
The gap between the two is much smaller than most people understand because of those recent agreements and because of the massive hours that junior doctors are working. Indeed a lot of consultants are working excessive hours particularly in smaller rural hospitals. There are people working one in two rotas, which basically means that every second 24 hours they are on duty for 24 hours throughout the year. That is unfair and unacceptable. They too are covered by the European working time directive, so this cannot continue either.
There are GPs working all the time who are not covered by any directive.
Mr. Hanly
I accept that and I will come to the various points the Deputy made about GPs in a moment. I accept that he is absolutely right. However, they are not covered by the European working time directive, which is perhaps the difference.
We are again back to the word "downgrading" and people saying we protest too much. Basically we are saying this a spin put on it by somebody, which we simply would not accept. What we have proposed here is a much enhanced integrated network of hospitals in each region and each region becoming much more self-sufficient. Many services that are currently being provided in the major centres and not available in those regions would not only be available in the regions but would be available in the local hospitals. A basic principle of trying to put this report together was to allow us safely to get as much of the service as close to the patient as possible. That was a fundamental plank of this particular report.
We are not saying that hospitals are being replaced by ambulances. That is certainly not the case. We are saying that in order to get people to the hospital where they can get the correct range of service for whatever their particular need is, a better ambulance service is needed. It does not replace hospitals but it will take people more quickly, more directly to the centre that has the service. If that service is relatively minor, the ambulance will take them to the local hospital, but if it is a major road traffic accident and multi-disciplinary services are required, it will take them to the major hospitals.
How do they get there without dying? What good is a major hospital if someone cannot get there?
It will be unfortunate if the language becomes alarmist. People in the centre of Dublin can get so acutely ill that they die even though there are hospitals all over the place. We have to be fair here. If somebody has an acute medical problem that requires intervention, as I said earlier, the treatment they get when they are picked up by the ambulance staff is probably going to be more critical than whether they go to hospital A ten miles away or hospital B 25 or 30 miles away. Every part of this country would like to have the peat of Benbriggan in each parish but we have to be sensible and realistic.
We need to provide the certainty that when a patient gets acutely ill or has a less acute urgent problem or a less serious problem there is a greater likelihood that more patients will get the care they require more speedily with the implementation of this report than is the current reality for a whole lot of patients all over the country. I would strongly advocate that this report would be closer to providing that certainty.
What about the example I mentioned earlier of a patient with a ruptured spleen who has to wait to get to Galway rather than Castlebar?
The Deputy is first of all presuming the outcome of phase two, which has not taken place. He is presuming a decision has already been taken——
The report says that. Mr. Hanly explained that accident and emergency, maternity, etc. will not be provided in general hospitals.
No, that is not actually true. If the Deputy reads the report, he will see that there is a provision in it which allows, for geographic and demographic reasons, the availability of a 24 hours a day, seven days a week emergency service including A&E and obstetrics precisely because the patients live in a location in which it would be dangerous not so to provide. It happens that, in the two pilot areas we studied, it was agreed and it was felt by the committee that there was not a requirement for that general hospital type of model. Clearly implicit, by mentioning it in the report, is the acknowledgment that when phase two commences, there will be in some parts of the country a requirement for a general hospital which will still function within the context of a network of hospitals. Where these will be has yet to be determined. It is not fair to say——
But what about the other specialties such as urology, etc.?
For patients, the services that are being proposed and advocated in this hospital will be hugely advantaged. I fully accept the biggest hospital is not best. I accept that smaller hospitals are extremely good and very efficient. This report is saying that in the future in a defined region of 350,000, regardless of the way structures are altered in our health system in the future, there will be the certainty of provision of a whole range of services and specialties which currently are not available. Even at the Cork University Hospital where I work - and the same would apply to any of the other regional hospitals around the country - there is a considerable amount of activity being undertaken which does not specifically have to be undertaken there. It could just as easily be provided in other hospitals affiliated to the network if the facilities were so arranged.
May I interrupt Dr. Twomey?
May I continue? In relation to orthopaedic surgery, there will be a minimum of five or six orthopaedic surgeons in our network for a population of 350,000. At any one time, there will be an orthopaedic surgeon on emergency duty, dealing with major accidents, while others will be doing outpatient clinics and fracture clinics. All of us are well aware of the chaos at fracture clinics in major hospitals at present. Many of the patients concerned will now be seen at their local hospitals for follow-up attention, as is more appropriate, having had their fractures dealt with in a major hospital. I have just taken orthopaedics as an example.
In reply to Dr. Twomey, the problem is that the local hospital to which he refers is almost as remote from Galway as from Dublin.
To which local hospital is Deputy Cowley referring?
In terms of sending somebody with a fractured hip from the end of Mayo to Galway, that is not much shorter than Dublin to Galway. However, there is a proposal for an orthopaedic unit at the Mayo General Hospital in Castlebar. Under the Hanly report, it is spelled out very clearly that——
That area has not been reported on. Deputy Cowley should wait until it has been reported on.
I cannot wait. The people cannot wait because it will then be too late - it will be a fait accompli.
In all fairness, only two areas have been covered at this stage.
(Interruptions).
It is written here in black and white that they would not provide the same comprehensive——
In fairness, Dr. Twomey addressed that particular issue from the report.
He did not address it. He misquoted from the report, which stated that the same comprehensive range of specialist services would not be provided to major hospitals on a 24 hour, seven day a week basis. It spelled out all the elements, but there is nothing about A&E, maternity services, orthopaedics, or——
There is nothing about Mayo, because it has not yet been reported on. Can we move on, Chairman?
I ask Mr. Hanly to continue with his responses to the questions.
Mr. Hanly
Certainly, Chairman. Deputy Neville referred to psychiatric care. On our task force, we had two psychiatrists and we met with the College of Psychiatry and the psychiatric groups in each area. Psychiatry comes under the working time directive also. What may happen to the older hospitals, in terms of upgrading, is not a matter on which I can give an answer as that was not within our brief, which was to ensure there was a proper psychiatric service in each region. In fact, the number of psychiatrists in each region is to increase substantially according to the report. The total number of psychiatrists in the east coast area will increase from 28 to 53 and, in the mid-western area, from 21 to 53. There will be a much wider range of psychiatric services including young adult, child and adolescent services.
It is envisaged, in that regard, that there would be regular clinics covering the range of psychiatric need, including elderly or old age, general adult, child and adolescent psychiatry in the local hospitals at a frequency commensurate with the existing demand and need. Psychiatry is very largely a community-based specialty. There are, of course, patients who require in-patient care, but a considerable amount of psychiatric medical intervention and care is provided on an outpatient basis, which will be more regionally spread throughout the dedicated network of hospitals.
We will be waiting for it. I fully agree it should be community based, but the investment over many decades has not been provided and the service is simply not in place. It is there in theory, but never implemented.
Mr. Hanly
We have certainly dealt with it in the report. On the question of the time span for completion of implementation in the two areas which were studied, it will probably take three to five years for full implementation in each area. The facilities have to be put in place and all of the required personnel recruited. Our strong recommendation - I understand the Minister is already working on this and may have acted already - is that the implementation project groups, both locally and nationally, will be put in place immediately. Once they are in place, they will begin to work on the two areas concerned. The reason it will take the length of time I have indicated, on which I am only speculating at this stage, is that it is difficult to be absolute as to how long it would take to recruit the 200 additional consultants needed for the mid-west. Also, the European working time directive will be phased in between now and 2009; accordingly, there is a six year period to implement fully.
In the mid-west, the Irish Hospital Consultants' Association gave the task force a vote of no confidence yesterday in stating that the result of Mr. Hanly's report would amount to 104% occupancy and that patients on trolleys would remain a permanent feature if the bed capacity problem is not addressed.
Mr. Hanly
I have not seen that particular report, if such it is, from the Irish Hospital Consultants' Association.
After a considerable evaluation of Mr. Hanly's report that was their view.
They are not saying anything in conflict with our report. We have taken it as a given that the additional bed capacity, which has been recommended as being needed, will be delivered. It needs to be delivered and I expect it will be delivered.
I would welcome an extension to the mid-west regional hospital to cater for the situation in three to five years - it did not happen in the past.
I will have to rule out interruptions in order to allow Mr. Hanly to answer the questions which have been asked already.
Mr. Hanly
All I can say in answer to what has been said is that we have made our recommendations and it is up to others to implement them. I will come to the issue of implementation in a moment. I have a list of Senator Feighan's questions, one of which related to access to consultants as the Senator's first concern. Given the implementation of this report, patients will have far more ready access to consultants, of whom there will be many more, on a daily basis. One of the fundamental planks is that the entire service would be consultant provided, not consultant led. Those consultants will not only be available in the major hospitals to deal directly with patients, but also in the local hospitals, where appropriate. In using the term "where appropriate", I am referring to outpatient clinics, day surgery and day medical procedures, all of which should be carried out as close as possible to the patient. Unlike today, there will be sufficient consultants to do all of that.
If I may——
The Senator may not. If I allow him to intervene, I will also have to allow others. He can intervene later.
Mr. Hanly
I believe I have already dealt with the issue of replacing hospitals with ambulances - that is simply not the case. The accident and emergency services - the current services to which Deputy O'Malley referred - are what we described as minor injuries and illness clinics. Those facilities will remain in all of the hospitals in which they currently exist - there is no question of doing otherwise. In relation to Portiuncula Hospital, I cannot give any answers because we have not looked at that. The situation is exactly the same as the one to which Deputy Cowley referred. We have to look at that region of the country, following which we will then make a recommendation as to what we believe to be correct. There is certainly no question of anything happening to Portiuncula until that recommendation has been made.
On the Minister's commitment to implementation, to which Deputy O'Malley and others referred, I do not know enough about how Ministers conduct their business and I am sure no Minister would give anybody an absolute commitment to do anything - that cannot be the way they do their business. However, I am aware that many past reports have not been implemented for whatever reasons, financial or otherwise. The imperative behind this report is the European working time directive. If we do not implement this report, this country will be open to the imposition of substantial fines by the EU. As I understand it, there are substantial fines per incident, per day. Since we have over 4,000 non-consultant hospital doctors, the bill could be a rather hefty one. This report has to be implemented. Nobody has suggested a viable alternative during our consultations and dealings.
The viable alternative is to put services in local hospitals - not to take them away.
Deputy Cowley will have an opportunity to speak later.
Mr. Hanly
It is absolutely essential that this report is implemented. The option of doing nothing simply does not exist because of the law. I assume that, as a country, we will comply with the law. That is my answer to the question "Will it be implemented?".
I thank Deputy Fiona O'Malley for her comments. She mentioned that this report was completed in a way that was above politics. That is absolutely true. We decided at the outset that we would not be influenced by the politics of this issue or by the industrial relations issues involved. If we had allowed ourselves to be influenced in this way, we would not have been able to come up with something we can stand over and that we believe represents an honest and objective way forward. Deputy O'Malley also argued that local hospitals will increase in importance. The task force certainly believes that local hospitals will increase in importance and will become more viable as institutions. We will be able to deliver many new services directly to patients. The things that will not happen at local hospitals are those things that should happen in large multi-disciplinary institutions. The Deputy also asked whether the concept of emergency medical technicians is a new one. It is not a new idea as training for advanced emergency medical technicians has already commenced. I will allow my colleague, Mr. Fergal Lynch, answer the question that was asked of him.
The Department is working on a number of aspects of implementation. The two major elements of this process are the reduction of NCHD working hours and the negotiation of a new consultant contract. The process of establishing discussions has been commenced in both of these areas.
The Minister has asked the LRC to convene a meeting of management and unions to agree a process for the NCHD hours issue. It is hoped that agreement will be reached in respect of an implementation group, which will comprise management and unions, to be established as quickly as possible. The Health Service Employers Agency has discussed this matter with the medical organisations.
The Department and the HSEA want to work intensively with the medical organisations with a view to agreeing a new consultant contract as quickly as possible. Work has started in that regard.
A third major element of implementation may be said to be the two phase one regions. We are working to establish pilot groups in the east coast and mid-west regions as recommended in the report. The groups will ideally comprise management and health professionals in all the hospitals involved. The working groups will conduct detailed work to identify the services that should be provided in each hospital, in line with the recommendations of the task force. We are discussing the best means of putting that in place with the local groups. We have started to make some progress in that regard.
A fourth element of implementation relates to the rest of the Hanly report - what could be referred to as Hanly phase two. We have already noted that a group chaired by Mr. Hanly will prepare a plan for the reorganisation of acute hospitals on that basis. We are ready to start our work in that regard pretty much immediately. I have summarised the main elements of implementation so far.
Mr. Hanly
I will respond to the questions asked by Deputy Cowley. He asked what we are doing about GPs. I answered that question earlier when I said that it is not part of our brief to do anything about GPs. The general practice, or primary care, task force is quite separate from this task force. We have said that many more GPs are needed in the system. It is not for us to say how many extra GPs are needed or where they should be located. We have simply noted that there is a great shortage of GPs and that many people who are working very hard in general practice need much more support. We fully endorse that.
The Deputy also asked about medical schools. I answered that question earlier. A report to be published soon will assess the numbers of people who need to be included in the system, not only if we are to have the numbers of consultants we have been talking about, but also if we are to provide sufficient numbers for general practice in the future.
There will be an interruption in supply.
Mr. Hanly
I am not quite sure——
If members of the committee wish to ask supplementary questions, they should make a note of them. They can ask questions after the delegation has concluded its response.
Mr. Hanly
Deputy Cowley also asked about the timeframe for implementation and how we can ensure it will happen. The task force cannot ensure it will happen. I respectfully suggest that those who can ensure it will happen are those in this room who are Members of the House. The more support the report receives from politicians, the quicker its recommendations can be implemented.
I was also asked about the possible downgrading of hospitals in the west. We have not said that hospitals in that region will be downgraded. We have not yet looked at the western region and it would be premature to make sweeping statements about the downgrading of hospitals in the region until we have done so. Where the geography and the demographics require it, we have said that there will be a general hospital in addition to the major and local hospitals that we have identified. The general hospital will have full accident and emergency services. Perhaps the principal purpose of a general hospital relates to distance and time. We cannot say where such hospitals will be located until we have completed phase two. I have already addressed all of that. Dr. Twomey has responded to a number of points related to general hospitals. He has spoken about whether they will provide orthopaedic or maternity services, for example. All of that is catered for. We will not know where the general hospitals will be until we have completed phase two.
Senator Henry asked about implementation, a subject I have already addressed. We believe there has to be implementation because there is no alternative. I have said that this matter is in the hands of the Minister, the Government and everybody else. The Senator also mentioned the issue of rostering officers. We have said that there should be centralised rostering in every hospital. The ad hoc basis on which it is done at present should not continue in the future. That is part of the management structure which we have addressed.
The Senator also made a point about nurses picking up the slack, but that is not our intention. There is no question of giving it to nurses if NCHDs do not like doing it - that is not what is intended at all. We intend that the role of nurses can and should be enhanced. Nurses are trained to do many things that they can legitimately do but which they are not doing today for various reasons. This is coming from the nurses. We consulted with all the senior nursing people in the two regions who said that they ought to be doing certain things. I will not go into a great deal of detail in that regard. We are consulting with the nurses in the region. It is not a question of trying to offload things. We are trying to have a much more efficient delivery of the service and nurses can play a major part in that. I am aware that there is a shortage of nurses, but that is a separate issue that needs to be addressed. I think that covers the various points that Senator Henry raised.
Yes.
Mr. Hanly
My colleague, Mr. Fergal Lynch, answered the question about what will happen on phase two.
While the proposal as regards assistants in the operating room and intensive care and anaesthesia appears to be a good idea, surely major training programmes and perhaps the agreement of the royal colleges will be required if it is to be implemented?
Mr. Hanly
Training programmes will need to be introduced and if all these things are implemented together, we should get a much more efficient and cost effective health service. Staff will do the things they were trained to do. One should not expect highly paid people to do things they should not have to do.
As we have not examined the position in the North-Eastern Health Board area, I am not sure of the source of Deputy Morgan's information as regards Cavan and Drogheda hospitals.
I cited them as examples.
Mr. Hanly
I ask the Deputy to wait until we have completed phase two. It would be wrong for me to speculate on which hospitals will do what and how the system will be structured. We have not yet examined how things are done in that region, but will do so.
I am not sure I can answer the question why the service was better 40 years ago. While I am not suggesting Dr. Twomey is older than me - he is not - perhaps he has some thoughts on the issue.
It is not fair to say the health service 40 years ago was better than today.
It is better in some fields.
Enormous advances, innovations and developments in health care delivery have taken place across a range of fronts. Who 40 years ago would have thought it would be perfectly acceptable for a person aged 88 years with aortic stenosis in the aortic valve to have the valve replaced? The attitude then would have been that the person in question is 88 years old and should look forward to a happy retirement. Advances in treatment, surgical procedures and diagnostic ability have been such that the level of care has vastly increased. In more recent times, we have had advances in cancer care and there are significantly enhanced proposals for cardiovascular disease. Health staff worked extraordinarily hard 40 years ago in extremely difficult circumstances with considerably more limited resources.
I also share Senator Feighan's view that many consultants in small hospitals already offer a consultant provided service. The current position whereby these consultants work extraordinarily long hours is unsustainable and it is unfair to expect them to work such hours.
If the general view is that the proposed changes amount to downgrading, people will believe that is the case if they hear it often enough. Equally, if we protest that this is not true sufficiently often, those who do not believe us will argue that we would say that in any case. I will illustrate this point with hard facts. The mid-west does not have a neurologist, nor does the region have an appointed consultant plastic surgeon - this service is accessed by borrowing a consultant plastic surgeon for one or two days a month from a neighbouring health board - or rheumatologist. It has 1.3 cardiologists, two physicians with endocrinology and diabetes expertise. In each of these cases, the plan proposes to increase the number of consultants to four or five.
Similarly, in surgery the mid-west region has 1.5 surgeons in vascular disease. The plan would increase this figure to four. Currently, the region has 1.5 urologists, bladder specialists, which will also rise to four. How can anyone argue that four as opposed to 1.5 urologists serving a region with a population of 350,000 will not enhance the urology needs of the people of the region? The additional consultants will not be appointed to the so-called centre of excellence, which is a term we should knock on the head. The plan envisages regional networks of excellence and doctors will be appointed to the region where they will do emergency work in major hospitals and an enormous amount of elective, ambulatory work in the local hospitals. This means access to outpatient clinics in any language.
Access to treatment when outpatient visits have been completed will be significantly enhanced and improved. It will be necessary to drive home this message because the current lack of specialty provision in some parts of the country is a disgrace. This report addresses this problem immediately, not by putting people into large hospitals but by placing doctors, in this instance specialists, into a network of hospitals in which they will undertake a range of activities in rotation. This will mean that when one is on acute care duty, one will not be expected to do a clinic in a local hospital or vice versa. Patients will benefit considerably.
I did not receive a reply to an important question regarding the 30% to 40% of people presenting at accident and emergency departments who will not be catered for under the report's proposals.
Mr. Hanly
I had intended to address that point and I will ask Dr. Twomey to address the fact that 60% to 70% of people who attend accident and emergency do not require to be admitted. Of the 30% to 40% figure only 5% to 10% have serious trauma. In between these two groups are those people who require to be admitted. The size of this group varies between hospitals and regions. I ask Dr. Twomey to clarify the issue.
An analysis of the data for attendances at the smaller hospitals showed that the percentage of people who needed to be admitted was smaller. In the so-called smaller hospitals we studied in the two pilot regions, between 11% and 17% of attendances required admission. This means a considerable volume of activity is taking place in these hospitals and this will continue.
We should not downplay the value of clinical nurse specialists and nurse led treatment units. Enormous advances have taken place in the competences of nursing and allied health care professionals and these will also be part of the package. The east coast area, for example, has several nurse specialists, including one in cardiology, to whom I alluded at the launch of the report, who has a particular interest and expertise in the management of heart failure and in co-ordinating the care of heart failure patients with consultants and general practitioners in the community in question. The person in question is able to identify and intervene much sooner in the care of patients than has been the case traditionally.
Published scientific studies on this issue show that a number of benefits accrue from the appointment of nurse specialists. The number of visits for hospital admission has been significantly reduced among patients with access to this service. In addition, when they are admitted to hospital their stay is considerably shortened because of the support of the nurse specialist in providing outpatient clinics and follow-up care in the home. Nurse specialists can work in many other areas, including diabetes and renal disease.
The mid-west currently has no nephrologist - a renal specialist - whereas it will have three in the new order. Renal failure and its management are currently co-ordinated by a neighbouring health board. A region of 350,000 people should be independent and self-sufficient in providing this service and implementation of the report's recommendations would be a significant advance in this regard. Patients would see the benefit fairly quickly.
May I make a further comment?
As we must leave at 1.35 p.m., members have ten minutes to ask supplementary questions.
Mr. Hanly stated the Government has no alternative to implementing the report if it is to comply with the law. The Government can comply with the law by taking an alternative route, namely, closing hospitals. The fear being expressed throughout the State is that this is what will happen if the money and commitment are lacking. This needs to be understood. In respect of the pilot regions, specifically the mid-west region, how many additional consultants will need to be appointed to guarantee cover from August next?
Page 75 of the document contradicts what Mr. Hanly has said. I am delighted he stated that general hospitals can and will offer other services. The alternative to the proposals is to put services such as urology and so forth into local hospitals. Where there are consultants, there are no waiting lists. This is about people, not money. Mr. Hanly said the proposals are about money, even though the report states the issue at stake is compliance with the EU directive, fines and so forth.
The witnesses mentioned ambulance services and helicopter emergency services. Did they consider the use of HEMS, helicopter emergency medical services? HEMS would provide a solution. Dr. Twomey will agree that a person with a ruptured spleen, for example, will die if he or she must wait to get to the centre of excellence in Galway or even Castlebar within the golden hour. Regardless of how many drips one puts up, saving the life of the person would require a flying intensive care unit, namely, HEMS. Were helicopter emergency medical services considered?
I welcome the statement that we cannot afford not to implement the report. It gives great hope that it will be implemented. Mr. Lynch referred to the pilot groups that are currently being set up. In due course, can we get a report on how they are working?
Mr. Hanly
There will be a balance between the number of consultants and junior doctors as we move forward through the implementation. I do not have the exact figures of how many we need by next August, in terms of the number of consultants, but we certainly need to be in the process of recruiting the vast majority of them. We will not get them all by next August. It will take a lengthy period of time and not all of them will be available.
In the current crop of doctors in training, a significant number are ready to be appointed as consultants. Equally, there are many Irish people working overseas who are anxious to come back into the system. The initial group who will be needed for the east coast and the mid-west can probably be achieved reasonably readily. It is more a question of whether the training system can turn out enough people for ten years from now as distinct from what is required immediately. We will be able to get the majority of the people we need immediately or at least within a reasonable timeframe.
Two hundred?
Mr. Hanly
We will not get 200.
If I can clarify, the trebling of consultants for the mid-west region is the projected number that would have to occur over a ten year period - between now and the year 2013. Clearly there will not be 200 additional consultants in the Mid-Western Health Board region in August but by 2013 there should be and we are saying that there will be.
How many are needed to guarantee cover by next August?
The pilot exercise will inform us of that. What will happen in the immediate implementation phase in the pilot areas will be this: we will look at the four hospitals, St. John's in Limerick - and by the way, St. John's has had a nurse led minor injury and treatment unit up and running for a considerable time which is working successfully - and the Mid-Western Regional Hospitals in Ennis and Nenagh. There will be immediate discussions to ascertain what aspects of work that are currently being undertaken in hospital A could quite easily be provided in hospital B and what amount of activity that is currently being provided in the mid-west in Limerick could be provided in Nenagh or Ennis, thereby freeing up some space to do the opposite exercise which is to have more availability of capacity to deal with the acute admissions that will go into the mid-west in the new order. It will be phased in. We would be happy to feed back to the committee on the piloting exercise when that practical experience of on the ground implementation is available to us.
That does not answer the question. The non-consultant hospital doctors can only work 58 hours a week from next August; somebody will have to provide cover when they are on leave.
As Deputy Mitchell saw in the report, there is a recommendation for some changes. For example, there is a pattern of practice in some hospitals which applies more in the major regional hospitals than the so-called smaller hospitals where there could be several layers of doctor on duty at any one time - an intern rota, a SHO rota, a registrar rota, perhaps a specialist registrar and consultant rota. What we are advising and recommending in the report is that first, those rotas can be flattened and instead of having a rota for interns and one for SHOs we can have an intern and SHO sharing a rota and perhaps registrars and consultants sharing a second rota. That is already a reality in some of the smaller hospitals but it does not happen in the bigger hospitals. The other issue that can be put into play straight away, and the rostering officer will be critical to this, will be to look at activities currently undertaken by doctors, things like resiting IV lines and drip tissues, reinserting catheters if blockages occur and they need to be taken out which traditionally have been done by doctors whereas, increasingly, it is acknowledged that they can also be done by other health care professionals, such as nurses. If a range of such things can be addressed it will help to meet the requirement for 58 hours by August 2004.
Does Dr. Twomey think that huge cultural change can happen in time?
The Deputy has had her say. Next question.
Mr. Hanly
The other question was if we had looked at the helicopter service. We looked at it in the general sense of ambulance services but a report is being done separately on helicopter services and——
It is long overdue.
Mr. Hanly
That could well be.
The final question.
It has been answered already.
I want to wrap up this session. I thank the witnesses for coming before us, particularly for the frankness of their responses. This has made a major contribution towards understanding what will happen, particularly in regard to smaller hospitals. This report will be a milestone in the history of health care. It will make an outstanding contribution to the delivery of patient led services in the future.
Mr. Hanly
I thank the Chairman and committee members.
The joint committee adjourned at 1.35 p.m. until 9.30 a.m. on Thursday, 6 November 2003.