I thank the Minister for Finance for taking this motion. Last week I referred to areas I wish to cover — the absence of proper hospital and health facilities in the mid-west region with particular regard to the provision of proper consultancy services akin to those available in other health board areas.
The Mid-Western Health Board are seriously concerned in this regard and a plan has been drawn up to correct the situation by bringing facilities and services in the mid-west up to the level of other health boards. To this end, in October 1989 the Mid-Western Health Board requested Comhairle na nOspidéal to review the consultant manpower requirements for the mid-west in the light of a large number of consultancy vacancies both current and pending in the mid-west area. In response the comhairle set up a committee of seven of its own members to carry out a wide ranging review of consultant services in the mid-west; they produced an in-depth comprehensive study of hospital services and compiled a dossier of information on the level of activities in the four acute hospitals in the mid-west — the Limerick Regional Hospital which included its associated maternity hospital and the orthopaedic hospital in Croom; St. John's Hospital; Ennis General Hospital and Nenagh General Hospital.
Management and consultants at these hospitals were afforded the opportunity of making an input into the final report. Problems identified in that report indicate the crisis prevailing at present in the mid-west health service and appropriate action to correct the situation was outlined. The report stated that major changes were occurring in the consultant establishment in the mid-west areas mainly through retirements. The number of retirements up to 1995, together with vacancies existing at present, constitutes 29 per cent of the total establishment. In addition, there are ten newly appointed consultants who have taken up duty in the last two years. The extent of the change involves in excess of 40 per cent turnover of consultants in the area.
The changes occurring through retirement are more profound than might appear. Modem training programmes are radically different to the training of consultants in the past. Changes in specialisation have happened at an increasing rate within each of the major disciplines of medicine. Being less of a generalist than his/her predecessors, the modern consultant is more dependent on the availability of colleagues in allied specialties. Medical litigation is an increasingly constraining factor in attempting to practise as a generalist. All this will have a bearing on the situation now developing in the mid-west. Because of improved employment conditions young consultants are not willing to undertake the onerous commitments of continuous on-call which consultants of 30 or 40 years ago accepted as the norm. It is not possible to replace like with like in the case of retiring consultants in the mid-west.
The hospital scene in the mid-west has, over the last three years, undergone dramatic alterations. Developments have included the closure of Barrington's Hospital and the consequential relocation of services to Limerick Regional Hospital and to St. John's Hospital. The increased demand on the facilities of the Limerick Regional Hospital which were in any event badly in need of improvement has resulted in grave strain on services in that hospital. Staff of Limerick Regional Hospital have worked commendably under extremely difficult conditions and are only too aware of the difficulties there. The maternity unit in Cahercalla Hospital in Ennis was closed and virtually all births in the mid-west are now centred on the Limerick Regional Maternity Hospital with an increased gynaecology workload being undertaken at the Limerick Regional Hospital and to some extent at St. John's Hospital.
In 1988 there was a significant and permanent scaling down of the bed complement of each mid-west acute hospital. The reduction of beds at St. John's Hospital was fixed by the Department of Health at 22 per cent; 230 beds overall were lost in the mid-west in 1988.
Existing consultant services are totally inadequate and compare unfavourably with every other health board area. The administrative area of the Mid-Western Health Board comprises Limerick, both city and county, with a population of 164,500; County Clare with 91,300 and Tipperary North Riding with a population of 59,500; the total population of the board's area is 315,500. The most striking feature of the population profile is that 58 per cent of the total population in the mid-west resides within a 20 mile radius of a central point in Limerick city. From the viewpoint of hospital services this is particularly important since there is a single centre which a majority of the population regularly access for a variety of services, including shopping, entertainment, etc.
The largest acute hospital in the area is the Limerick Regional Hospital, which has a scaled down bed complement of 376. Since the closure of Barrington's Hospital the only other acute general hospital centrally located in Limerick city is St. John's Hospital — a small voluntary hospital with 90 beds plus a ten bed day unit.
In 1990 Comhairle na nOspidéal's consultant manpower statistics indicated that the mid-west, which contains 8.9 per cent of the population of the country, has only 6.1 per cent of the total consultant establishment. The consultant population ratio in the mid-west is one per 4,600 population compared to the national average of one per 3,200 population. The comparative figure for the east is one per 2,300 population; in the south it is one per 3,300 population; and in the west it is one consultant per 3,100 population. In the mid-west, the consultant ratio of one per 4,600 population is the worst of any region in the country. All these indicators point to an under-provision of consultant manpower in the mid-west. To achieve the same consultant population ratio as in the south, that is one consultant per 3,300, an additional 25 to 30 consultant posts would have to be created.
The current deployment of specialists is designed to deliver a general — and this is important — rather than a specialist service in the two main disciplines of medicine and surgery. Further the relatively even distribution of general physicians and surgeons between the four centres makes it extremely difficult for special interests, to be developed within the overall group of consultants. Comhairle na nOspidéal state that Limerick Regional Hospital is only marginally stronger in general medicine and surgery than the other three hospitals; I contend that it cannot therefore be properly called a regional centre for the two clinical branches of hospital practice, medicine and surgery.
At the same time the resources of the smaller general hospitals are not used to their full extent for the delivery of appropriate specialist services, for example, outpatient clinics and day care services. It follows, therefore, that referrals for specialist services must flow from the mid-west to other centres. Seventeen per cent of patients from Clare, 15 per cent of patients from Limerick and as many as 26 per cent of patients from Tipperary North Riding were treated in hospitals outside their health board area in 1990, reflecting the absence of proper services in the mid-west and a major weakness in the consultant manpower profile in the area. This, in the comhairle's view, constitutes the major priority to be tackled in providing proper medical services for the mid-west.
While problems of space, facilities or lack of beds exist at all four general hospitals, the deficiencies at the Limerick Regional Hospital relative to its activity and regional role are the most serious and acute. There are only three theatres and a recently opened day theatre for a total of 16 operating consultants. The orthopaedic surgeons cannot get access to the theatre for acute trauma except outside normal working hours. Gynaecology is restricted by the same problem. The radiology department is divided in two by a public corridor and it is unacceptable that the public should be constantly passing through a radiology department where patients wait on stretchers, in wheelchairs, and in various stages of undress for X-rays.
Key areas such as the availability of theatre time to enable surgeons to operate and the availability of a reasonable number of beds are very basic. There is an urgent necessity to give early relief to the area of theatres, beds and diagnostic facilities. Looked at from the perspective of consultant manpower, the other three general hospitals, Nenagh, Ennis and St. John's, are small hospitals which cannot be expected to encompass the multi-disciplinary spectrum of consultant level services which modern medicine requires. Their immediate catchment population is insufficient to generate enough overall clinical activity to justify the broad range of consultant expertise in medicine and surgery which their present roles as general hospitals open to all types of conditions and emergencies would require. However, they do have resources and potential to facilitate the delivery of nonresidential specialist care to their local catchment populations, thus minimising the necessity for patients to travel to a major specialist centre and alleviating the demand on the hard pressed facilities at the centre.
In terms of consultant staffing levels, An Comhairle is firmly of the view that the standards to be adopted should at least equal those currently provided in other parts of the country with similar sized population. It is only fair to expect in the mid-west that the level of services outlined by An Comhairle should be funded by the Government. The majority of major teaching hospitals in Dublin, Cork and Galway serve populations in the region of 200,000 to 300,000. The population of 315,000 in the mid-west is entitled to hospital services of similar scale and complexity from a specialist viewpoint as those provided for similar sized populations elsewhere in the country.
The policy of the Mid-Western Health Board is to develop the hospital services on the basis of a flagship hospital with complementary and supplementary roles for the other acute hospitals in the area. We believe that the regional hospital should be the flagship hospital of the region and that adequate investment should be allocated by the Government to ensure that the hospital is brought up to the level of similar hospitals in other regions.
The present state of development in the mid-west falls considerably short of the situation elsewhere. Other areas with populations of similar size already have a consultant manpower profile akin to what we are seeking to have provided in the mid-west. Funding to develop the specialist, as distinct from general, services on a regional basis for the mid-west as a whole should be provided in Limerick city utilising the services of the four general hospitals in the area in a complementary fashion in order to maximise the potential of all existing facilities.
I have in front of me a chart of the allocations to health boards between 1975 and 1990. The capital allocation to the mid-west region was about £12 million, to the southern region, which is nearest to us it was £62 million, to the western region it was £40.5 million, to the southeast region it was £60 million, to the eastern region it was £43.5 million and to the midland region it was £30 million. We are the poor relations in the mid-west getting only £12.5 million. This information was given to the Mid-Western Health Board by the chief executive officer at a meeting of the board on 13 December 1991.
I would now like to refer to another area of health care which is causing concern in the mid-west. At present there are 499 mentally handicapped people in the area for whom the health board do not provide either day or residential care. This represents 29 per cent of the mentally handicapped people in the area. Of the 499 persons requiring assistance, 183 are considered by the health board to be in urgent or immediate need of services; of those, 137 are in need of residential care — 60 of them have moderate handicap while 77 have severe or profound handicap. There is a great deal of concern about this in the mid-west and the friends of the mentally handicapped in the region have set up an organisation to lobby for funding. It has been estimated that the cost of providing the facilities necessary for the mentally handicapped in the mid-west would be £6.5 million. In the region of £350,000 was provided for that service this year. Of the 183 who are considered to be in urgent and immediate need of services, only five extra will be provided with residential care in 1992. This is totally inadequate. I would ask the Minister to convey to the Government our concern and request him to ensure that funding is provided to relieve this growing problem. I cannot over-emphasise the importance of this proposal and the concern of the people in the mid-west who have to deal with the handicapped, their parents and those caring for them. Next summer more people who are in need of residential care will come out of various institutions into the mid-west. That care is not available to them. We must recognise that, thankfully, the mentally handicapped are now living longer than heretofore because of an improvement in modern medicine. Places in the hospitals and in the centres do not become vacant as quickly as they did in the past and there is therefore a need for additional facilities.
As a Member of the Oireachtas Joint Committee on Commercial State-Sponsored Bodies, I wish to refer to the paltry provision given to that committee to do a very important task. The provision for 1991-92 for consultancy and publicity work of the joint committee is £40,000. Compare this to the cost of investigations into just one company which came under the auspices of the joint committee — the former Sugar Company, now Greencore. It cost the State £2 million to investigate the difficulties which arose in that organisation. The Oireachtas Joint Committee, as the State's watchdog on 27 companies, is given £40,000 to complete its work. That is derisory and would be comical if it were not so serious. A new and proper approach to the work of that body should be taken by the Government. It is a very important watchdog over the State's interest and investment in 27 companies, but it is inadequately funded. This shows the Government are not taking the work of the committee seriously.
The Oireachtas Joint Committee drew up a series of recommendations with regard to its own position in the past 12 months and I would like to refer to some of those recommendations. The committee, as currently resourced and empowered, is severely handicapped from carrying out the incisive and pervasive examination required of it under statute. Considerable resources in themselves will not guarantee 100 per cent effectiveness; nevertheless it can be argued convincingly that it is unreasonable and disingenuous to require the Oireachtas Joint Committee to act as an alert watchdog with only extremely limited resources — in the region of £40,000 in 1992. In order to do its work effectively the joint committee made five key recommendations:
(i) it be given power to compel witnesses to attend or produce documents and that penalties apply for non-compliance in accordance with procedures to be determined by law;
(ii) the question of the privilege of witnesses be resolved by extending qualified privilege to witnesses before public meetings of the Joint Committee;
(iii) a formal mechanism be provided to facilitate debates on its reports;
This is an ideal House to debate the reports of joint committees of the Oireachtas. We should use this House more to bring the views of Oireachtas representatives to bear on reports completed by that committee. The two remaining recommendations were:
(iv) adequate resources be provided; and
(v) the review of the sub judice practice be expedited as a matter of urgency.
Finally, I would like to raise another issue, the mistake the Government made designating one of the best and the most successful harbour in the west — Foynes Harbour — as a local rather than as a commercial port. The Government have effectively downgraded its status which will seriously inhibit the development of the port at Foynes; they should immediately reverse this decision.
The Operational Programme on Peripherality states:
The strategy for commercial seaports will place particular emphasis on the provision of appropriate port capacity and quality port infrastructure, strategically located in relation to the main internal transport arteries.
The strategy will promote investment in ports which are essential for the efficient and economic movement of export goods and the import of raw material for manufacturing.
In this context the following commercial ports have been selected by the Irish Government for priority investment: Dublin port, Rosslare Harbour, Waterford and Cork ports.
Foynes was not selected by the Irish Government for priority investment.
