Vol. 574 No. 5
77 Ms McManus asked the Minister for Health and Children his proposals for changes outlined in the Hanly report for the two pilot areas, the East Coast Area Health Board and the Mid-Western Health Board; the staffing and financial requirements involved; the timeframe envisaged; and if he will make a statement on the matter. [27546/03]
81 Mr. Hogan asked the Minister for Health and Children the timescale envisaged for the implementation of the Hanly report; and if he will make a statement on the matter. [27396/03]
99 Mr. Sargent asked the Minister for Health and Children his views on whether certain aspects of the Hanly report may not be implemented due to a lack of support; and if he will make a statement on the matter. [27599/03]
125 Mr. Broughan asked the Minister for Health and Children the steps the Government plans to take arising from the publication of the Hanly report on medical staffing; if the Government is committed to the provision of and funding for 3,000 additional hospital beds, a doubling of hospital consultant numbers to 3,600, the establishment of regional specialty self-sufficiency and the upgrading and retraining of emergency medical technicians; and if he will make a statement on the matter. [27549/03]
139 Mr. Durkan asked the Minister for Health and Children the hospitals most likely to be affected, positively or negatively, in the context of the implementation of the Hanly report; and if he will make a statement on the matter. [27587/03]
I propose to take Questions Nos. 77, 81, 99, 125 and 139 together.
I will shortly appoint project groups to progress detailed implementation at local level in the two regions studied by the task force. The project groups will be asked to identify the exact services to be provided in major and local hospitals in the two regions. In addition, I will soon appoint a group to advise on the reorganisation of acute hospital services nationally. The group will be chaired by David Hanly and will be asked to apply the principles of the task force's report to the rest of the country and to devise a national plan for the reorganisation of acute hospital services. In doing so, it will be asked to have particular regard to the demographic and geographic factors affecting local communities. It will also have full regard to the requirements of the European Working Time Directive, which requires substantial reductions in the average number of hours worked by our non-consultant hospital doctors.
I emphasise that no changes in services are proposed until hospitals have the required facilities and staffing to take on the new roles proposed for them. The training of emergency medical technicians to advanced standard will be a key requirement in this regard.
I hope I will be afforded the same leeway as the Minister and the previous questioner.
We have 18 minutes for this group of questions, let us not waste any of it.
I am not wasting time, but making a point. As I did not have a chance to ask a supplementary question earlier because I was cut short, I want to make the point that the controls on time are slightly ad hoc. I hope I am treated fairly.
As regards the pilot areas, the Minister has announced his intention to set up implementation bodies. Will he answer the obvious criticism which will be levied at him as a result of his track record, namely, that we are still waiting for the promised national implementation body, chaired by an independent chairperson, due to be announced in mid-October? In the meantime the process which developed out of the Brennan report has become bogged down in bureaucracy.
When precisely will the implementation bodies for the two pilot areas be established? Will democratically-elected public representatives have a voice on these bodies? Does the Minister not recognise that there is a growing feeling among many people outside the medical establishment that the Hanly report was dominated by hospital consultants and did not sufficiently address or recognise the needs of patients?
In his reply to an earlier question, the Minister used the vague sentence that it would take a number of years for the pilot area changes to be instituted. What does this mean? Will they be long-fingered due to lack of funds or dissension in the ranks of Government? Why have guinea pigs if the pilot schemes will be quickly overtaken by Hanly II, due for publication next August, which the Minister indicated will result in the extension of the schemes to the rest of the country?
With regard to the east coast area, is the Minister aware that one of the hospital accident and emergency departments he intends closing, St. Colmcille's Hospital in Loughlinstown, is treating 500 patients on an average, typical week and that the equivalent figure for St. Vincent's Hospital, which is due to become a major hospital, is about 780 patients? Does he have any concept—
I must intervene. The Deputy has greatly exceeded the minute allocated to ask questions.
I will conclude. I am merely matching everybody else as a matter of honour. Does the Minister have any appreciation of the demand which will be exerted on St. Vincent's Hospital's accident and emergency department if he proceeds to close St. Colmcille's Hospital accident and emergency department in line with the recommendations of the Hanly report? He should not shake his head, nor repeat nonsense about minor injuries units.
This is disgraceful.
These nurse-led minor injuries units will operate from 9 a.m. to 5 p.m. or 8 a.m. to 8 p.m. at maximum.
I must intervene under Standing Orders.
They are not accident and emergency departments and the sooner the Minister starts to tell the truth about this issue, the better.
The sooner the Deputy starts to tell the truth about it, the better. This type of emotional rhetoric is calculated to maximise the political advantage she wants to gain from this issue. That is the truth of the matter.
Is Deputy McManus lying?
I repeat that no one has said that any accident and emergency department will close.
Hanly has said it.
He has not said that.
Hanly has said local hospitals will not provide accident and emergency servcces.
—and I have said this from time to time.
Ask Deputy Killeen what he thinks.
If people wish to deliberately mislead, that is their prerogative. If the truth were told, Deputy McManus's proposals for the health service, which were to privatise it, would have closed Nenagh and Ennis much faster—
Rubbish.
—than any proposal put forward by Hanly. That is the truth.
That means the Minister is closing them anyway.
A slur was cast by Deputy McManus on the consultants involved in the Hanly group to the effect that they did not have patient care at the heart of their deliberations.
I did not say that.
The Deputy did.
I did not.
The Deputy certainly did. The Deputy said that because consultants were in the group, patient care might not have got the same consideration.
I want a right to reply to this.
The first prerequisite considered by the group, which included consultants along with Hanly and other non-consultants such as public health personnel, administrators and so forth, was patient care. On another day and in a less politically charged atmosphere Deputy McManus would agree with much of the report. She has in the past agreed with the need to move to a consultant provided service and to reduce hospital doctors' working hours to 48 hours per week. People cannot have a bet each way and every way, which is what the Members are seeking.
With regard to Loughlinstown, the accident and emergency department will not be closed down. We are not closing down a department and moving every patient to another department.
Is the Minister saying it will be open 24 hours a day?
Those are matters which can be worked out locally in terms of implementation. It can be.
That is not what the Hanly report says. The Minister is misleading the House.
Band aid hospitals.
The Hanly report says otherwise. Is the Minister changing Hanly?
Order. Please allow the Minister to reply.
I am not changing it. The Deputy should read page 68 of the report. It deals with certain agreements. It is probably not on a 24 hour basis in terms of accident and emergency.
There will be no accident and emergency department to deal with small injuries.
The Deputy is well aware that we do not have senior consultants on a 24 hour basis. What is she talking about?
The Minister is not talking about junior hospital doctors but about consultant provided services.
We do not even have that at present. People are talking about 24 hour cover when we do not have it in terms of senior consultant provision. Everybody says we should have it. No services will be transferred until facilities are in place and investment is made. Nothing will happen until there is an ambulance service in place which can provide the type of EMTA training that is required.
It will never happen.
People can draw certain conclusions from the Hanly report and hype them for political purposes. That is the game in the political arena but it does not do justice to the future of the health care system.
Does the Minister agree that the Hanly report is just one plan among many? It is not the holy grail and it is not our patriotic duty to accept it in total, as has been indicated. That is extremely arrogant. Given that so many people agree with much of the content of the report and that it is the arrangements for accident and emergency departments that are causing distress, would it not be bull headed to stick slavishly to that aspect without considering what people actually want?
The report states that an irreducible number of 21 consultants must be on site. Most hospitals have never had that and it is not what they want. People are choosing something similar to what they have at present. Surely it is not beyond human ingenuity to provide 24 hour cover in many of the hospitals throughout the country and still proceed with many of the principles which underlie Hanly. That must be possible.
The Minister says that nothing will happen until services such as the ambulance service and the improvement of local GP services are in place. How does that fit in with the implementation of the working time directive next August in the two pilot areas? There is a 16 week cycle and within 16 weeks of 1 August we will know if the target of 58 hours per week is being met. If not, and it will be extremely difficult to meet it, what will happen to those hospitals, given that nothing will happen until the ambulances and so forth are in place? How will it be possible to have those services in place by this time next year?
The Hanly report will not be implemented by this time next year.
The Minister said it should be.
The working time directive has to be implemented.
The working time directive has until 2009 to run.
The hours have to be reduced to 58 hours.
The Deputy asked a fair question. The terms of reference the Hanly group received related to reducing junior doctors' hours to 48, achieving a consultant provided service and organising an acute hospital service from that. I am not saying that when we establish the project team it will follow every syllable of the report. The project team will take the principles in the report on board and see how they reflect into the locality. The team will include representatives from the local hospitals and will be independently chaired. There will be flexibility for the local group in arriving at its conclusions.
I have already asked the House for a substantive alternative to this report. It is fine to knock and condemn the report but I challenged the House last week to come up with a substantive alternative—
It is a little disingenuous to ask us to come up with an alternative.
—in the context of the working time directive. It is a fair question.
Over the last number of years, as the Oireachtas and the Governments have watched, the College of Anaesthetists, the College of Surgeons and the Institute of Obstetricians and Gynaecologists have been making new rules and drawing up new guidelines to comply with international best practice. These are having a huge impact on whether accident and emergency services or surgery continues in hospitals. We can continue to ignore that phenomenon or do what I am trying to do, which is to put a blueprint in place that will offer a degree of certainty about what will happen over the next ten to 15 years. For the last four years I have watched hospital after hospital getting into difficulty because of this phenomenon. We need to deal with it in a proactive way.
It is not coincidental that Deputy Killeen has decided to grace the House with his presence at this point.
I am present at least as often as the Deputy.
Who is telling the truth about the Hanly report, Deputy Killeen or the Minister? The Minister has vehemently and repeatedly assured the House that accident and emergency services will not be downgraded in Ennis and other hospitals. Deputy Killeen is telling his constituents something different, that they will be downgraded but that he will stop it. What is the truth?
Another untruth from Deputy Gormley, unsurprisingly.
My colleague, Brian Meaney, will stop it if he has his way. The Minister spoke about the challenging terms of reference given to the Hanly group and said that people wanted an every way bet. If matters remain as they are, the Hanly report is not implemented in terms of the downgrading of accident and emergency units and the working time directive is implemented and we comply with it, what extra expenditure will be required? I have seen the extra expenditure required in Germany for compliance with the directive and keeping the system as it is. If things stay as they are and we comply with the directive, what extra cost will it involve?
Hanly originally costed the changing of the ratio between junior doctors and consultants at approximately €100 million in today's prices. In other words, the number of junior doctors would remain as it is and the number of consultants would double. Given the closer proximity in pay scales between the two in recent years because of the pay deal concluded in 2000, the costs are not as exorbitant as they might have been under the older pay structures that prevailed prior to 2000.
I passionately believe in a consultant provided service. I do not wish to encourage more marches but it is worrying that thousands did not march to protest the fact that there is only one rheumatologist in the mid-west and only one neonatologist on the western seaboard.
There were 15,000 marching against the Hanly report.
I acknowledge the importance of accident and emergency service provision but we need to change the way we have historically planned the development of acute hospital services. It has evolved in a patchy way with a concentration of services in the east. This concentration has moved somewhat to Galway, Cork, Limerick and Waterford and there have been other developments throughout the country. However, many people in the west still have to travel to Dublin, as do many in the south-east and the mid-west, for a range of specialties that should be provided within those regions. The positive benefit that can result from the Hanly report is stopping that one-way traffic from the regions.
Deputy Killeen has every right to be in the House. He has always been a consistent advocate for Ennis General Hospital.
Like the Minister, Deputy Michael Smith, in Nenagh.
No, he wants to work constructively with the Hanly proposals.
He is posturing.
He has communicated likewise to me long before there was any brouhaha about the issue.
I have a specific question on the remit of the project groups in the pilot areas. Will they be in a position to address the perceived consultation deficit in the Hanly report? I am not sure whether the deficit is the fault of the consultants in the group who prepared the plan or the consultants and others in the areas. Will the project groups examine the accurate numbers put through accident and emergency in Ennis, for example, which caters for 22,000 people rather than the 15,000 which has been considered? The project groups will undoubtedly examine the geography and the demographics and reach inevitable conclusions. It would be helpful if the criteria for general hospitals were set out more clearly than at present and if the project groups were enabled to examine the relative cost benefits or otherwise of proceeding along the Hanly route or the more sensible route of improving the level of services in the existing acute hospitals.
What are the inevitable conclusions?
In answer to the first question, the local project teams will be in a position to consult local interests in working out what is required by way of additionality, including services and facilities. On the accuracy of numbers, this should be ascertained in an area if there are issues around the numbers attending accident and emergency departments and so on. I am informed that the vast majority of people turn up in accident and emergency departments between 8 a.m. and midnight, which is the critical period. An analysis of figures is important. Some of us might be surprised to discover the numbers who turn up in accident and emergency departments.
It is more than the Minister thinks.
The issues of accident and emergency and medical cover to which Deputies Killeen and Olivia Mitchell referred are the two issues that have been crystallised in recent weeks. I welcome the debate because it is a long time since we have had a decent debate on acute hospital services. I put out a challenge last week that I would be prepared to examine the issues if there was a substantial alternative to the way we do business in the context of the parameters set in terms of the 48 hour working week and the consultant-based service.
Will the Minister accept that we need to have a truthful debate? Will he consider what the Hanly report said, namely, that St. Colmcille's Hospital, St. Michael's Hospital, Ennis General Hospital and Nenagh Hospital should function as local hospitals?
I am sure the Minister will agree that one of the redeeming features of the Hanly report is its clarity. It states that a feature of the local hospital is that it would provide a nurse-led minor injury unit for an extended day intake, for example, and that all major traumas and medical emergencies would go directly to the major hospital. There is nothing clearer than this. It also states there should not be a requirement for on-site medical presence overnight or at weekends, but that would take a little longer.
The Minister must be honest and accept that the Hanly report states that there should be no 24 hour accident and emergency service in these hospitals run by doctors with nurses. They will become local hospitals with minor injury units – a daytime service provided by nurses. This is not an accident and emergency department in anyone's language.
On Deputy Killeen's question, will the Minister explain the range of consultation that will be held given that the Hanly report is so specific in its recommendations and the Government was so specific and made a clear statement that it supported and would implement the report, although it is now becoming a case of whatever you are having yourself? Consultation will not change the facts because the Hanly report is specific about the end of accident and emergency services in St. Colmcille's Hospital, St. Michael's Hospital, Ennis General Hospital and Nenagh Hospital. Let us not divert from the facts as stated in the report.
The facts are not as articulated by the Deputy. The Hanly report does not advocate closing accident and emergency departments and sending every patient who turns up at them elsewhere. The Deputy is working a clever play on language. She says that, if accident and emergency as a title is gone, the accident and emergency department is closed. The reality under the Hanly proposals is that 70% of those who attend at accident and emergency departments will continue to do so in the same department.
That is not the case because nurses will provide the service.
The Deputy inquired about the Hanly report. The context I have outlined is the true one in which the proposals around accident and emergency departments are framed.
Just because nurses—
Hanly did not invent this. I made a point earlier about the Royal College of Surgeons. I can list the hospitals over the past three to four years that were under threat in terms of their accident and emergency departments. We had to intervene and work agreements with the Medical Council or with the college to preserve accreditation for junior doctors in some of these hospitals to maintain surgery on-call, including accident and emergency services overnight.
Underfunding?
I could list seven, eight or nine hospitals where we have had these difficulties and challenges. It is better to try to plan a blueprint for the future which would end that uncertainty. In the intervening years, the Government set up a forum comprising the colleges and the Medical Council to try to avoid sudden jolts to the service because of accreditation issues.
The Minister has exceeded his one minute.
The Medical Council visited Ennis over two years ago and produced a report. There had to be sudden interventions to meet the requirements of the hospital, the health boards and the Medical Council to reach a workable agreement. This cannot go on forever.
I want to ask the Minister one simple question. When David Hanly was in Ennis last week, he said that the report was the Bible and that no aspects of it could be changed. He said it would have to be implemented in full. Does the Government propose that there could be changes to the Hanly report, especially where the 24 hour accident and emergency service is concerned, to suit the backbenchers and the 15,000 people who marched last week in Ennis? There will be more marches on this issue. Is there room for manoeuvre on the Hanly report, especially on accident and emergency services?
I have replied to this issue already in terms of the need for people to come up with substantive alternatives.
Is there room for manoeuvre?
The Minister is asking us to come up with alternatives.
I am not. The Government has accepted the Hanly report.
Order, please. The Minister is in possession.
It is disingenuous to ask the Opposition to come up with alternatives to the Hanly report. The Government is three years—
The Deputy is being disorderly. She has not been called.
The Hanly group has produced the blueprint. It goes back to 1998 when the Manpower forum was formed. Much of this is not new. It has been well signalled, not just by the Hanly group but by other professional bodies, in terms of accreditation and so on. Obviously people have political and other concerns.
In regard to working out the Hanly report principles in a local context, it has been signalled that project groups should be established in both these regions to work through and flesh out the details of the report in so far as they apply to the services in the mid-west or the east coast area.
Is there room for change?
As a general practitioner I am concerned about one aspect. The Minister said that 70% of people will continue to attend accident and emergency departments. I am concerned about the 30% of patients with a serious illness who will not receive the treatment they require.
Let us take the case of Ennis which I visited last week. Some may have to travel 70 miles to Ennis. There is a golden hour. No matter what one does, one cannot do anything for the man with the ruptured spleen who is bleeding internally. He has a greater risk of dying if he has to get to Limerick hospital. It is not possible to give him the service he requires which is an emergency operation. Unless helicopter emergency medical services are available and he is adjacent to the hospital – Ennis is more adjacent than Limerick – the bottom line is that man will not survive. Has the Minister considered helicopter emergency medical services? It has been mentioned in the Hanly report. That is a service that is badly needed. In the context of Hanly such a service is definitely needed.
I cannot see how Hanly can be implemented by downgrading Ennis General Hospital which will be a nurse-led unit. I was in that unit last week. It reminded me of Mayo General Hospital before money was invested in it. What that hospital needs is to have money invested in it and not taken out of it. If one is looking for an alternative that is it – invest in Ennis General Hospital. I cannot understand why some of the 24-hour consultants cannot be sent to Ennis General Hospital where there is a greater need for them than in Limerick. What is to happen to those 22,000 cases who are seen at Ennis General Hospital? To where will they go? Limerick Regional Hospital cannot cope at present. This is pie in the sky and the Minister knows that.
On the issue of trauma, some health boards, even those in the mid-west, recommend that people should be taken to the major hospital. That also applies in other parts of the country. What the Hanly group says is that the first line of response in this area would be a properly-trained ambulance service, up to emergency medical technician advanced stage.
He cannot perform an operation.
I am not saying he can. In the event of a major road accident, even before one gets to any hospital, be it a local or a major hospital, one could still be an hour or two away from a hospital, given the topography and rural nature of the country. The first prerequisite in the implementation of the Hanly report is to get that EMTA training in place and to get a properly expanded and strategically placed ambulance service in place. During the past three or four years we have invested significantly in the ambulance service and significant progress has been made.
The Deputy asked about a helicopter service. We have undertaken a feasibility study on such a service with the authorities in Northern Ireland. My priority would be to build up the ambulance fleet on the ground first, in every part of the country, to give adequate coverage to every part of the country.
Geographic and demographic considerations are fudging the issue. As Deputy McManus said, we want clarity. Were the geographic and demographic factors taken into consideration by Hanly in the pilot areas or can the implementation groups take into consideration the geographic and demographic factors? Is it Hanly, the implementation groups or both who take them into account?
Will the Minister accept there are serious implications for a number of hospitals throughout the country contained in the Hanly report, some of which have been mentioned? Will he clarify what undertakings he has given to his backbenchers in the discussions he has had with them recently on this matter? Has it been determined that a rolling scrum will roll around the countryside meeting the expectations of all those concerned depending on where they might be, or is it intended to wait until after the next general election to pull the plug on all those hospitals in their entirety?
Deputy Neville said he was appealing for clarity. I am not sure that certain Deputies across the House want clarity.
We are inviting the Minister to give it.
It might not satisfy their political objectives if they got clarity. They have a greater motivation in clearing the fog, so far as I can see.
Is the Minister saying "Yes" or "No"?
My understanding is that health boards bid to become pilot areas under the Hanly group.
That is not question I asked.
The Minister should answer the question.
Allow the Minister to conclude.
It is a very relevant point. The health boards in the areas said this was something good and that they would make a submission to get in on it. Why did the health boards make that bid? They did so because they saw additionality coming to the region.
My question was about the demographic and geographic factors.
I am answering. They were taken into consideration by the Hanly group.
Written Answers follow Adjournment Debate.
