I welcome the representatives from Teamwork Management Services, Mr. Martin Dove and Mr. John Saunders. They are here to discuss the report, Improving Safety and Achieving Better Standards: An Action Plan for Health Services in the North-East. I ask them to curtail their opening statements to ten minutes, if that is possible, so members can have 30 minutes in which to ask questions and contribute to the debate.
Teamwork Management Services: Presentation.
I understand a copy of the presentation on which we base our opening statement has been circulated to members. Members may also have seen the report which was produced in June. It is nice to see one or two familiar faces of members who attended the briefing we gave when that report was presented.
With regard to our terms of reference, we were asked to investigate four important issues, namely, the optimal configuration of acute services according to international norms and best practice; the risks and benefits of the current services; the gap between current services and best practices; and, perhaps most importantly, the production of an action plan for delivering safer and better services.
Global changes in health care are being largely driven by three factors. The first driver comprises advances in health technologies in a variety of different areas, such as genetics, changes in patient treatment from inpatient to day case settings, increasing home care and telemedicine and other new technologies. The second driver is the huge advance in patients' expectations from health services. Patients demand the best and increasingly prefer self-care to staying in hospitals, one of the reasons for which is MRSA. The third driver pertains to the increasing needs of the elderly. In the north east, the projected increase of the aging population is in the order of 25% by 2015. All these factors mean that current systems for providing services will not be able to cope with future requirements.
I will now specifically address the current system for delivery of acute care in the north east, with a particular emphasis on issues which force compromises on patients and staff. The current system is locally based, offering five sites across the north east. As a consequence, limited numbers of true emergency patients are generated from the small local populations which have easy access to a small number of consultants. Due to a catch-22 situation which has arisen from an insufficient workload to justify a full specialist team on every doorstep and too few consultants to provide 24 hour supervision, these populations are exposed to unacceptable levels of clinical risk. These issues give rise to significant problems in terms of poor staff health, low job satisfaction, frustration, excessive stress, deskilling and dysfunctional behaviour, all of which predispose the system to clinical errors, failures of recruitment and, eventually, failures of service.
Having painted a stark picture of the current system, what can we learn about the shape of health care in the future from international best practice? We investigated international best practice by assessing health systems in the USA, Australia, Canada, New Zealand and other parts of Europe, as well as Scotland, Wales, Northern Ireland and England. By 2015, treatment will be as close to home as possible, with a variety of different health care services being delivered to patients in the home. These services will include primary and community care, chronic disease management, emergency care, hospital at home and home telecare. Treatment will also benefit from the advent of smarter homes, which will be designed with patients in mind, and a variety of social housing schemes. Immediately surrounding the patient at home service is a full range of locally based primary and community services. Members will be aware of the expansion in community and primary care teams and these services will also include a local community bed base.
The intention for the future is to provide services for the vast majority of the population in and around the home, local and primary care and local hospitals and other centres. The types of care provided close to home will include emergency care for minor injuries, local assessment, planned care for day surgery, short stay services and outpatient facilities. A range of diagnostics will be made available locally to support the care of routine conditions and minor emergencies, to provide facilities for visiting specialist consultants and to develop nurse and therapy led services.
Specialist regional hospitals will support local services for populations of between 300,000 and 500,000 people. This is where specialist acute services for emergency care, including accident and emergency services, major trauma, complex medicine and surgery and critical care, will be based, along with specialist surgery, which is dependent on critical care, and advanced high-technology diagnostics. Today's standards for the delivery of care in specialist hospitals requires teams of eight or more specialist consultants who can provide specialist and sub-specialist care and access to advanced diagnostics.
These services cannot exist in isolation because they have to be bound closely together. We suggest four different factors which can ensure the seamless delivery of services. The first factor comprises clinical networks which operate across the spectrum of care from special hospitals to the patient. The second area involves information technology, where major advances are needed in terms of single electronic patient records and clinical communications. The third factor is real time communications and remote advice using telemedicine, while the fourth involves ensuring quality based on peer review, best practice, pathways of care and clinical governance.
Clinical networks exist not only on a hospital basis, but also extend across the spectrum of health and social care. They require formal clinical teamwork in all services which is focused on the needs of patients and fosters the delivery of streamlined and best practice pathways of care. We have identified some of the networks which are needed for emergency care, planned care, critical care and chronic disease management, among other matters.
Our report asked the HSE to consider two sets of recommendations in the action plans, the first of which was, in the very short term: to establish a north-east steering group; to appoint a project director; to take immediate action to improve patient safety in a number of areas; to establish clinical network groups; to work on a national standards co-ordination group; and to implement a programme to build local services, clinical engagement and networks. In the longer term, our recommendations were: that there should be further engagement with various groups: that the most appropriate location for the regional hospital in the north east should be considered; and that a complete implementation strategy should be prepared to deliver a world class health service for the north east.
I thank Mr. Dove for his presentation. It is a pity representatives of the Department of Health and Children and the HSE are not present to discuss the matters raised with Teamwork Management Services. Many of the questions posed in the report will never be answered without the presence of a much broader spectrum to discuss it.
Why do so many leave the north east for health care? Is it due to the lack of services in the area or because there are poor outcomes in hospitals in the region? Is there a perception that hospitals in other regions are better? They are distinct elements. If there is a lack of resources, the matter can be corrected to improve the position in hospitals in the region. If there are poor outcomes, there is a radical need to change matters along the lines Teamwork Management Services advocates. If there is merely a perception that something is wrong with hospitals in the region, somebody must be fuelling this perception. It is necessary to present strong evidence to the committee that something along those lines is happening in the north east before we can accept some of the points the delegation has made.
It is necessary to consider whether the most appropriate action for patients is to resource hospitals in the north east or act on the more aspirational idea that a new hospital should be built to deliver care to patients in 15 years. Many patients in the north east will require to be treated between now and 2015 and beyond. There is a huge lack of trust in the Government and the HSE to deliver. I do not wish to insult the delegation but it is a very long journey between the ivory towers of an aspirational idea in respect of health care delivery and the front line trenches from where health care is delivered.
There have been two fundamental reports on health service in the past five or six years. One dealt with the primary care strategy, on which Mr. Dove touched, while the other dealt with the health strategy, Quality and Fairness — A Health System for You. The primary care strategy which was the easier of the two to understand aimed to deliver primary care centres, not primary care teams. The Minister who announced the project spoke of approximately 200 primary care centres across the country but as we approach the end of 2006 there are ten. Realising the aspiration is a very long journey. There is a huge gap between aspiration and delivery. This must be taken on board before the report of Teamwork Management Services can be taken seriously by politicians, especially those from the Opposition.
Mr. Dove focused on telemedicine and services to be delivered in the community by 2015 but some of the aspirations ten years ago have not materialised. That also applies to what was promised five years ago. There is huge underresourcing of general practitioner services, while public health nurses cannot provide the services to which he referred. In the budget for 2005 €70 million was set aside for small IT projects across the health care system concerned with the delivery of patient care but not one cent of that €70 million has been spent and the Estimates for next year are about to be announced. Mr. Dove will understand that members of the Opposition are very cynical as to the likelihood that telemedicine will become a reality in our houses.
Was Mr. Dove aware when he wrote the report of the number of advanced paramedics operating in the north east? Does he know whether the legislation is in place, the level of training provided or if regulations have been made to allow paramedics to deliver the drugs needed? Does he know whether the ambulance fleet in the north east can cope? The services which he suggests will replace centralised services are not in place. Primary care services cannot cope. Advanced paramedics are not available in the numbers needed. I have a reasonable knowledge of the situation in the north east and believe there are huge deficits.
On a number of occasions Mr. Dove mentioned that there was demoralisation but I would be grateful for his opinion on the level of service provided in the north east. Many believe services in the region are on the point of collapse because of under-resourcing. What is needed is not a grand plan for the future but a huge sticking plaster to stop services falling into the sea. Services are in a bad state of affairs in terms of consultant numbers and resourcing. Even in Our Lady of Lourdes Hospital, Drogheda, the subject of the Neary report and subsequent recommendations made by Judge Harding Clark, there is a shortage of 40 staff nurses and midwives. It is amazing that, despite a report being delivered to the Government just over one year ago, the hospital is back in crisis in respect of nursing staff.
Those are the practicalities that must inform any discussion on the health service. I would love to be a professor in a well resourced private or Dublin teaching hospital talking about what we would like to see in the north east, the mid-west, the south east or the south but, in reality, communities are getting a raw deal.
Services in the north east are the way they are because they have been starved into submission. It is the most underfunded health region, per capita. That is a deliberate ploy to run down services in preparation for change. Deputy Twomey said that before the report could be taken seriously by politicians, certain things would have to happen. Regrettably, it is being taken very seriously by the Minister and the team she is putting in place to implement the proposed changes. What are Mr. Dove’s views on how they are being implemented? If we are to read the Teamwork Management Services report as a theory document, the theory is good. The services outlined are good, to some extent, although I would like to see a number of changes in that regard. If, however, we were serious about change at any level of the service, there would be a period during which there would be dual funding to ensure a smooth transition of services from one area to another but that is not happening. In implementing the changes proposed in the report all we will witness is a withdrawal of services. That is the view of the current board which refers to the experts in Teamwork Management Services in that regard.
In the past maternity services were removed and we were promised replacement services. We were also promised a midwife-led ambulance service to cover emergencies and emergency teams. I repeat that midwife-led units will never be provided outside a level 1, 2 or 3 maternity care hospital because they would not be safe. The prospect was tossed at us as a carrot but I would prefer a degree of honesty.
We learned a lesson at Our Lady of Lourdes Hospital, Drogheda, that will have to be taken on board in respect of the new regional centre of excellence. An excellent deal was offered to maternity staff to transfer with the maternity services. The board could not be faulted on that score but staff did not transfer. I can see the problem recurring in Our Lady of Lourdes Hospital. As staff are happy to travel a certain distance to work, they voted with their feet and stayed at Monaghan General Hospital, despite the very best deal being offered.
At times our reactions to reports are misjudged. For example, I know change is required in the health service and better services are needed. I would be very foolish to sit here and state we have adequate services when we do not. Much of the time people feel we want an all-singing and all-dancing hospital on every crossroads. I know this is not achievable. What we require are very basic services, and I am suggesting how those can be complemented.
How would removing services from Monaghan General Hospital be of benefit? For example, last Thursday the Minister told this committee that a better service would be provided. The first action of the Minister will be to close the acute medical ward in Monaghan General Hospital, taking us off acute medical cover operating 24 hours a day, seven days a week. She will close down the high care unit in Monaghan, the accident and emergency facility and the medical on-call service, which is approximately 95% of the services.
This is the type of better service the Minister will provide. She will replace the existing services with a seven-day, 12-hour, nurse-led accident and emergency unit. The Minister also stated the hospital will have a residential component. This news was delivered last Thursday to every public representative in Monaghan. Every public representative and all political shades of opinion were completely united in opposition to the proposed changes.
We were told they would be provided at Cavan General Hospital, initially, until the Cavan hospital suffers the same fate as us and its intensive care unit is closed and moved to Drogheda. This frustrates us. Any day the national trolley count is announced, two hospitals in the north-east account for 20% of the total. Of those hospitals, Our Lady of Lourdes Hospital in Drogheda regularly puts out radio adverts appealing to the public not to attend the hospital as it cannot cope.
The Minister, with the Teamwork report at her back, thinks this is the opportunity to close the Monaghan facility, which is effectively what is being done. There is talk about leaving us with a residential component, effectively leaving us as a step-down nursing home. That is not my interpretation of a better service, nor is it the interpretation of the public and every public representative in Monaghan. If there is a better service out there, we would be very foolish not to go out and grab it. People would vote with their feet.
The Minister recently wrote an opinion and analysis article, in which she indicated that small local hospitals should not provide certain services. The types of services referred to included AIDS treatment, total joint replacement, paediatric surgery and aortic aneurysm surgery. She was absolutely correct in her views. I agree there is no place for that type of procedure in a small local hospital.
Why should an already overcrowded and overworked regional centre of excellence perform five-day surgery? Why should it carry out minor or intermediate-level surgery? Why can that not be passed back to the local hospital? The local hospital should be allowed to perform at a level where it has proven itself.
Monaghan General Hospital carried out hernia surgery and cleared the waiting list for Craigavon. There is a role for smaller hospitals. I agree that having a consultant for accident and emergencies in a hospital every night is neither practical nor financially possible. With telemedicine and different modern ways of delivering services, why can a senior registrar or some other professional not be on call?
The volume of work is not that great, but we had a practice run at what is now being proposed to be implemented on a full-time basis, running from mid-2002 until January 2005.
I will allow Deputy Connolly resume in a minute, but I have promised to let people in before the Order of Business.
I have another engagement.
The Deputy may continue then.
When those services were withdrawn for that period, between 2002 and January 2005, the loss of 17 lives was attributed to the withdrawal of services at Monaghan General Hospital. We addressed this issue in speaking to Professor Drumm, who told us we were scaremongering. If there is no alternative service, how are we scaremongering? This is what is proposed again, and it will cost lives. I am talking about having a unit at the smaller local hospital, where a patient could be stabilised. If the life is saved, I would have no difficulty moving forward.
The whole nation might be fed up hearing about Monaghan General Hospital. The regrettable aspect of this report is that this is a template for a national delivery of health care services. This is a pilot project in the north-east region and it has implications for the five hospitals there. The penny has not dropped with the people.
The Minister stated that 20 hospitals around the country will suffer the same fate as we have, or enjoy the same fate, as the Minister might say. The recommendations in the report are required, but we also need our local services. The Minister and the Department of Health and Children will meet difficulties at every turn.
People may currently think their local hospital is not under pressure, and money may be spent on it. More money has never been spent on Monaghan General Hospital than now, and a fantastic upgrade to two of the wards is being carried out. There is a state of the art six-bay accident and emergency unit that most of the major hospitals around the country would die for. Other hospitals may think they are safe because certain plans or actions have been announced. The fact is they will suffer the same fate.
I regret this will be driven through without consideration for replacement services. The term "better services" has been used but my interpretation of "better" is that if a person's life is under threat, that person can get to a service immediately and be saved. It has been indicated to us that Monaghan will have a viable future, it will be a great facility and it will have much work. I do not care how much work the hospital does; we should get back to basics. If my life is under threat, I should be able to go to Monaghan General Hospital and be stabilised, before being taken further if necessary.
I ask that the report be reconsidered. Our views should at least be taken on board or else witnesses should be critical and tell us where we are wrong.
I appreciate that I am not a member of this committee, but the Teamwork report has serious implications for Cavan-Monaghan. I welcome the opportunity to meet the Teamwork personnel. We met at the launch of this report, and we were told several things would be done within three months. Thank God that has not happened, and I hope common sense will prevail to ensure it does not happen.
Mr. Dove referred in one of his slides to poor staff health, low job satisfaction, frustration, etc. I wonder who Mr. Dove is talking about. I know he is at a grave disadvantage in that the terms of reference objected to his engaging with any of the personnel or stakeholders in the hospital. However, the witness does not appear to be talking about the people I know. I know two brilliant surgeons — there were three until the death of Archie Moore — and until their protocols were curtailed by management they enjoyed their work and experienced great job satisfaction in working for the betterment of Northern Ireland. Then they had the rug pulled from under them.
The summary of the Walsh report, which coincides with the Teamwork Management Services report, cites continued failure on the part of management over a sustained period as the main reason for the death of Pat Joe Walsh and related issues. I do not know why the Minister for Health and Children, and former Tánaiste, brought in Teamwork Management Services through the Health Service Executive but refused to allow it interact with local people so they might understand the group's goals and decisions.
The good news, as announced by the Minister and HSE representatives recently, is that the ventilation unit in Monaghan will not be closed down. A single bed was provided in the Our Lady of Lourdes Hospital, Drogheda, and everything will be fine if it is provided with personnel. I want to make it clear that this was not the type of answer we sought.
My brother has served as a Presbyterian minister in Scotland for the past six years and I saw a centralised hospital work perfectly there. However, it was in place before services were removed, not afterwards and the situation here does not make sense. As Deputy Connolly has noted, the record will show the number of deaths that have occurred, yet the Minister will only say we are scare-mongering on the issue. Even this week the famous country and western singer Big Tom McBride and his family thought it safe that he be looked after in Monaghan General Hospital. He has no financial problems, but he knows he will get the best possible service there, near his home, and that speaks for itself.
I have studied hospital services on Prince Edward Island, Canada, the Isle of Man and in Scotland in a layman's capacity as part of an Oireachtas group. In Scotland there is a primary care service that stretches as far as John O'Groats and which is second to none. Rather than merely talk, Scotland has delivered. When we visited the primary care centre patients were waiting to be seen by the six doctors, chiropodists and staff. As Deputy Twomey noted, this sounds very good but our history of delivering on suggestions and proposals is not good. To create security in the health service we must first ensure we give the necessary support to local health services in the short term until we can deliver better services in the long term.
A report for the North Eastern Health Board in 2004 stated that due to major increases in numbers, especially in Meath and Louth, the area was €130 million short in terms of funding and 1500 short in terms of staff. As Deputy Twomey pointed out in the Dáil yesterday, the so-called centre of excellence in Drogheda, which people in the north east are supposed to attend, is short a dramatic number of staff. The proposals to upgrade structures have been put on ice and we have no alternative.
We will have to come to a conclusion.
My conclusion will be short and to the point. Services should not be removed until they can be provided to the same standard, or better, elsewhere.
I remind members the group from Teamwork Management Services has published a report on reducing or adding to health services and I request responses.
Mr. John Saunders
The report sets out a clear direction of travel for the short, medium and long term, though the Deputy sees a credibility issue, which I respect, relating to a history of non-delivery of support in the north east. The direction of travel set out in the report is not one devised by Teamwork Management Services, it is one followed in numerous other similar countries which is, therefore, robust and evidence based. The issue of transition from things as they stand to the new direction of travel is a difficult, contentious subject because it relates to the current shortfall in services and the intention to reduce this before a new system is put in place.
We have consulted the HSE and others and strategies are under development. The primary, community and continuing care, PCCC, and ambulance strategies are more advanced than the acute direction of travel. The issue of a preference for having one's life saved in Monaghan, Roscommon or wherever does not take the argument far enough.
The direction of travel suggests the emergency response should come to the patient not that the patient should go to a particular institute, as is traditional. This means the ambulance and pre-hospital services must develop a more sophisticated clinical response that will start to save the patient's life and institute treatment wherever he or she may be. This is in line with the ambulance strategy being developed in Ireland and 50 advanced paramedics have been trained and will graduate this year. This is the direction of travel for the ambulance service.
The issue, which is legitimate, is where these services in the north east are provided. Allied to this is the issue of the future facing over 40 accident and emergency departments across Ireland, based upon the number of people each sees every year. Where accident and emergency departments suffer due to a small volume of patients that does not justify a full team of consultants, the appropriate response should be services for minor injuries and illnesses. This is part of the advanced nurse-practitioner development programme.
All this involves an investment in local workforce skills and competencies, ambulance services and minor illness and injury services which dovetails with the PCCC strategy. There must be a major investment in the local workforce. I understand why the bricks and mortar attract all the attention, but the improvement of local services comes through people. This transition is part of how things are implemented in real life. This is not happening in the north east at present but the plans are advanced and are working. The issue is the timescale. The withdrawal of any service before that is in place does not seem to be common sense or appropriate. It is a matter of balancing that act in terms of how we maintain services and transit to the director travel that we have laid out. My first response is to examine the emergency response at local level, which is to save these lives, but it is not dependent upon a traditional accident and emergency circumstance in an institute.
Mr. Dove
One of the other questions posed was what has happened since the report was produced. The report came out in June. We had not been involved subsequent to June but we understand, in terms of the Health Service Executive's actions of picking up some of the issues we raised and starting to address the management issues that have come up, that three things have happened. One is that a steering group is being established under Mr. John O'Brien to take forward the issues set out in the report. The second is that a project team has been set up to work out how the changes will be implemented. The third is that the embryonic structure for the future clinical networks across a number of specialties within the north east has been set up.
There is now a structure to start examining the practicalities of improving the local services at the same time as starting the ground work for what is required for the regional hospital. It is our understanding, in terms of implementation and action, that the HSE, through a three-strand approach, is looking to develop local services and start the ground work for developing a new regional hospital.
We have ten minutes left in this slot.
I agree entirely with Mr. Saunders's remark to the effect that it is not common sense to withdraw services before putting in place a replacement service. I would like to think that what we are about here is common sense. That is our appeal. We want better service first. Let people vote with their feet. We are being hammered in that our services are being withdrawn. I referred to the need for what I would call dual funding. We should let people see what we have got and then let them see the better service. That remark by Mr. Saunders made a good deal of sense.
On the question of communication, the representatives said they had discussed issues with people. One of the major complaints people have at ground level is that the service providers — the consultants, the staff at Monaghan General Hospital, the GPs in County Monaghan, the surgeons in Cavan and Monaghan — have been ignored. They are the people who are expected to pick up the slack and deliver this new service. Those service providers have not been consulted about the withdrawal of service. The backbone of the representatives' report relies on grades of staff that are non-existent.
The representatives referred to the training of advanced paramedics. There are approximately two dozen paramedics in the eastern region but there is not one paramedic in the north east. An advanced paramedic is one of the planks of the service delivery in the report. That grade does not exist yet our service is being withdrawn.
On the notion of advance nurse practitioners, there is one advance nurse practitioner in Monaghan, but one person can only deliver so much. Are the representatives in a position to monitor how their report is being implemented? That must be done. To simply present a report and tell us to get on with it is not good enough. I would like that comment to get back to the Minister, the implementation team and the head of the steering group, Dr. Eilis McGovern. They should know that the authors are not happy or that their report is being misinterpreted. We owe it to the people of that area to do so.
It must be borne in mind that this is a pilot project in the north east. It is in the nation's interest that it is rolled out smoothly because when the focus is moved to the Clare-Limerick area or the Loughlinstown, south Dublin area, which will happen, the people in those areas will be equally opposed to the report.
The perception of what is happening on the ground can be very different from the reality. Deputy Connolly quoted the Minister, Deputy Harney, who said that no small hospital should treat aneurysms and do hip replacements. I am not aware of any small hospital treating aneurysms or doing hip replacements. The Minister is either being disingenuous or she does not know what she is talking about. No hospital of a certain size would dare do an aortic aneurysm because they would not have the expertise. It is wrong to confuse people with that sort of talk.
The concern of the public is that the Hanly report, which recommended downgrading a significant number of hospitals, is very much Government policy. Even though the author of that report, the Minister, Deputy Martin, has moved on to the next photocall, and Mr. Hanly has moved on also, their legacy remains for the people. We must look after the health service and even though what the representatives say in the report might be best for the people of the north east, the reality on the ground could not be further from the aspirational ideas in the report. That must be made clear.
There is only a handful of advance nurse practitioners for accident and emergency services here and they are more likely to stay in one of the major accident and emergency departments than to take up a post in an accident and emergency department in Monaghan hospital or a hospital of similar size.
Comhairle na nOspidéal produced an accident and emergency report which again was written by consultants for consultants. It said that every hospital in the country should have an accident and emergency consultant. Prior to that one of the surgeons in the hospital had responsibility for the smaller accident and emergency departments. With the advent of medical admissions units, the work that should properly come into accident and emergency, the trauma cases, remained under the care of the general surgeon on call in the smaller units, but in the mad rush to achieve Mayo Clinic standards, we are losing the run of ourselves as to the way the health service is organised, and that is not helping patients. The aspiration must be put up for examination but the reality of what is happening on the ground should be shown also.
The representatives should not be here on their own. They should be here with representatives from the HSE and the Department of Health and Children to allow us make the contrast between what they believe is best practice and the actual practice on the ground.
I appreciate the views of the representatives but they must appreciate where we are coming from. Our area does not have the road structure to allow us to access an ambulance service. I am aware of a case where an ambulance brought a patient from Cootehill to Cavan. The man's wife met him in Cavan and on the way from Cavan to Drogheda the ambulance crashed and both of them ended up in hospital. The road structure is unacceptable and that must be taken into account when we talk about having top quality ambulance personnel and so on. That is not the sole answer. I welcome the comment that we must have a service in place before a service is removed. That message must go to the Minister and to the HSE personnel.
We have had a good exchange. I thank Mr. Dove and Mr. Saunders for coming before the committee and outlining the report for us. We will have an opportunity to discuss it with the Minister when she comes before the committee in January.
Sitting suspended at 11 a.m. and resumed at 11.05 a.m.