With health top of the election agenda, Maev-Ann Wren predicts the likely impact of the Hanly Report in the different regions.
Hospital action groups are forming throughout the country in the lead-up to June's local elections. Bertie Ahern knows health can break governments, which is why he spoke solely on the issue in his opening address to the Fianna Fáil Ardfheis this month.
Could it be that Fianna Fáil is taking a principled stand on healthcare reform? Or does the evidence of fudge in the Taoiseach's address mean that the healthcare reforms proposed in the Hanly Report will be jettisoned?
Ahern was a minister in 1990 when the government did a deal with Independent deputy Tom Foxe on the future of hospitals in Roscommon and Castlerea, thereby avoiding defeat on a motion of confidence in the then health minister, Rory O'Hanlon. Fourteen years on, the spectre of Roscommon County Hospital looms over this June's local elections.
But now it is not just Roscommon's future which is in doubt. There is uncertainty about the future of hospitals in Bantry, Mallow, Tralee, Ballinasloe, Letterkenny, Cavan, Wexford, Naas, Blanchardstown and elsewhere - that is, hospitals in virtually every county.
What on earth is Fianna Fáil doing? The party that is prepared to turn the Civil Service on its head to achieve decentralisation appears to be centralising hospital services. What is the logic? How does one interpret the politics? Fianna Fáil has opposed the regional consolidation of hospital services ever since the publication of the FitzGerald Report in 1968.
The National Task Force on Medical Staffing, chaired by David Hanly, chairman and former chief executive of the PARC group with experience of running hospitals in the Middle East, has reported on only two pilot areas of the country and has not recommended the closure of any hospitals. Yet local hospital supporters are preparing for the battles they expect after publication of the second phase of the Hanly Report, which will apply its principles to the entire country. The above chart discusses its likely impact.
Since the first report recommended changes in hospital functions in the mid-west (Limerick, Ennis and Nenagh) and south Dublin (St Vincent's, St Michael's and Loughlinstown), an estimated 10,000 people have marched in Nenagh and 20,000 in Ennis. Defence Minister, Michael Smith was rebuked by the Taoiseach for his public criticism of the Hanly Report, and forced to apologise. Action groups are threatening to run candidates in the local elections.
This is not an ideologically motivated kamikaze action by the Government. The logic of the Hanly Report is fairly straightforward. Under the European Working Time Directive (EWTD) junior doctors must reduce their working hours from the current average (according to the Department of Health) of between 65 and 68 hours a week to 58 hours from August 1st and 48 hours from August 2009.
The hospital service already depends too much on junior doctors working long hours. Almost 60 per cent of hospital doctors are either in their first three years following graduation or, even when more experienced, are undergoing no higher training.
Smaller local hospitals are highly dependent on doctors from outside the EU who are undergoing no higher training. This is both unfair to these doctors and a cause for alarm in terms of patient care. The inadequacy of existing care is the subtext to the Hanly Report and widely accepted by doctors. Yet "your local hospital may kill you" is not the stuff of Department of Health PR campaigns.
It is now Government policy that the Republic should move to a consultant- provided service. Last October the first Hanly Report recommended that by 2013 the consultant workforce should have increased from 1,730 to 3,600 and that the number of junior doctors should have fallen from 3,944 to 2,200.
To deliver high-quality healthcare in the State's 36 so-called acute hospitals - with bed numbers ranging from more than 700 at St James's, Dublin, to 75 at Nenagh - the Hanly group proposed that hospitals should be arranged in networks, centring on a designated Major Hospital in each region, with satellite General and Local hospitals. The Major Hospitals would provide round-the-clock, seven-days-a-week, high-quality acute care and treatment in all but a few specialist areas, such as neurosurgery, which would remain available in only a few centres. For regional hospitals acquiring Major status, this would represent a substantial upgrading, which the Taoiseach emphasised at the ardfheis. Patients who had hitherto travelled to Dublin would be treated closer to home.
Meanwhile, the smaller hospitals of the network, where patient numbers could not justify investment in such large skilled teams, would be termed Local Hospitals. At these, consultants from the Major Hospitals would perform elective day surgery and medical procedures (now the bulk of hospitals' non-emergency activity) and conduct outpatient clinics. Overnight patients would be long-stay or in rehabilitation, primarily requiring nursing care. In place of an accident and emergency department (A&E), local hospitals would have a nurse-led minor injury clinic, capable of treating the majority of cases currently handled by the A&E. More serious emergency cases would go straight to the Major Hospitals.
Given that hospitals face enormous problems from the competing demands of emergency cases, patients requiring elective procedures and the so-called "bed-blockers" who no longer require acute care but have nowhere to go for a longer stay, this model offers a possible way of separating these functions within each region.
To the defenders of Nenagh, members of the Hanly group would point out that with only 7,414 new A&E patients in 2000 (of whom 8 per cent were admitted, under two per day on average) and with less than 5,000 admissions per annum, it is impossible to justify providing round- the-clock consultant cover in all the acute specialist areas. In its absence, should emergency or complex cases receive treatment there?
The Hanly Report identified a further category, a General Hospital, which, with too low a workload to maintain full teams in every sub-specialist area, would nonetheless continue to offer acute care. Such hospitals would be chosen for geographic or demographic reasons. So, it is widely anticipated that the hospitals in Tralee, Castlebar and Letterkenny will be recommended as General Hospitals in the second Hanly Report. Indeed, as the map above shows, seven or more hospitals could end up with this status. The Mullingar action group, which is presumably gearing up for a fight to the finish with Tullamore, may be agreeably surprised if its hospital is designated a General, or indeed a Major Hospital.
Hospital supporters are currently engaged in subterranean battles, each trying to prove the superiority of their hospital's claim for major or general status and suspecting that competitors are massaging their numbers. In Dublin, with five Major Hospitals, there is nonetheless anxiety about how rational principles might re-order hospital rivalries.
It seems likely that were there no EU directive on junior hospital doctors' working hours, there would be no Hanly Report and no Government commitment to its implementation. Muddling along with much patient care provided by junior doctors would remain the norm. The Taoiseach looks not so much like a man taking a principled stand as a man caught between a rock and a hard place.
For the Hanly plan to achieve either local acceptance or improved care, the Government must deliver in other areas, such as the 3,000 additional acute beds promised in the 2001 Health Strategy. This would require a programme of capital investment in hospitals unlike anything undertaken since the 1950s. If focused on the 12 potential Major Hospitals identified on the map, their average bed numbers would have to rise to around 700. Sligo and Drogheda would double in size. A Major Hospital in the Midlands would be, in effect, a new hospital, given that today there are about 200 beds each in Mullingar and Tullamore. The average bed numbers of these Major Hospitals might be kept lower by dispersing additional beds throughout the network.
It is a legitimate concern of the opponents of Hanly that the Government is showing no evidence of planning such investment. The Minister for Finance, Charlie McCreevy, stated in late 2002 that funding for the strategy could not be addressed before 2005. How will the Government deliver on its 2001 primary care strategy, which proposed a country-wide network of 1,000 well-equipped primary care centres staffed by inter- disciplinary teams and offering round-the-clock care? An additional 500 GPs and 2,000 nurses were to be hired to staff them by 2011. Hanly's newly designated Local Hospitals could host such centres. Communities would be assured of the availability of doctors at night (and fully trained GPs offer greater skills and experience than junior hospital doctors undergoing no training).
Instead, there is a staffing crisis in general practice. GPs' fees are high and GPs tend to refer patients to hospitals. Understandably, in the absence of accessible primary care (free in most other EU states), local communities see their hospital's A&E as a lifeline.
Another essential prerequisite for Hanly to work is investment in the ambulance service and in staff trained to treat patients en route to hospital.
Hanly group members agree that their strategy cannot work without the extra acute beds, the primary care strategy and investment in ambulances. Although some opponents of Hanly oppose it root and branch (see panel below), others concede that were these three components in place, they might find the plan acceptable. Disagreement on the feasibility of Hanly can come down to one's view of the Government's bona fides and its commitment to investment in healthcare. And local communities have reason for suspicion, given the Government's track record since the last election.
Instead of reassuring doubters by producing a credible investment plan, the Taoiseach has attempted to assuage local concerns by promising continued overnight medical cover in all acute hospitals. This looks more like a fudge than an essential compromise of the Hanly principle that local hospitals should not provide emergency care, since medical cover could be provided by a GP. Now medical supporters of Hanly are asking why they should defend the plan when the politicians undermine it. Meanwhile, David Hanly has expressed disappointment about the silence of hospital consultants in the two pilot areas, the majority of whom he says agreed privately with the taskforce's approach.
The Government is stuck with the issue of local hospital reform, with no end in sight. The Hanly group won't publish the second part of its report in July as originally promised. The Irish Hospital Consultants Association is blacking Hanly's work as part of its protest about clinical indemnity. For the same reason, there have been no negotiations on the consultants' contract of employment, which must change if they are to work as rostered members of teams. It remains to be seen if the Government will pursue a public-only contract, essential if the two-tier system is to end.
Meanwhile, the health boards will soon disappear once the Government legislates for the new centralised Health Service Executive. The real crunch on junior doctors' hours won't come until 2009 and might even be deferred for a few more years. The local elections are the least of the Government's worries. What about the general election of 2007? Health will dominate politics until then and beyond.