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Major concerns on mid-west revamp plan
[ by Niall Hunter, Editor www.irishhealth.com]
There is a key line in the HSE's statement outlining the plans for the centralisation of hospital services in the mid-west, recommended in the Teamwork report, which after a long delay has finally been released by the HSE.
The HSE, referring to the new facilities that will be needed in the Mid-Western Regional Hospital in Limerick and in the smaller hospitals following the revamp of services, admits that while these developments will require additional investment, "the majority of the funding will need to come as a result of new ways of working and organising services."
There is no mention in the HSE's statement of the exact level of capital funding that will be required to make the changes proposed.
Nor does the HSE statement refer to the Teamwork report's recommendation that 135 extra beds and a new A&E be built at Limerick regional to accommodate services moving from the smaller hospitals and that Ennis, Nenagh and St John's hospitals be redeveloped to facilitate their new role as local "centres of excellence."
Yes , the dead hand of "budget neutrality" seems to permeate the HSE's plans for implementing Teamwork in the mid-west.
In spite of this, the revamp of services in the mid-west is expected to start within the next few months with the centralisation of round-the-clock A&E services to the Mid-Western Regional Hospital in Limerick
A&E services will no longer be available on a 24-hour basis at Ennis and Nenagh Hospitals from March.
There will be other changes to follow and Ennis, Nenagh and St John's hospitals in Limerick will in future, according to Teamwork, eventually provide only minor injury and illness care from 8am to 8pm.
However, it has yet to be clarified to what extent the HSE will go ahead with this level of downgrading of local hospital A&Es to minor injury unit status.
The HSE appears to have rowed back for the time being on the Teamwork proposal that the smaller hospital minor injury/illness units be nurse-led, and says the local emergency units will be doctor-led.
What is definite is that all major surgery is to be centralised at the regional in Limerick under the plan, with emergency surgery moving to Limerick in June.
Also, general medicine services are to be rationalised, with joint medical rotas between all hospitals in the region to provide for seamless transfer of patients between the local and regional hospitals.
While many might agree with the Teamwork conclusion that moving major emergency and other specialist care from smaller hospitals to the larger regional centre, and delivering routine care locally as part of a streamlined community care system may make sense from a safety perspective, the HSE's non-committal statement about funding will be grist to the mill for the Teamwork plan's critics.
Those concerned about the plan are querying whether the Mid-West Regional Hospital will be able to cope with the extra A&E, emergency surgery and critical care workload that will result from the Teamwork centralisation, whether the necessary facilities will be provided to the smaller hospitals in their new role of more routine care and diagnostic testing, and whether the planned primary care teams charged with delivering an expanded range of services to keep people out of hospital will ultimately be delivered.
Labour's Health spokesperson Jan O'Sullivan says there are huge questions about the mid-west hospital revamp plan, and believes that whatever is to be the future role of the smaller hospitals in the region, the Teamwork report does not provide the answer.
She has queried whether the HSE had the managerial ability or financial capacity to deliver on the aims of the Teamwork report.
Ms O'Sullivan, who is TD for Limerick East, has specifically queried whether funding will be made available for a new A&E in Limerick, whether funding will be provided to overhaul the ambulance service, and whether the 36 primary care teams promised will be put in place.
She has also queried whether local GPs, who will be crucial to the implementation of the teamwork plan, will support it. Already, many local GPs have expressed concern about what will be out in place when many services are centralised in Limerick.
While local opposition can be expected to any regional hospital revamp, figures quoted in the Teamwork report, and the apparent insistence that many of the changes will be 'cost-neutral', must be a cause for concern even to those who might agree with the quality and safety principles behind the reconfiguration.
Figures quoted in the Teamwork report give a good idea of the extent of the hospital reconfiguration task, and of the workload that the regional hospital in Limerick will have to take on.
The Mid-Western Regional Hospital in Limerick currently has 54,000 A&E attendances per year, and 16,686 admissions from its A&E.
Currently, the smaller hospitals in the mid-west, Ennis, Nenagh and St John's in Limerick, have between them around 54,000 A&E attendances each year, and around 10,000 admissions through A&E
Even taking account that Limerick Regional will not be taking on minor work from the other hospitals and that new community care systems may in time keep more people out of hospital, the figures still indicate that the Regional will be taking on a considerable workload.
This extra work is to be taken on while services there are already pressurised.
At present, around 70% of Limerick Regional's clinical workload comes from its emergency department - it has seen a 7% increase in A&E presentations between September 2007 and September 2008.
Last month, it had an average of 18 patients in A&E on trolleys awaiting admission each day. Last week, it had on average 16 patients on trolleys each day.
These trolley and emergency workload figures are not as high as those of some of the Dublin hospitals, but are still significant and give some idea of the current capacity in Limerick Regional.
Whatever the misgivings about funding and resourcing the brave new world outlined in Teamwork, the report does present a strong case about the viability of services as they are currently organised.
It points out that in Nenagh, the total number rof patients who go to the A&E between 8pm and 8am each night is on average 7.6, of whom six are self-referrals. It says many of these patients could have been more appropriately dealt with by a GP.
However, this indicates that the bulk of the 3,500 admissions from A&E in Nenagh every year probably occur during normal hours. While some of these , under the new plan, will eventually be cared for in revamped local hospital and community settings, there will still be concern about how Limerick will cope with the patients from peripheral hospitals who will still need major emergency care.
Also, taking on additional non-emergency work from the smaller hospitals will presumably put extra pressure on Limerick Regional.
The Teamwork report contains a serious warning for the HSE. It says it is absolutely essential that the HSE act now to tackle risks that could undermine its attempts to reorganise hospital services.
Specifically, it says unless full and effective pre-hospital services (eg, ambulance, paramedics) are put in place, down to the most local level, the HSE will not achieve its intention to implement international standards of acute care and will find itself unable to proceed to major acute hospital reconfiguration.
The HSE's statement,however, says plans are only now underway to introduce advanced paramedic services to Clare and North Tipperary. These will need to be provided fairly quickly.
The "bottom line" of Teamwork is that in future in the mid-west in future, the majority of patients; those who require only a routine, straightforward level of urgent or planned care, will be safely managed locally, with treatment being delivered at home, or as close to home as possible.
The minority of patients, it says, who require major emergency or more complex planned (non-emergency) care, will be safely managed in Limerick Regional, where all the relevant clinical expertise will be concentrated so that consultant-led high-quality care is available around the clock.
This,Teamwork points out, is the HSE's template for the delivery of care in all regions, and has already started to be implemented (not without considerable difficulty) in the north-east. With emergency services transferring from smaller hospitals in that region, Our Lady of Lourdes Hospital in Drogheda is suffering from serious A&E overcrowding.
The report says it found that, in its examination of hospital services in the mid-west, there are still clear and substantial shortcomings in the way core acute hospital services are currently planned and provided compared to international best practice.
It says 'substantial reconfiguration' is needed to move acute services in the mid-west towards the delivery of safe, high quality patient care. The report stresses that this reconfiguration is about "reallocating existing HSE resources."
The report says consultant resources for hospital care in the mid-west are currently too dispersed across units that are too small to meet the 'critical mass' criteria of workforce and population, such that it is not possible for staff to systematically deliver high quality acute care.
"Critical mass" can be roughly defined as the minimum amount of patient throughput and complexity of work needed to guarantee a high quality and safe service.
The report says too many patients in the region are being admitted unnecessarily to hospital and too many are staying too long in hospital.
It proposes one regional A&E "centre of excellence" at Limerick Regional, managing major emergencies with a view to providing a 24-hour seven-day-a-week emergency service led by consultants.
Ennis, Nenagh and St John's in Limerick, and possibly other sites, are to be developed into key elements of an emergency care network. This network is to be an integrated, seamless service connecting all professionals on emergency duty, from GPs to paramedics, and all the duty teams in acute hospital specialties.
The three peripheral hospitals will provide services for minor injuries and illness from 8am to 8pm only. This care is to be led by an advanced nurse practitioner accountable to the regional A&E consultant team.
The report says in the meantime, until implementation of the service revamp is completed, additional medical staff should be out in place to improve levels of patient safety in Ennis and Nenagh.
The HSE has stressed that while most major hospital care will be moved from the three smaller hospitals in the mid-west to Limerick Regional, the smaller units will still be providing significant local services as part of the new integrated network that includes primary care services.
In addition to providing for minor illness and injury treatment, Ennis, Nenagh and St John's will carry out day surgery and there will be an expansion of local outpatient clinics and CT scanning at Ennis and Nenagh.
There is likely to be considerable political, local and healthcare-provider opposition to the plan for the mid-west as its implementation is rolled out and services move from smaller centres.
Added to this will be the concerns over the proper resourcing of the plan and whether it can really be done on a 'cost-neutral' basis.
Dr Christine O'Malley, consultant geriatrician at Nenagh General Hospital, told irishhealth.com she felt it was not necessary to centralise services to provide optimal hospital care. Expressing concern about future capacity in the system, she felt more people would support the plan if it included a new 700-bed hospital being built in Limerick.
She pointed out, however, that the version of the Teamwork report published this week has no mention of the amount of capital funding required, despite it being estimated at €370 million in a previous version of the report.
The HSE, for its part, appears determined to push this through with its plan, emphasising the need to provide a safe and quality-driven service, which is presumably what everybody wants. Whether the mid-west hospital revamp achieves this goal remains to be seen.
You can view the Teamwork report at...http://www.hse.ie
|anonymous Posted: 15/01/2009 16:49|
The HSE are not implementing the Teamwork recommendations in the Mid-West but their own version of it. They are going to cherry pick what suits their purpose and run with that. Anything that they think will be cost neutral will go ahead and they live in hope that the GPs and the paramedics will take up the slack. This is the Hanly Report in action - 12 Regional Hospitals providing all acute care and the other hospitals downgraded to day-hospitals or step down units. Many of the Teamwork recommendations will not be fulfilled, as is happenign in the North East, but the HSE will forge ahead regardless. As for the 'quality driven and safe servcies' - forget it. This is not going to provide it but cause even greater problems and cause greater risks for patients. This is all about creating a market in Limerick for the private for-profit co-located hospital to keep the investors happy and then, with the public system decimated we, the tax-payers, will pay for public patients to be treated in the Private facility, while the HSE continue to spend their huge budget on conferences and swanning about. In the meantime the Private health Insurance will be so costly that only about 20% of thepopulation will be able to afford it thereby increasing the numbers requiring the Public, aka Private at tax-payers expense, treatment. This must be fought tooth and nail.
|BJ Posted: 15/01/2009 17:10|
Limerick A & E cannot cope with it's own problems at the moment, the waiting time is scandalous. I do not believe the statistics given out by the HSE, I believe that these figures are taken over an annual basis and do not give accurate information. The HSE really needs to get it's act together, and if they cannot then they should resign and bring in people who are able to manage the system, which they clearly incapable of doing. This mess with the HSE has been ongoing for years, even in good times it was bad. This is just the most ridiculous suggestion to date.
|Anonymous Posted: 16/01/2009 08:45|
It seems to me that this is less about developing centres of excellence and far more to do with keepign costs down. GPs won't pick up the slack for A&E being closed becuase they themselves are closed out of hours.
Anonymous you may well have a point about the aim of this being related to provate hospitals. The Amerianisation of the health system is totally wrong and far removed from a social systemoif medicine and healthcare which is in place in our (civilised) EU neighbours.
|concerned Posted: 18/01/2009 16:13|
|gar Posted: 23/01/2009 13:08|
limerick a&e is already not able to cope with patients waiting overnight for a bed.
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