The rural health services are being downgraded by closures and cutbacks, as well as an increasing emphasis on centralisation. Theresa Judgereports
Anger over declining health services in rural areas, due to an increasing emphasis on centralisation, has been compounded over the past week by wide-ranging cutbacks being imposed by the Health Service Executive (HSE).
In different parts of the State there have been reports of staff being let go - four consultants and 30 nurses in Sligo - the closure of an operating theatre and six surgical inpatient beds in Clonmel, and reductions in the number of patients who can be treated in Mullingar.
Meanwhile, campaign groups, which were initially set up to protest at plans to cut local services as envisaged in the Hanly report, are continuing to get bad news.
At a meeting last Thursday, Minister for Health Mary Harney told TDs and local mayors from Co Clare that the 24-hour A&E service in Ennis General Hospital would be closing and that a mammography unit shut down in July would not be reinstated, bringing to pass the worst fears of the Ennis hospital action group.
Harney made this admission in the same week as campaigners were told a consultants' report of a review of acute services in the mid-west region would not now be published in September as promised, but in December or January.
In the midwest, hospital action groups in Ennis and Nenagh are adamant that people will die if A&E units are closed.
Former senator Kathleen O'Meara, a member of the Nenagh group, points to a case highlighted in the local media of a man who had a serious accident within a mile of Nenagh hospital last week.
"He had lost seven pints of blood by the time he got to Nenagh hospital, as he said he wouldn't have made it to Limerick," says O'Meara.
Peadar McNamara of the Ennis hospital action group was outraged leaving Dublin last Thursday evening.
Ennis hospital would be nothing but "a glorified nursing home", he said, as all acute care is to cease. He points out that of the Clare population of 103,000 people, some 44,000 live more than an hour from Limerick Regional Hospital.
However, the Ennis campaign is determined not to give up and is planning a large demonstration on Saturday, September 29th, in protest.
A wide range of organisations from the Irish Farmers' Association to trade unions will be taking part, says McNamara. He points out that a total of 23 small hospitals around the State are affected by plans to centralise services, and representatives from all of these areas have been invited to the Ennis demonstration.
In the northeast region, where plans to centralise services have already been unveiled, Monaghan hospital campaigners are planning to meet politicians who, before the election, pledged to support the retention of services in Monaghan.
Peadar McMahon of the Monaghan hospital action group points out that Taoiseach Bertie Ahern and Minister of State and former Green Party leader Trevor Sargent were among those to make this promise.
McMahon says both the quality and accessibility of services have been deteriorating over recent years. "People are having to travel further to go to overcrowded facilities. People are being sent to Cavan or Drogheda but these two hospitals are totally overstretched. Anyone with health insurance is going to private hospitals in Dublin," he says.
McMahon's point is backed by comments made recently by Judge Maureen Harding Clark who carried out the Lourdes Hospital Inquiry into Our Lady of Lourdes Hospital in Drogheda. She said that while the maternity unit was now a changed place in terms of how it is managed, "the buildings are still inadequate and they've got a massive throughput of patients and staff".
While there may have been a medical argument to close the maternity unit in Monaghan hospital to send women to a larger better unit in the region, such an argument is considerably weakened when the regional centre is "inadequate".
This is a point made by campaigners across the State - when services at smaller hospitals are closed, patients are redirected to already overcrowded centres.
O'Meara makes this point about the A&E in Limerick. "The A&E unit in Limerick is already in crisis - at one point recently they ran out of trolleys - and some 1,100 people use the A&E in Nenagh every year."
An A&E taskforce set up by the HSE, which published its report in June, visited 18 hospitals with problems in their A&E departments and found seven of them were unfit for their role. A number of others were "less than optimal". The report, which was published months later than expected and after the election, also highlighted that targets for reducing waiting times in A&E had not been met.
In Monaghan, McMahon rejects the argument for the centralisation of acute services, which claims that the highest standards can only be guaranteed in very large centres with a sufficient number of patients.
"Research on that point is not definitive. It holds true for a small number of complex cases but the proof is not there that it is true in general," he says.
McMahon argues that other options have not been fully researched or explored, such as the use of telemedicine, where scans taken in a county hospital could be sent to specialists in large urban centres for a second opinion within minutes, thus eradicating the need to transport people to large centres unnecessarily.
In Mayo, former Independent TD and GP Jerry Cowley gives the example of the orthopaedic unit in Castlebar hospital as a facility that would never have been opened if the centralisation argument had been followed. "It is an excellent unit, one of the best on these islands, and where people had been waiting five years for hip operations now they are only waiting two months," Cowley says.
However, in other areas of medicine there are very long waiting times, he says. "Rheumatology is an absolute disgrace - people are waiting six years for an appointment with a rheumatologist and people, especially children, can be irreparably damaged if the window of opportunity for early treatment is missed." A Comhairle na nOspidéal report last year highlighted the massive gaps in rheumatology services.
Cowley says the same applies to neurology, urology and ear, nose and throat care.
"What we find is where there are consultant services in Castlebar, there are little or no waiting lists, but the further you are from the centre of excellence, the longer you have to wait, and that's because the consultants are already so busy in Galway," Cowley says.
He is also angry over recent cutbacks to transport services, saying he met an elderly man last week who paid €130 to go to a hospital appointment in Galway. "I have no doubt that people are missing appointments because of this," he says.
While the downgrading of local hospitals has prompted the most vocal and focused criticism of rural health services, there is a whole list of specialisms and services where rural people have been losing out.
BreastCheck is only finally being extended to the west later this year but it will be 2009 before all eligible women are seen.
The roll-out of a regional network of radiotherapy services may not now be complete until 2015, four years later than promised, and even then Donegal cancer patients would still have to make up to five-hour journeys to Dublin or Belfast.
While there has been opposition to the closure of local breast cancer units, recent controversies in Barringtons hospital in Limerick and Portlaoise will add to the argument that women should be treated only in centres where triple assessment is possible, involving a surgeon, a pathologist and a radiologist.
While most regions are now covered by out-of-hours GP co-ops and most appear to be working well, O'Meara says there is concern in north Tipperary that people can be left waiting a long time as there are only a small number of doctors covering a very large area in the ShannonDoc scheme.
She also highlights inadequacies in mental-health services - in north Tipperary there are no high-, medium- or low-support hostels as promised in the Government's Vision For Change plan.
While dissatisfaction with rural health services may be high, there is little prospect of any radical improvements over coming years, given a statement by Mary Harney last week.
She said: "The rate of expenditure in health will not be as rapid as it was over the last decade and we've been listening to the Minister of Finance that spending next year and perhaps the year after will not be at the rate it's been over the last 10 years or so."
Harney said "solutions" would have to be found "in the context of greater efficiency, more effectiveness, greater productivity, and trying to get more from less very often, which I think we are all capable of doing".