The NEHB has a clear, explicit policy for the development of acute hospital services in the north-east, writes Paul Robinson.
Much has been written and spoken about Monaghan Hospital in recent months, a lot of it inaccurate and not well informed. Dr Muiris Houston, Medical Correspondent, presented an analysis of the situation in his article, "Failing to put patients first" (Weekend Review, Saturday, December 14th) which contains a number of such inaccuracies from which conclusions are drawn concerning the board, its management and the health boards in general.
I am currently unable to comment on the sad and tragic death of Bronagh Livingstone, but have undertaken to do so when the inquiry ordered by the Minister for Health and Children has been completed and made public. However, I think it important to address some of the general issues raised in the article.
Perhaps a very brief outline of the background to the suspension of maternity services at Monaghan and Dundalk will illustrate the inaccurate information from which significant conclusions were drawn:
The board (representative of the political and medical professions) established an expert independent review group on maternity services in the north-east (the Condon Review) in September 1998. This group reported in November 2000. In essence it recommended, inter alia, that consultant-led maternity services should cease at both sites on grounds of safety of mothers, babies and staff, and cited the recommended standards and requirements of the Institute of Obstetricians and Gynaecologists in support of its recommendations.
The board considered this report at a number of meetings and proposed various alternatives to closure. At a meeting on February 5th the board requested me to seek approval of the appointment of the necessary consultant obstetricians and paediatricians to allow services to be maintained at both sites.
Financial approval was received from the Department of Health and Children subject to conditions. I then submitted the proposals to Comhairle na nOspideal for approval. Comhairle decided to establish a sub-committee to consider the requirements of the north-east region in respect of obstetrics, gynaecology and paediatrics. The report of this sub-committee is awaited.
Each of the single-handed consultant obstetrician/gynaecologists at Dundalk and Monaghan formally indicated to me that the situation was unsafe in early January 2001.
The board's insurers indicated on January 19th, 2001, that they could not maintain insurance cover in view of the issue of safety and that it would be withdrawn with effect from February 28th, 2001.
The board at a special meeting on February 15th, 2001, decided to establish a further review (the Kinder Group) to examine issues not included in the terms of reference of the Condon Report. The board also requested me to take the necessary steps to ensure patient safety in the event of insurance cover being withdrawn.
Maternity services were suspended at Monaghan and Dundalk on February 28th, 2001, as the consultant resources required to ensure a safe service could not be put in place in the absence of Comhairle approval, and insurance cover ceased in respect of both units.
It is a tribute to the collaborative working co-operation received from the unions of medical, midwifery, nursing and management staff concerned that the transfer of services was managed smoothly, efficiently and safely in an extremely short space of time.
The conclusions drawn that "the health board has apparently failed in the most basic manner" (by failing to build an extension to the maternity unit in Cavan within a period of some 2-4 weeks) and that "the NEHB appears to have been more concerned with forcing through change than in managing the process" simply cannot be sustained in the light of the actual sequence of events and timescale involved. The maternity unit at Cavan is quite capable of dealing with the extra workload from Monaghan, which would not even equate to a birth per day.
Dr Houston's conclusion that health board officials failed to anticipate the possibility of expectant mothers in need of emergency medical attention turning up at the hospital also cannot be sustained: a simple inquiry to the health board would have established that a detailed protocol has been developed and issued to all hospitals in the region which do not have obstetric units, and has been shown to be effective in a number of such incidents both at Monaghan and other hospitals in the region.
The prediction by Dr Houston that the three smaller hospitals will become long-term care units is totally without foundation. It is envisaged that all five sites will continue to provide a full range of elective and emergency medical care 24 hours a day, seven days a week. Surgical, trauma orthopaedic and A&E services in the region are currently under review by a group established earlier this year, and I have already accepted recommendations from this review group regarding the future delivery of surgical services in Cavan/Monaghan. I await their final report due in early 2003. Suffice to say that I envisage in the future a significant level of surgery will be provided on each site in the region.
It is tempting to continue a rebuttal of various points raised in the remainder of the article, but that would do nothing to advance the understanding of proposals for the development of hospital services in the north-east, which are based (despite imputations to the contrary) on looking after the patient first, but to do so in an environment which, on current authoritative medical evidence, maximises the prospect of an optimum outcome.
It must, however, be understood that the board is not a free agent in developing either the hospital infrastructure or the range of specialist services proposed. The interrelationships between the many bodies which have an influence on the provision of acute hospital services is too complex to outline in a short article.
Suffice to point out that these bodies include the Department of Health and Children, Comhairle na nOspideal, the Medical Council, royal colleges and institutes representing the various medical specialties, An Bord Altranais etc. While these bodies have a wide range of differing objectives and functions, all have a legitimate part to play in ensuring the delivery of safe, sustainable patient care. Co-operation and collaboration between all these various interests is essential and is a process that must be managed carefully and constantly.
The board has a clear, explicit policy for development of acute hospital services in the north-east which is certainly not based on absolutist change and which seeks to balance the needs of local communities with the criteria for the provision of specialist services mentioned above. In summary, this policy is:
To network the five hospital sites into two hospital groups, Cavan-Monaghan and Louth-Meath with clearly defined roles for each group and site. This policy has been in place since 1993.
To expand the range of specialist services available and to become self-sufficient in regional services for a population rapidly approaching 350,000 (adopted in March 2001).
To allocate these regional services between the two hospital groups, but with the service delivered on a regional basis to serve the entire population; with inpatient services provided on one site and outreach (outpatient and day care) on other sites in the region to bring services as close to patients as possible, subject to the criteria outlined above.
To significantly upgrade the physical infrastructure of all five sites. Staff at all sites have been participating in project teams to finalise briefs for these developments for presentation to design teams which have already been selected.
The proposals will certainly mean changes and a reconfiguration of the way in which services are delivered. The trends both nationally and internationally towards an increasing amount of day services and development of five-day wards are part of the proposals.
To conclude, Monaghan General Hospital is an integral part of the Cavan-Monaghan Hospital Group and has a significant, secure and viable part to play in the provision of acute hospital services. The proposals, implementation of which is currently under discussion, are designed to meet the standards and criteria of the regulatory and training bodies and to be patient-centred, safe and sustainable.
Paul Robinson is chief executive officer of the North Eastern Health Board