The role of many small acute hospitals across the State will be radically changed if what is recommended for two regions in the Hanly report on medical staffing in the health service ends up being used as a blueprint for the reorganisation of hospital services in the Republic.
The report, which has yet to be published, has made specific recommendations on how hospital services in the Mid Western and East Coast Area Health Board should be organised.
A final draft of the report, dated May 2003 and seen by The Irish Times, states that each of these regions should have a single major hospital meeting the full range of acute hospital services for people in their areas, each of which has a population of about 350,000 people. These services would include emergency medicine, obstetrics and gynaecology, paediatrics, radiology, surgery, anaesthesia and pathology.
All other hospitals in the region would then be referred to as local hospitals and these would concentrate on treating minor injuries, doing elective daycare procedures and outpatient diagnostic tests, providing respite and opportunities to convalesce. They would not have accident and emergency units or maternity services but the report states that "many of the main life-saving measures in emergencies are not affected by the immediate proximity to a hospital". Ambulance personnel would be given more responsibilities and training.
At present, acute hospital services in the MWHB area are provided at six sites: the Mid Western Regional Hospital in Limerick, St Nessan's Regional Orthopaedic Hospital in Croom, St Munchin's Regional Maternity Hospital in Limerick, Ennis General Hospital, Nenagh General Hospital and St John's Hospital in Limerick.
The Hanly report recommends that Limerick Regional Hospital become the major hospital in the area, with Ennis General Hospital, Nenagh Hospital and St John's Hospital functioning as local hospitals. This would mean Nenagh losing its A&E unit.
"At present many hospitals try to provide a large range of emergency, often complex, services including the smaller facilities. The current situation is not sustainable, either from the viewpoint of patient safety or staffing," the report said.
All hospitals in each region should, it said, function as part of one integrated network and each network would have a chief executive officer who would report to a new national hospitals authority, which it said should be established with its own CEO. That recommendation was also made in the Prospectus report published on Wednesday and the Government has announced it will set up a National Hospitals Office which will carry out these functions.
In the East Coast Area Health Board, it said St Vincent's Hospital should be the major hospital, with St Columcille's in Loughlinstown and St Michael's in Dún Laoghaire becoming the local hospitals.
Furthermore, the report states that a number of specialties currently provided in single-speciality hospitals should ultimately be provided on the site of the major hospitals. "This would enable more speedy access to on-site specialist support, increased efficiencies in staffing cover and reduce the duplication of staff and support services". This could result in the National Maternity Hospital in Holles Street and St Luke's in Rathgar moving to the site of St Vincent's.
The report also states that national specialties such as liver transplant surgery will continue to be provided at single sites and supra-regional specialties such as as neurosurgery and radiation oncology were "most appropriately confined to a limited number of centres".
This is, it said, because there is considerable evidence to suggest better outcomes for patients treated in units with appropriate numbers of specialist staff, with the high volumes of activity and access to appropriate diagnostic and treatment facilities.
The report states that acute hospitals need to be reorganised if the working hours of non-consultant hospital doctors are to be reduced in line with a EuropeanDirective. It requires that NCHDs work no longer than 58 hours a week by August 2004, 56 hours a week by August 2007 and 48 hours a week by August 2009. At present, some are working up to 129 hours a week, the report states.
But it says these hours cannot be reduced by employing more NCHDs. The solution lies in employing 1,300 more hospital consultants by 2009 and 1,870 more by 2013. They will be rostered to work around the clock, resulting in a consultant-provided rather than a consultant-led health service. This will require the immediate renegotiation of consultants' contracts.
Hanly estimates the additional costs involved in employing so many extra consultants by 2009 as €52 million and by 2013 as €111 million. However, it stresses that ultimately a saving will be made due to a reduction in NCHD numbers and overtime payments.
Furthermore the report recommends an extended working day for all those in the system. Elective work could be provided from 7 a.m. to 8 p.m. and outpatient clinics could open for longer.
Earlier drafts of the Hanly report had suggested a plan for the reconfiguration of hospitals all across the State but this draft, which is expected to be signed off soon and published by the Minister for Health, Mr Martin, next month, points out that the Hanly team will not look at how services should be planned in all areas outside the MWHB and ECAHB regions until the second phase of the taskforce's work.
However it states: "The proposals set out here should be used to help inform the development of proposals nationally".
The report also points out that in some regions there may be a case for having a regional hospital which would be a step below a major hospital and a step above the local hospital. "A general hospital could be provided in areas where, for geographic or demographic reasons, access to a major hospital for emergency care is problematic", it said. No such hospital was recommended for the two pilot areas.
Referring to the need for hospitals to be reorganised the report states: "Acute hospitals in Ireland have evolved without a national plan. Often, they were developed in response to local needs, or owe their origins to history, rather than to clear national or regional priorities. This has resulted in inefficiencies, duplication and a system that is often designed around institutional, political and administrative concerns rather than those of patients". It adds: "These problems can and must be addressed".