Tuesday, 17 October 1978
Dáil Eireann Debate
That Dáil Éireann calls on the Minister for Health to fully implement the arrangements for a federation as negotiated between the Western Health Board and the management of Portiuncula hospital in regard to the Roscommon County hospital, thereby ensuring a full scale maternity unit in the County and, to this end, to take whatever steps to ensure that such appointments of professional staff as are necessary to honour the agreement, be made without further delay.
The agreement referred to was freely negotiated and entered into by the health board and the authorities of Portiuncula Hospital in the interests of providing the very best in patient care. It sought to provide full medical, surgical and maternity services at Roscommon County Hospital. Members are aware of the impasse that has arisen in relation to the implementation of the full terms of this agreement due to the decision of Comhairle na nOspidéal not to ratify the creation of the post of consultant obstetrician-gynaecologist for Roscommon County Hospital, an appointment advocated by both parties to the agreement.  Members are also aware of Comhairle na nOspidéal proposal for a third consultant based in Portincula, an appointment sought neither by the Portiuncula hospital authorities nor the Western Health Board.
I agree with the views of Comhairle na nOspidéal that there is a need for a third consultant but the person appointed should be based at Roscommon County Hospital. I should now like to give the House some relevant facts in relation to this matter. The Portiuncula Hospital authorities and the Western Health Board agree that the appointment should be to Roscommon County Hospital. The major centres of population in our country are Roscommon town, Castlerea, Cortober, Boyle, Ballaghaderreen, Frenchpark, Elphin, Strokestown, Ballyleague, Keadue, Arigna and Roosky. The route to Portiuncula Hospital is through Roscommon town which is 45 minutes journey from Ballinasloe over very inferior quality roads.
Roscommon has approximately 60 miles of national primary roads, Tarmonbarry-Ballaghaderreen, Boyle-Carrick-on-Shannon, and Athlone-Ballinasloe. The remaining roads, almost 2,500 miles, although well maintained by our council are of inferior quality and will remain so by national policy. The national primary routes referred to are of no significance in linking the centres of population in Roscommon with Ballinasloe. The route from Roscommon town to Ballinasloe runs in the main, over very poor ground, boggy and wet. It runs through the catchment area of the river Suck. This route is notorious for fog and frost during the autumn and winter months. Does this time factor and potential travelling difficulties make for good patient care?
Roscommon County Hospital has already a new maternity unit, consisting of 25 beds and a modern labour ward, an admission ward, waiting rooms, a nursery, and isolation rooms with incubators. That unit was provided less than ten years ago. Is it not financial suicide to let this building lie idle simply because we cannot afford the salary of  an obstetrician-gynaecologist? Roscommon, as a centre, is ideally situated to serve the centres of population of Lanesboro, County Longford, and Ballygar, County Galway. Those towns are within a 15-minute journey of the hospital. In matters of this kind we are often inclined to forget the visiting of patients. Suffice to say that Roscommon as a centre is within easy reach of all towns in the county. Visiting patients is now recognised as an integral part of patient care and that should be borne in mind.
The Roscommon hospital is a modern cut-stone building on approximately eight acres of ground. It was opened in the early 1940s and in 1968 a modern maternity unit consisting of 25 beds was added which brought the total number of beds to 137. The hospital also has a modern surgical unit. The maternity unit lacks consultative staff, an obstetrician-gynaecologist and a paediatrician. The hospital has full x-ray and laboratory services also. The original federation agreement with Portiuncula Hospital in 1974 provided for the appointment of an obstetrician-gynaecologist at Roscommon County Hospital. A letter, dated 21 August 1975, from Comhairle na nOspidéal states that the Portiuncula Hospital authorities would not agree to the appointment of an obstetrician-gynaecologist at Roscommon County Hospital. The Western Health Board have applied for such an appointment and unanimously agreed not to fund a third obstetrician-gynaecologist at Portiuncula Hospital until Roscommon County Hospital obtains such a specialist.
Roscommon County Hospital is a public hospital administered by the Western Health Board while Portiuncula is a voluntary private hospital. It is funded but not administered by the Western Health Board. The Roscommon hospital is situated in the centre of a very large catchment area of the Shannon basin and is linked by road, rail or bus service to every corner of the county. Portiuncula Hospital, on the other hand, is on the perimeter of the Western Health Board area and is connected to Roscommon county at large only by second and third class roads.
 That hospital is on the main Dublin-Galway road and it would appear that it would be better if its services were used to relieve the great pressure of maternity services at Galway Regional Hospital.
It as been satisfactorily established that, for the first time since the Famine, the population of County Roscommon has stabilised and may be increasing. The marriage age has been lowered drastically. The Department of Education figures reveal a boom in the number of four year old children attending primary school.
The IDA reports for the years 1973-1977 show Roscommon at the top of the other mainland counties—Laois, Longford, Offaly, Roscommon, Westmeath—in new industries. The number of industrial jobs, 1,319 in 1973 increased to 2,316 in 1977, by almost 1,000 jobs. In the 1978-1980 period further jobs for the area are estimated at 1,200—Ballaghaderreen 250, Roscommon 250, and Clondra/Tarmonbarry 700. Further advance factories under construction in Boyle, Castlerea and Carrick-on-Shannon will ensure 600 to 800 jobs in the near future. Developments proposed by the ESB and Bord na Móna at Lanesboro, Shannonbridge and Ballyforan will give an unknown but substantial number of jobs. Increased industrial activities in east Galway, within 20 and 30 miles of Roscommon, will also have its effect.
The hospital services—acute, general and maternity—are one of the most important infrastructures in any area for industrialisation. When industrialisation is considered a major factor in the improvement of the economy in the west and the midlands, why should a Government Department try to withdraw such an infrastructure?
Capital input has already been spent at a new maternity unit at Roscommon. In a speech in Mullingar on 10 October 1978 the Minister for Health stated that the complexities of modern medical services were not easily understood by laymen. He went on to say that these included the realisation of limited resources and the fact that everything could not be provided everywhere. The structure, fittings and so on are already provided at Roscommon. The only extra  cost involved is the salary of two consultants.
Mrs. Burke: The Western Health Board have been advised by the top obstetrician-gynaecologist in the Chair of Obstetrics in University College, Galway, that the Roscommon maternity unit without consultants was a second-class unit giving only a second-class service. Surely this is not in keeping with modern social thinking. It is understood that a letter giving the medical case for a maternity unit, fully staffed, at Roscommon Hospital has been sent to the Minister.
Prior to the availability of an obstetrician-gynaecologist in the area, a ten-bed maternity unit had a turnover of 700 to 900 births per annum at Roscommon Hospital. The new maternity unit of 25 beds did not have consultative staff. People who had money, private transport and time, travelled to where the consultants were, while 240 to 300 mothers who did not have the time, money or private transport to bring them to the best maternity services available went to Roscommon Hospital. These 240 to 300 mothers are constitutionally entitled to the best maternity service near their homes.
Seventy five per cent of mothers in the Roscommon area eagerly await the consultant staff at Roscommon Hospital. A mother expecting her first baby may be free to travel a distance to a maternity unit, but it is not quite the same issue to leave small children and spend days waiting in ante-natal accommodation in a distant hospital. It is then that a suitably staffed central maternity unit is necessary on social as well as medical grounds. The maternity unit at  Roscommon Hospital is staffed entirely by nurses fully qualified in midwifery. This is not the case in teaching hospitals where students, but not fully trained staff, work with a minimum number of fully trained midwives.
Roscommon Hospital is seeking the continuance of full services of an acute hospital incorporating a fully-staffed maternity unit. The proposed out-patient maternity hospital is a downgrading of hospital services in Roscommon. The appointment of the obstetrician-gynaecologist will be ensure that the second anaesthetist will be fully employed and the existing backlog in gynaecological surgery and so on will receive attention.
Considering that births in County Roscommon in 1977 were approximately 900, it is evident that there is ample work for the obstetrician-gynaecologist in Roscommon Hospital. Should the figures rise to the point where one consultant is overpowered then back-up services, registers and so on should be supplied by the Western Health Board Maternity Unit from Galway Regional Hospital.
An obstetrician-gynaecologist will, after all, be appointed to take up a position in the maternity unit of Roscommon's County Hospital. A usually reliable source leaked the news to The Champion this week and, although the appointment has yet to be officially confirmed it looks as if the local members of the Health Board and the vigorous Community Council Hospital Action Group have finally won their long-running battle.
Mrs. Burke: ——told us that he was “particularly happy about the line the whole issue is taking.” He said: “There is no doubt in my mind that, having regard to discussion I have had with the Minister over the singular issue of an obstetrician-gynaecologist in recent days, Mr. Haughey is going to honour his commitment.”
 Following The Champion's exclusive story last week that the three year fight by residents of Roscommon to maintain a maternity unit at the County Hospital had been successful, Mr. Terry Leyden, T.D., confirmed our report at a Fianna Fáil meeting in Fuerty on Sunday. Mr. Leyden said that he had been informed by Mr. Charles J. Haughey, Minister for Health, that an Obstetrician-gynaecologist is to be appointed to the hospital in the near future and an official government statement to this effect will be issued soon.
The two Deputies claimed that the Department official had refused to carry out the instructions of the Minister to vote for the appointment. The appointment is being opposed on the grounds that it runs contrary to the proposed federation of the hospital with Portiuncula Hospital, Ballinasloe.
This is a very serious allegation. What action has the Minister taken, or has the civil servant referred to denied this allegation? Did the Minister give a directive to the official of his Department to act in a particular manner in relation to the appointment, and, if so, was he, as Minister, empowered to give such a directive? If so, what was the nature of the directive and to which official of the Minister's Department acting in what capacity was it given? I should like to know also if the Minister was empowered to give such a directive, and, if the civil servant involved refused to carry out the Ministers orders, as alleged by Deputies Doherty and Leyden, what action was taken by the Minister? What action does he intend to take? If the Minister was not empowered to give such an order why did he attempt to do so? Furthermore, I should like to know whether the civil servant involved threatened to resign, as has been alleged.
Referring now to the Minister's commitment, as referred to by Deputies Doherty and Leyden, I come to a letter dated 24 March 1977, again as reported in the Roscommon Herald of 1 April 1977 in an article entitled “Fianna Fáil Commitment on Hospital”—and this was prior to the election:
The Fianna Fáil spokesman on Health, Mr. Charles J. Haughey T.D., has given “a firm undertaking” that the “next Fianna Fáil Government” would fully implement the arrangement for the federation of Roscommon and Ballinasloe hospitals as already negotiated. The announcement was made at a Roscommon/Leitrim Fianna Fáil constituency dinner in Roscommon on Friday night last by Dr. Hugh Gibbons, T.D., who read the following letter:
“Dear Hugh—Following our recent discussion on the situation in Co. Roscommon and the need for a full scale maternity unit in the county, I have carefully considered the matter. I now wish to give a firm undertaking that the next Fianna Fáil Government will fully implement the arrangement for a federation, which has been negotiated between the Western Health Board and the management of Portiuncula Hospital in regard to the Roscommon County Hospital.”
Mr. Burke: When the Minister replied to Deputy Boland on Tuesday, 27 June 1977 he accused the Deputy of playing politics with the health of the people. Who brought politics into it in the first instance? The Minister also assured us that the federation would come into operation on 1 July. What has happened since? The function of Comhairle na nOspidéal includes the regulation of the number and type of appointments of consultant medical staffs and such other officers and staffs as may be prescribed in hospitals providing services under the Act. It is very strange that there is no woman member of Comhairle na nOspidéal despite the fact that over 50 per cent of the population are women. I have no doubt that there are as many women as men ill in hospital.
Mrs. Burke: This is certainly a glaring ommission. However good the advising opinion of the present comhairle may be it cannot be complete without the viewpoint of women. I have no doubt that there are several women doctors, nurses and others willing to serve on this body.
An Leas-Cheann Comhairle: Precedents could be created but we will not create one, I am afraid. I would remind Deputies that the composition of Comhairle na nOspidéal does not really arise on the motion.
Mrs. Burke: I also ask the Minister to amend section 41 of the 1970 Health Act to enable the health boards to appeal to the Minister against a decision of Comhairle na nOspidéal if necessary. That is not an unreasonable request. The Irish Independent of 26 August 1978 under the heading: Deputy to challenge powers of hospital body in Dáil,” stated:
The power vested in Comhairle na n-Ospidéal, which is firmly committed to a policy of trying to phase out the Republic's large number of small maternity units, is to be challenged, when the Dáil re-assembles.
It's stand, backed up by expert medical opinion, is that the dangers of mental and other handicap among infants is less in large, adequately-staffed and equipped units with proper back-up GP and other services.
The fact that Comhairle, in pursuit of this policy, can veto the appointment of specialist staff to small maternity units in a bid to phase them out, will now be pursued at Parliamentary level, the “Irish Independent” learned last night.
 Deputy Leyden, who is also a member of Roscommon Co. Council, said he would be pressing on the Minister for Health, Mr. Haughey, the need for amending legislation to reduce the functions of the Comhairle.
Minister for Health (Mr. Haughey): At the outset I wish to make it clear that I subscribe fully to the proposed federation between Portiuncula Hospital, Ballinasloe and the County Hospital, Roscommon. I am anxious that the arrangements under the federation should be implemented as soon as possible. So far as I am concerned there will not be any obstacle placed in the way of their implementation. I have listened with interest to what Deputy Burke had to say and I was somewhat saddened that the Deputy, especially as a woman Deputy from the area, should have concentrated so much on rummaging through newspaper clippings and endeavouring to score political debating points on the basis of newspaper clippings. However, that is an old Fine Gael gambit.
Mr. Haughey: Fine Gael have been on the benches opposite for the best part of 50 years and all the time they have continued to rummage through old and tattered newspaper clippings. That has been their main contribution.
Mr. Haughey: However, when Deputy Burke managed to move away from the newspaper clippings and offer what was perhaps the only contribution of her own to this debate she made a sensible suggestion, that was, that there should be a woman on Comhairle na nOspidéal.
Mr. Haughey: I subscribe fully to that suggestion but I suggest that in future the Deputy should concentrate on putting forward sensible and constructive suggestions while leaving the newspaper clippings to people like Deputy Boland, for instance.
Mr. Haughey: The federation of these two hospitals was approved first by the then Minister for Health in 1975 as part of the arrangements for the development of general hospital services in the Western Health Board area.
Officers of the Western Health Board and representatives of Portiuncula Hospital drew up an agreement in October  1976 for a federation of the two hospitals but difficulties arose regarding this agreement and it was not possible to implement it then. When I became Minister for Health I was concerned with the failure to achieve federation and in January 1978 I arranged a discussion between officers of my Department, representatives of the Western Health Board, Portiuncula Hospital and Comhairle na nOspidéal. It was agreed at that meeting that the parties would participate in discussions under the chairmanship of an officer of my Department to consider arrangements for the federation. Five meetings of the group were held between February and June 1978.
It was agreed at the outset by the group that with a view to achieving a realistic and effective federation, as many services as possible should be provided from the combined resources of the County Hospital, Roscommon and Portiuncula Hospital.
Agreement was reached on the establishment of joint departments, straddling the two hospitals, in surgery, medicine, anaesthetics and radiology. These arrangements would involve the consultants in each specialty in the two hospitals providing consultant cover for both hospitals on a continuous basis and with the Portiuncula consultants providing services at Roscommon County Hospital as required. It was agreed also that arrangements for casualty services in both hospitals would be served by the joint department of surgery. It was agreed further to share certain services in relation to pathology and paediatrics.
The one service in respect of which agreement was not reached was obstetrics and gynaecology. The Western Health Board wished to have a joint department of obstetrics and gynaecology between the two hospitals, with at least one consultant obstetrician/gynaecologist being based at Roscommon Hospital, but the parties failed to reach agreement regarding this proposal. I will be referring again to the position regarding obstetrics and gynaecology.
The group recommended that 1 July 1978 should be the date on which these  arrangements should commence for a proposed two-year trial period—that is the federation in respect of those services on which agreement had been reached—and that the arrangements for obstetrics and gynaecology be left over for further consideration.
This motion calls on me to ensure that such appointments of professional staff as are necessary to honour the agreement be made without delay. I should like to point out that already I have approved the appointments of a surgical registrar, a medical registrar, and a registrar in anaesthetics for the County Hospital, Roscommon for that purpose. As I mentioned to Deputy Burke by way of intervention, the funding of an obstetrician/gynaecologist at Roscommon County Hospital is not a difficulty in this situation. There will be no difficulty about making funds available to pay for such an appointment if agreement could be reached in relation to it.
Comhairle na nOspidéal have agreed also in principle to the appointment of an additional consultant anaestheist under the Western Health Board to be based at Roscommon County Hospital. That matter is to be finalised on the formal agreement of the health board and the authorities of Portiuncula Hospital to the agreed arrangements for federation. When the arrangements for this appointment have been finalised I will make available the necessary funds.
The Western Health Board at their meeting of 3 July 1978 considered the terms for the federation which had been drawn up by the group and adopted the resolution deferring further consideration of the proposal until the meeting of 4 September 1978 pending a decision from Comhairle na nOspidéal on the application of the health board for the appointment of an obstetrician/gynaecologist to be based at Roscommon County Hospital.
One might ask at this point why, at that meeting, the Western Health Board did not accept the general corpus of the arrangements for the federation which were agreed then by everybody and leave the obstetrician/gynaecologist  situation for further consideration. At that time the Western Health Board rejected the federation proposals although they had agreed earlier on most of them.
Mr. Haughey: It would seem to have been a sensible decision for them to have accepted the federation arrangements that had been agreed on and to leave over the question of an obstetrician/gynaecologist for further consideration. The application was made by the health board to Comhairle na nOspidéal on 13 June 1978.
Here I should like to refer to newspaper reports regarding allegations that an officer of my Department who is also a member of Comhairle na nOspidéal had refused to carry out my instructions in connection with the comhairle's consideration of the application by the health board for the appointment of an obstetrician/gynaecologist to Roscommon hospital.
All the members of Comhairle na nOspidéal are, under regulations approved by this House, selected and appointed by the Minister for Health. Members of the comhairle when acting in the capacity are not subject to formal directions by me. Three of the 23 members of the comhairle are officers of my Department. As is the case with the several other health bodies on which departmental officers serve, detailed directions are not given to such officers on the performance of their role as members of the body.
However, it is expected that in participating in the work of outside health agencies, officers of the Department will act in accordance with the general policies of the Minister of the day and, indeed, a significant part of a civil servant's role as a member of an outside body lies in his being able to interpret  ministerial policy to the body concerned.
The question of the appointment of an obstetrician/gynaecologist for Roscommon County Hospital came before a meeting of the comhairle on 21 June 1978. The issue is a complex one. At a number of informal discussions between officers of the Department and members of the comhairle it was made clear that the medical view of the comhairle was in accordance with the expert report “Development of Hospital Maternity Services” which the comhairle issued in May 1976 and which stresses the medical advantages, both for safer births and the avoidance of handicap in children, of concentrating obstetrical work in large units, well staffed and properly implemented.
I respected this authoritative medical advice on the location of maternity units although I might have to decide to weigh social factors with medical considerations in taking these decisions. The Western Health Board in advocating a post of consultant obstetrician/gynaecologist for Roscommon County Hospital were influenced by social factors but I should say also that they had expert medical advice within their area which suggested that such an appointment would be satisfactory.
Bearing in mind all the factors I was willing to accept the view of the Western Health Board and I let it be known that should be comhairle approve of the post in Roscommon I would approve the necessary financial provision. Before the comhairle meeting of 21 June, the chief medical officer of my Department and a member of the comhairle had it made known to me that he shared the very strong medical views against the appointment for Roscommon on the terms sought by the Western Health Board and he could not in conscience as a doctor support this proposal of the comhairle. I respected his medical opinion and I agreed that he should not be asked to attend the meeting of the decision on the 21 June at which the decision on the Roscommon appointment was to be taken. I am glad to avail of this opportunity to say that the chief medical officer of the Department of Health is an honourable man, an excellent, dedicated  conscientious officer in whom I have complete confidence and, furthermore, that no problem or difficulty of any kind whatever has arisen in the Department of Health over this matter.
The comhairle at their meeting of 21 June, decided not to approve of the post of obstetrician/gynaecologist for Roscommon Hospital and wrote to the health board on 21 August 1978 setting out in full the basis for their decision. In that letter the comhairle also acknowledged that local opinion may be very reluctant to accept the complete discontinuence of in-patient obstetrics at Roscommon and suggested an alternative arrangement under which inpatients obstetrics might be continued in both Portiuncula and Roscommon Hospitals as part of a federation, while at the same time ensuring that those mothers and infants who are considered to require the intensive services of a larger maternity unit would not be without them.
The comhairle suggested that this might be achieved by making appropriate arrangements to ensure that all at-risk patients are delivered at the major unit in Portiuncula Hospital, with the most highly trained staff including the consultant staff concentrating their activities at the centre where the at-risk cases are to be delivered. The comhairle went on the explain that the at-risk patients could be identified through a well-organised system of screening in advance by a consultant obstetrician. It was also envisaged that the safety of those mothers having their babies at Roscommon could be further safeguarded by the provision of a flying squad service to Roscommon Hospital from Portiuncula Hospital in the event of an unforeseen emergency arising.
In their letter of 21 August the comhairle suggested that the position might be discussed between representatives of the health board, Portiuncula Hospital and the comhairle. The health board considered this letter at their meeting of 4 September 1978 and agreed to accept the offer of the discussion. I understand that arrangements have now been made for the discussion early next month. At this stage it is advisable to await the outcome of that discussion before considering  further the position regarding maternity services in Roscommon Hospital and the general arrangement for the federation of the two hospitals.
In speaking on the Health Estimate on 27 June 1978 I referred to the difficulties of deciding on the development of the hospital services, that there is frequently a conflict between the best medical answer and the best social answer and that sometimes these two conflicting pressures have to be reconciled. I think in the case of Roscommon and the maternity service there we have a classic example of that, where on the one hand we have very authoritative medical opinion, expert medical advice in one direction and a considerable number of people taking account of the social considerations of a different opinion.
....not everybody is thinking clearly in regard to this situation. The one thing that people should keep in mind in regard to maternity units is that we will never get to grips with the problem of eliminating mental handicap until we have proper maternity units. Anybody who becomes emotional about keeping a maternity unit in a particular area should bear that in mind. The onus of responsibility is on them if they insist that a maternity unit should be kept in a particular location when we know that the proper level of service cannot be provided in that place. It is not just a question of providing a service for the mother. Lurking behind the problem is the deadly question of mental handicap. If we do not take the right decision in regard to maternity units, we will have an avoidable level of mental handicap.
Since I made that statement in the Dáil I am sure some Deputies have had the opportunity of viewing a very compelling documentary which was shown on either the BBC or UTV television and which dealt in great detail and very authoritatively with this whole question  of the size of maternity units and related it directly to the incidence of mental handicap. I do not want to be contentious about this question of Roscommon. I would like to see if we could generate an atmosphere of sensible discussion about it, try to marshal all the different arguments of all the different sides and arrive at some sensible conclusion. I want to emphasise that it is not a matter of depriving Roscommon of something or refusing to appoint an obstetrician/ gynaecologist to Roscommon County Hospital. As I have already said, if it were only a question of the salary of an obstetrician/gynaecologist in Roscommon Hospital there would be no problem. I have indicated all along the line that the funds for such an appointment will be gladly authorised by me if that is the decision that is come to by the bodies concerned.
It is more than that. It is a question of what is the right structure of maternity services for the people of Roscommon in particular, for Galway and the surrounding areas. Is it the right thing to have a small unit of 200 or 300 beds in Roscommon or is it desirable to make some other arrangement on a federated basis with Portiuncula, such as that being proposed by Comhairle na nOspidéal? Comhairle na nOspidéal are not prejudiced in this matter. They have produced a very important guideline for the proper development of our maternity services. They have laid down what in their view is the right way in which the maternity services in Roscommon should be provided.
I readily admit that there is another scientific, medical gynaecologist/ obstetrician opinion, which does not agree with the comhairle views. Therefore, we are confronted with the situation where there are conflicting views as to the right thing to do. I want to assure the House, as far as I am concerned, that there will be no obstacle placed in the way of whatever solution is agreed on, hopefully, between the comhairle and the Western Health Board. They are meeting shortly now. I understand that it is possible that the Western Health Board may wish to see me after their meeting with the comhairle. If they do, I welcome seeing them and discussing  the matter further with them. I am only concerned with ensuring that the right decision is taken. That certainly involves the elimination of any risk of inadequate services in any area resulting perhaps in the incidence of mental handicap which could be avoided. That is a primary, fundamental, important consideration. If there is any question that a particular maternity unit can never be of the size needed to provide the full adequate service, which modern medical science demands, then we should not pursue that particular line of development.
I would like to say, as I said at the beginning, that I am very anxious to see the arrangements for federation proceeding. I genuinely cannot understand why the health board did not accept the bulk of the arrangements which were agreed by them and go on and implement them and have them in operation now for the benefit of the people. I have given constant personal attention to this situation since I took up office. It is a situation which has been constantly with me since I took up office.
Mr. Haughey: The difficulty is that there are a number of different bodies involved. They have different views and different priorities. As of now, I have not been able to bring them together to provide an agreed solution which would be satisfactory to everybody. I am going to continue to try to do that. I give the House, Deputy Burke and the other Roscommon Deputies an assurance that as far as my Department are concerned any service which we can provide to bring these consultations to a successful conclusion will be cheerfully and willingly provided. It is not a question of finance or a question of money. It is simply a question of what the authoritative medical bodies concerned think is the best solution, As Minister for Health, I am involved in that difficult situation. I should like to be able to produce some deus ex machina solution to it, but I cannot. We can only continue with these consultations and  discussions. I have no wish, and nobody in the Department of Health or in Comhairle na nOspidéal has any wish to deprive the people of Roscommon of any service to which they are entitled. It is just a question of trying to decide the right solution in the interests of the mothers and the future babies to be born in Roscommon and in Galway.
Mr. Boland: It has been interesting sitting here for the past 25 minutes listening to the Minister in all sweet reasonableness enunciating the reasons why one should not have small maternity units and putting forward good and compelling medical reasons why that is so. If those reasons are valid today, they were equally as valid on 24 March 1977 when he wrote a letter deliberately promising the people of Roscommon that, upon his party being returned to Government, he would honour the terms of the Federation already negotiated between the Western Health Board and Portiuncula Hospital, which provided for full maternity services. That is the reason we are here today. That is the reason for the confusion, upset and public demonstrations. The people of Roscommon believed that the undertaking was given genuinely and would be honoured when the Minister's party was returned to power—presumably with the help of additional votes garnered from the promise now so readily forgotten, the promise which Deputy Burke is exhorted to throw away as being petty political points written on tatty scraps of paper.
What the Minister has confirmed to the House this evening is that one honest man served as Minister for Health and he is sitting in the Labour benches. Because he decided to be honest and to present the situation to the people of Roscommon prior to the election, as the present Minister now decides to present it to them after the election, he is now sitting in the Labour benches and the  Minister is sitting where he is. It is also one of the reasons why we are having this debate this evening, and this may not be the only debate arising from promises gaily given and now described as being tatty pieces of paper. It is too bad that a lot of the difficulties and upset have been created through the promises and action—in some cases, the inaction—of the Minister at national level and by his local Deputies bearing different words to different people, depending on their audience and its receptiveness, in the County of Roscommon.
Mr. Boland: I am speaking about the man who, as shadow Minister for Health, gave an undertaking which he must have known he could not fulfil. He now says that Comhairle na nOspidéal are the only people who can appoint obstetrician/gynaecologists and that it is not now within his power to do so. Is he seriously suggesting to the House that he did not know that in his capacity as shadow Minister just three months before he took office?
Mr. Boland: That is the sort of person I am talking about. The other sort of person I am speaking about is the sort who will get an opportunity to get up in this House and will presumably say the same sort of things to us in the hope of convincing us in the way in which they have endeavoured to convince their unfortunate electorate in the past year. I refer to the two gentlemen who have been playing cowboys and indians with each other and the people of Roscommon, Deputies Doherty and Leyden. It sounds like a comedy act, a Leas-Cheann Comhairle, and that is what it is rapidly becoming.
 The previous Government decided not to accept the recommendation originally made to it, and referred to by the Minister, and decided that Roscommon County Hospital should be continued. It was suggested that there should be a federation between Roscommon and Portiuncula which should be carried out on a trial basis for two years. All that was suggested between 1975 and 1976. Hard bargaining went on between the Western Health Board and the authorities of Portiuncula Hospital, the result of which was an agreement eventually reached on 30 September 1976 and ratified by the Western Health Board on 4 October 1976. The agreement provided for “One additional obstetrician/gynaecologist to be based at Roscommon County Hospital. Present staffing in this specialty at Portiuncula Hospital to remain as heretofore”.
The Minister asks why the Western Health Board do not now agree to the federation, with the exception of this difficulty in obstetrics and gynaeology, so as to allow it to operate. He asked the question as if he was a political innocent and expected us to accept him as such. He knows very well that the terms of the federation negotiated more than two years ago included the provision of full maternity services for Roscommon Hospital. He knows very well that no one in a negotiating position will accept part of the bargain and not accept the rest when it has already been clearly indicated by his officials, by Comhairle na nOspidéal and by others that that maternity service will not be provided. He invites the Western Health Board to walk like lambs into his carefully set trap and agree to the remainder of the federation so that further discussions can go on on the provision of a full maternity service at Roscommon.
Mr. Boland: The Western Health Board did what any group would do in the circumstances. They had negotiated a federation on certain terms agreed by them and by the authorities of Portiuncula Hospital. One of the vital aspects of that agreement was the provision of full maternity services at Roscommon Hospital. Comhairle na nOspidéal declined to sanction the appointments and the Minister declined to honour his pre-election promises.
Mr. Boland: I imagine the people of Roscommon are now coming around to that point of view. As a result, the Western Health Board were not prepared to enter into the federation because it was not the federation which they had negotiated. I believe they were right to do so. If the Minister was a member of the Western Health Board he would be inclined to take the same view. However, it is annoying for him now that they have taken that viewpoint, that logical political step as representing their people which serves to remind him and the public of his pre-election promise.
Mr. Boland: The amount of embarrassment and shame this is causing Fianna Fáil is quite obvious from the presence here of so many of their deputies from that region and their persistent interruptions due to the facts being brought home to them.
Mr. Boland: We are here this evening because of the undertakings given prior to an election and because of a pending election, undertakings which were not fulfilled. I want to draw the Minister's attention to a possibility that may help to get him off the hook. He suggests that he would like to produce a solution deus ex machina. Let me draw his attention to a report submitted to the Western Health Board on 1 February 1977 by the CEO of the board at the time in which he said that he was of opinion that Comhairle na nOspidéal in purporting to terminate in-patient maternity services at the County Hospital Roscommon acted ultra vires. He said that these functions fall within the ambit of the Western Health Board and the Minister for Health alone. That is one aspect that might be explored by the Minister if he genuinely wants to honour his promise—whether Comhairle na nOspidéal have the right to refuse to sanction the appointment of an obstetrician/gynaecologist to Roscommon County Hospital on the basis that the decision given by his predecessor was to agree for a trial period to a federation between Portiuncula and Roscommon hospitals on a basis to be agreed by the Western Health Board and the authorities at Porttiuncula. Those authorities came together and made an agreement which contained provision for the appointment of an obstetrician/gynaecologist at Roscommon County Hospital.
Mr. Boland: If the Minister wishes to resolve this controversy he might consider examining the possibility that the terms of the trial federation negotiated between the two bodies did not allow Comhairle na nOspidéal the right to decide whether they would be prepared to sanction any appointment, if the submission of the CEO of the relevant health board has any validity in it. That might be a way of bringing the vexed question to a satisfactory outcome.
In the second page of his report the CEO deals with the fact that there were not as many births in Roscommon hospital as might be required to retain it at a viable level. He points out that the unit was built in 1968 but had not been staffed at consultant level from 1968 and that if there had been sufficient staff the requisite number of births might be brought about.
There is another aspect of the matter which the Minister has not yet come across personally—perhaps he will before this debate is over. I understand that during the lifetime of the last Government certain people involved in politics were wont to invite bodies involved in controversy to take legal action to establish what they might be entitled to. It might be interesting for the Minister to seek advice on his own behalf as to how the legal requirement for the provision of maternity services in County Roscommon stands at present. I do not accept that a woman should have to travel from the far end of the county up to 60 miles to receive maternity services in the Portiuncula Hospital, if the federation is implemented without providing maternity services at Roscommon as the Minister has invited the Western Health Board to consider. I do not believe any reasonable court would suggest that such a woman was being afforded natural justice, her right under the Constitution. For an ordinary confinement without complications I do not believe any court would suggest a woman should travel 60 miles, bypassing a hospital in which there is a modern 25-bed unit with all facilities available, on her journey to Portiuncula. Yet, that is what the Minister is suggesting should be done. Again, here this evening the Minister invited the Wesern Health  Board to agree to this. I do not agree it would be acceptable or that it is acceptable to close down a 25-bed unit in Roscommon when you look at a list of the areas in Roscommon and the adjoining areas. Out of a list of 16 areas that I have here, eight of them are materially nearer geographically to Roscommon as a centre than to Portiuncula. They are Ballaghaderreen, Boyle, Carrick-on-Shannon, Tulsk, Lanesboro', Frenchpark—would you believe it?—Castlerea, Clonfad——
Mr. Boland: Of course there are only 200 births in Roscommon Hospital because it has not traditionally been staffed by consultant staff. If the Minister himself were faced with the choice of attending for medical services at a hospital where there was not a specialist as opposed to attending another hospital where such services were provided, I have a strong suspicion as to which hospital the Minister would choose. That is what the people of Roscommon have been saying and are continuing to say: “Appoint an obstetrician/gynaecologist to Roscommon Hospital and we will attend that hospital”.
Despite the annoyance it causes the Minister I have already quoted from the piece of paper that outlines the terms of the agreement for the federation which included the provision of an obstetrician/gynaecologist at Roscommon Hospital. I want to reiterate from another tatty piece of paper the Minister's promise of 24 March 1977 the fact that he says in it:
I now wish to give a firm undertaking that the next Fianna Fáil Government will fully implement the arrangement for a federation which has been negotiated between the Western Health Board and the management of Portiuncula Hospital in regard to the Roscommon County Hospital.
Mr. Boland: No. The letter does not say: “I now wish to give a firm undertaking  that the next Fianna Fáil Government will try to fully implement....” It says: “The next Fianna Fáil Government will fully implement....” You get no marks for trying; ten out of ten for honouring your commitment. That is what the people are asking to have done. Let us go back and look at the agreement. It provides for a consultant obstetrician/gynaecologist and one additional consultant anaesthetist to be appointed to the County Hospital, Roscommon. That is the agreement referred to in the Minister's letter and the firm undertaking which he gave in March 1977 is to implement fully that agreement. None of us will be so naïve, not even some of the cuckoos in the backbenches, as to suggest that the terms——
Mr. Boland: There is a further and more far-reaching implication to the Minister's undertaking because he knows now, if he did not know in March, 1977, that the professional body representing the obstetricians have stated they will not staff a hospital, from a few years onwards, on an individual basis. To suggest that there should be an obstetrician/gynaecologist appointed to the Roscommon hospital really means, if it is to be on a permanent basis, the appointment of two professional people and the appointment of a paediatrician.
When we are talking about the provision of full maternity services that is what is needed on a permanent long term basis in order to maintain a permanent maternity unit in Roscommon. If the Minister wants to honour fully the terms of his letter and his undertaking, this is the type of situation he will have to examine rather than talking about the appointment of a single obstetrician/gynaecologist. This may serve even further to confuse or upset some of the ruffled feathers of those who are not to be referred to as cuckoos.
In considering this problem the Minister will have to look at the idea that, if a maternity service is to be provided in Roscommon hospital, it must be provided on the basis of having two obstetrician/gynaecologists and a paediatrician, and a full paediatric service. Then all the talk about dangers at birth, difficult births, children being born with mental handicap or mental illnesses, children having difficulties at birth, will be overcome. We are all assured a full range of physical services is provided, but what is needed is a full consultancy staff. The Minister has assured us money is not a problem. I am sure the House is glad to hear at least that that obstacle has been set aside.
Mr. Boland: I will not go into all the  tatty bits of paper, quoting Leyden and Doherty where they set out their close personal relationship with the Minister. I am sure if the relationship is so close as has been professed, they will have made him aware of the letter signed by the local bishop and a great number of local clergy of different denominations as reprinted in The Roscommon Champion of Friday, 1 September. In part of that letter it is pointed out that the United States have possibly the highest standards of maternity care in the world. They take, for example, the city of Stamford in Connecticut which has a population of 110,000 people with 1,500 obstetrical deliveries a year and 15 obstetricians to care for them. The Roscommon community care area of the Western Health Board has a population of 90,000 and there is no resident obstetrician.
Mr. Boland: The question of the scanners and where they came from might be embarrassing for us to go into now. Obstetricians in Stamford have a smaller number of maternity patients than that mentioned by the Comhairle as necessary without any loss of skills. I do not accept that there is not sufficient work for an obstetrician/gynaecologist in Roscommon. There have not been sufficient births to satisfy An Comhairle and to justify some of the figures suggested as the optimum for the provision of maternity services but certainly there are sufficient births in Roscommon to justify a service. It is not fair to say there would not be sufficient call on the services because there has never been a full-time consultant attached to the Roscommon County Hospital.
I was saving this for last because I did not know how many interruptions I would get. I want to put forward what I think might be a way around this. I understand the professional body have suggested that, after three years, they will not staff a maternity unit on the basis of one obstetrician/gynaecologist. The period they are allowing the Minister to  upgrade his unit is something like three years. If it is acceptable in Roscommon and Portiuncula I suggest that for a three-year period a full-time obstetrician/gynaecologist be appointed to Roscommon County Hospital and when he has to be matched by a colleague, there could be an examination of the level of births in the hospital having regard to the rising population and the forecast of population trend.
This would give an opportunity to the federation to continue in the fruitful way the Minister has set out. It would give an opportunity to the people of Roscommon to see whether their point is valid and that births will rise to a level at which a service can be sustained. It would also give an opportunity to An Comhairle to put their point of view. I am not suggesting that over three years births will rise to a level which would satisfy An Comhairle. I am suggesting that, if what the people of Roscommon are saying is right, births will rise to such a level as to justify a service in the context of the other types of maternity units which exist around the country. That might be a way of rescuing the Minister and his two cowboys.
Mr. Boland: I am suggesting a solution which may rescue the Minister and his advisers in County Roscommon from the political morass into which they have managed to get themselves. I am putting it forward as a genuine suggestion in an effort to see if it would allow both sides to this argument to have their point of view indicated or not over the next three-year period.
As to the situation between the Minister and his civil servant, I believe that is very unfortunate. It should never have been raised in public. As someone who has had a fair amount of experience with public servants, I regret that the situation between the Minister and his official was raised in the way it was raised. Because it was raised, Deputy Burke and I felt it incumbent on us to issue a statement asking the Minister to clarify the position. I regret the Minister did not clarify the situation when that statement was issued. I am not being flippant now, but I do not think it is fair for Deputies on any side of the House, when they exausted every possibility of blaming every other conceivable body for promises they made and could not keep, and knew they could not keep when they made them, to seek the last low refuge of hiding behind a civil servant who is not in a position to defend himself because of the nature of his employment.
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