Wednesday, 26 February 1986
Seanad Eireann Debate
Mr. Browne: Tá mé an-bhuíoch díot go bhfuil an seans seo agam labhairt ar an ábhar seo agus tá mé buíoch den Aire freisin go bhfuil sé anseo chun éisteacht liom. At the outset I want to make it quite clear, lest my words might go astray, that I am opposing completely the closure of St. Dympna's Hospital in Carlow. I do so, not just on sentimental grounds, but because of the facts that I will produce as I go on with my speech. There is an idea abroad and I saw it in the papers that some of the shock that was talked about when the announcement was made was hyped up and that it was artificially created. Coming from Carlow I know exactly the genuine shock that was felt. It was not just organised by political groups; it may have been helped perhaps, but it was quite genuine. I was at a meeting within 24 hours of the announcement and I saw one of patients who was not put up to anything reacting in a way that was quite genuine. I regard Carlow as a special case, not again because of sentiment, but simply and solely because it was the one hospital that was not earmarked. The other hospitals were told four or five years ago that they were being replaced or being amalgamated. Some that were closed had alternative arrangements in accommodation. Carlow has not got that. We are being pushed too quickly too soon. It is not possible to put the cart before the horse and make progress.
It is well known that community-based care has been discussed but it is not ready in Carlow. This is the big problem. If it was ready there would not be a problem. While I cannot speak officially for the staff I know from speaking to them that  they were all geared towards community-based care and they are quite willing to put it into practice. Carlow has a special case. If we look at the staff-patient ratio in Carlow it is the best in the country and I have been told it is the best in Western Europe. That figure will probably be disputed but that is the figure that has been given to us. The staff itself has been integrated years ago. Long before integrated staff became a bone of contention in many hospitals, Carlow was using integrated staff in the wards.
The reference to these walled-up buildings being an anachronism does not apply to Carlow either. The walls were gone in Carlow long before it was thought to remove them in many other hospitals. It has been a community hospital for years. It may not be community-based in the sense that the patients were still in the hospital but the community were in there; I played football there 25 years ago and so did many other better footballers. It was a short cut for people for many places. The patients were being allowed to mix; the walls were down and there were beautiful gardens. The whole scene was one of modernisation. The staff cannot be faulted for the fact that community-based care had not come into action. From a cost point of view the hospital must be giving great value. The maintenance staff who look after St. Dympna's Hospital also look after our district hospital, the maternity hospital and the district hospital in Bagnalstown. That is fair value for money from one maintenance staff. The kitchen staff provide meals for all of those except the district in Bagnalstown and they also provide 100 meals a day for St. Laserian's Special School for the Mentally Handicapped.
We hear a lot about planning for the future and community-based care so that these people should not be in hospital but should be out as much as possible in the community, either with their own people or in hostels and flats. Carlow has started that; they have their hostel across the road from the main hospital and they bought a house last summer. That is still there. They have not the wherewithal to  put it into action. They have been setting up a pre-hostelling course to train the patients who would have to go out into ordinary life again. I was surprised to find that you would have to train people to plug in kettles — simple jobs like that — people who have been in hospitals and unable to cope. The preparation of the patients is a very slow process; it takes a lot of time and it needs a lot of care. If people are pushed out into the community after being in hospital they do not fit in. A psychiatrist in another area told me that it took three attempts by one patient to settle down in the community. He went to live in a house with a few more; he came back into the hospital. He tried it a second time and he failed; he came back into the hospital. The third time he managed to settle down. Even patients who are willing to take part in community-based care are often not able for it when it is available. They are used to being hospitalised and they have a relationship there with the staff.
The patients have to be cared for and trained. The staff have to be trained also; many of them are used to working in hospitals for a long number of years; they are used to the routine of wards. They have to be updated in training to get them used to the whole question of managing in the community. When we talk about community-based care we must also talk about the community. If the community are inundated with people that appear to be dumped out without any preparation we can have more trouble. The Minister will know this from what psychiatrists have said. They have given examples of other countries where all kinds of trouble arose simply because the transition scheme was rushed. For that reason alone it is not possible to close Carlow hospital as it stands now. The people are not geared to come out unless we throw them out into the community and say; “There you are sink or swim; there is nothing wrong with you”. That cannot be done.
To provide all the back-up services for community-based care there is money needed. I am well aware of the cost of the medical services. I am a member of  the health board. We had a meeting last Monday and there was a cut of £6½ million. I have to admit publicly I was not able to contribute much even though I had the escape that I am on the community care section of the health board and that was the one section where we were asked not to cut back, if at all possible because of the demands of that service.
If the money is not provided by the health board perhaps, through the Minister, to set up a system nobody can go anywhere. This is what I find difficult to understand, how we can just announce the closing down of a hospital and find that the staff are there. I would be appalled if all it meant was that we were going to start transporting older patients, those who are institutionalised through no fault of their own; they are in the hospital for years. There are 155 of them who are over 60 years of age and 108 of them over 65 years of age. These are not people who will settle down too well in any other place that they do not regard as home. They do regard St. Dympna's as their home. Again, speaking to an independent psychiatrist — in the sense that he had no connection with Carlow — I asked him what was the real position, how could one close St. Dympna's in a short space of time. He said it was not possible. He said there was probably 80 patients who could be lined up for community-based training to go out into the community. If you were lucky 60 of them might succeed. There are 340 patients in Carlow. That means one is left with 280 patients. These are the older patients, the patients who are institutionalised, no matter what we feel about it. If I had my way I would have every hospital closed, including general ones if that were possible. But we cannot talk about that. People have to be in hospitals and we cannot do anything about it.
The uncertainty in Carlow is causing problems for the patients and indeed for the staff, because the patients feel that they are going to be thrown around. I certainly do not want to see an exodus from St. Dympna's Hospital to other hospitals in neighbouring counties or to see a fleet of ambulances or mini-buses  taking the old patients out of St. Dympna's. I do not want that and I hope we will not come to that stage. The older people there deserve to finish their lives in the surroundings they know. I think it would be most unkind, ungenerous and inhuman on our part to decide that they are going to be told: “We are taking you to Enniscorthy, Clonmel or St. Canice's in Kilkenny”. Maybe it can be done but certainly I am opposed to it. I hope the Minister does not want to do it either. I am appealing to him to make sure it does not happen.
Everybody who had any connection with the mental hospital at all was geared towards a phasing down of St. Dympna's. Long before the announcement came we had asked about the effect that this community-based case would have on the hospital and we were told then that there would be a phasing out of St. Dympna's. Nobody objected to that. That is part and parcel of the process of advancement. We cannot oppose what is good for patients. The staff are not opposed to that. They welcome the whole idea of modern methods and it would not affect them in the slightest because they would be dealing with the patients. It would be dreadful to think that we would just simply, overnight, decide to tell these people to go, let them sink or swim. I really do not want that.
We have another bad position as well as regards the RMS. What is going to happen about the filling of posts following this announcement. Will it wear itself out by degrees because we have not got the staff? In that process there will be no care there, and we will have an accusation then that the patients are not getting proper care in the hospital.
I want to refer at this stage to the dreadful film that was made by RTE when they came down to do a feature on St. Dympna's Hospital in Carlow. I am sure it shocked people who did not know St. Dympna's. I can assure you it shocked the people who do know St. Dympna's. The way St. Dympna's was depicted that time was a scandal. I am quite sure it has influenced people who saw that film and concluded that it was a dreadful place. I  do not blame people who saw the film and did not know St. Dympna's. It was a completely unjust portrayal of St. Dympna's Hospital. I hope that the Minister and his officials who have since met at least once with the South Eastern Health Board officials and discussed the future of the hospital, will continue these talks. A lot more can be achieved in these talks than in much of the political posturing that goes on.
Mr. Browne: I will certainly withdraw anything you wish to be withdrawn but I was told about Lanigan's Ball and that was why I quoted it. I was not here, as you know. It shows the absolute hypocrisy of some of the politicians who have been trying to cash in on these hospital closures. Coming from Carlow I have a genuine interest in the saving of St. Dympna's hospital. I know the scene and I know some of the patients. I also know some of the staff. I think that we get nowhere when we start having outsiders — I mean people that are not from Carlow — who can cry crocodile tears and make a song and dance about the closing of a hospital simply because they want to make political mileage out of it. They may grab the headlines but that is not for me. I want to save the hospital and if anyone else was interested in saving Carlow hospital they could easily have asked me — this is always done — to share some of my time, but they wanted to attack me for raising this here and saving the Minister.  I am not saving the Minister: I am not attacking him. I am hoping that he will have news for me that will be of benefit to Carlow and I regret very much that so many politicians have simply come and said the right thing, got the cheers and have gone away with absolutely nothing achieved.
All this shouting and looking for notice and condemning Ministers and making scare headlines will not help Carlow hospital. I want this hospital saved. It deserves to be saved. The staff deserve to be treated properly and the patients above all deserve to be able to relax and feel they are not going to be pushed around the countryside. We have already had a maternity hospital closed in Kilkenny. Our district hospital is not a very big one. We have very little medical care in Carlow. Our mental hospital has set headlines years ago. The patients will not suffer in the slightest if they are allowed to end their days there. If modern treatment takes over and if all the hospitals — as I hope some day will happen — are closed because we do not need them then I will accept that, but only when there is no need for them.
Minister for Health (Mr. Desmond): I would like to thank Senator John Browne for raising the matter this evening. I know that on a number of occasions he has endeavoured to do so in the Seanad, I want to elaborate on my decision to close the hospital. I want to stress to Senator Browne that in doing so I was announcing a collective Government decision taken by myself and my colleagues in Government based, on the weight of opinion available to us, on the need for an urgent change of policy in relation to the provision of psychiatric services in this country.
The main impetus for this change came from the report referred to by the Senator “Planning for the Future” with which no doubt many Members of both Houses are now very familiar. The expert group that drew up this report included four experienced officers of the Department of Health including the Department's  inspector of mental hospitals as well as a clinical director in child psychiatry, a professor of psychiatry, a chief psychiatrist and two other consultant psychiatrists, a chief nursing officer and a chief executive officer of a health board. The main trust of their conclusions was, “the psychiatric needs of the community must be met by a comprehensive and integrated service made up of a number of treatment components and largely located in the community”. The group also stated that “in particular there must be a decided shift in the pattern of care from an institutional to a community setting with close links between psychiatry and other community services”. Finally the group called for the implementation of this programme in all parts of the country without delay. It was in that framework that the closure of the hospital in Carlow was considered and must be considered in the future. The reality is that unless large hospitals close a real change in community care just will not happen.
St. Dympna's, which was established to provide services in the Carlow and south Kildare catchment area, is one of five psychiatric hospitals in the South Eastern Health Board area and, in addition, there are associated acute psychiatric units in Ardkeen and in Clonmel General Hospital. Two-thirds of the population served by the Carlow hospital live in County Kildare. The Eastern Health Board are responsible for services in this area and they will be making arrangements to provide such services.
While everybody in Carlow has jumped to the defence of St. Dympna's hospital at this stage I think they are well aware that the hospital is a relatively old 19th century building. It has not been a pioneer in recent years in the development of our psychiatric services. The patient population which had dropped from 398 in 1965 to 318 in 1975 now stands at 340 in-patients.
We are aware that there have been some adverse reports at health board level—outside of the references made by the Senator—and indeed adverse publicity for its services in recent years. The  hospital has become overcrowded because it did have an excessively liberal admissions policy and it had a slow discharge policy. These two were the norm. The prospects of facilities for patient comfort as a consequence were bleak and rehabilitation of patients was not adequate. The call for action on those inadequacies has been somewhat minimal in recent years.
I am quite certain that the closure of the hospital will lead to a far better psychiatric treatment model and indeed a lifestyle for most of the 340 patients accommodated there and that it will moreover permit of the provision of better services to those patients from the catchment area of the hospital who will require psychiatric services in the future. It will also facilitate the opening of the geriatric assessment unit at Ardkeen hospital in Waterford which is a much needed facility in the South Eastern Health Board area. I want to assure Senator Browne that I am not neglecting the needs of the Carlow area because we are now providing over £4 million in capital funds for a new purpose-built 100-bed geriatric unit in Carlow to replace the existing substandard accommodation in the Sacred Heart Hospital in Carlow and that accommodation is now, as the Senator knows, being constructed.
In St. Dympna's, as of last September, for the 340 patients there were four medical staff, 133 nursing and allied staff, four paramedical, 37 catering and housekeeping staff, 18 maintenance staff, 11 clerical and administrative, six other grades, a total of 213 staff plus 33 locums. The budget last year was £3.7 million of which £2.8 million was pay. The staff of the hospital will as far as possible be redeployed to positions in Carlow and in the general environs of Carlow in which they will be providing a service which in future will be more relevant to the real needs of psychiatric patients. Those staffs will live, work and continue to generate their own employment and income in the area. I have given those assurances in other debates because I have always ensured that the interests of the 58,000 people employed throughout the health services  are always taken fully into account when any necessary policy changes are made.
I will come to the question of the patients. I can assure the Senator that in relation to any of the patients who are at the advanced psycho-geriatric stage I will take every possible care to ensure that those patients' interests are fully catered for. I would be appalled at the prospect of any policy decision involving very elderly people—over 100 persons in the hospital are over the age of 65—which would adversely affect them. I have given absolute assurances that that will not be so. On the other hand, I will not allow their plight to be exploited—not by Senator Browne, I can assure you—in terms of preventing essential changes which must take place. It has to start somewhere. We always talk about phasing in things in this country, about consulting at great length, about doing it over a period of years. Ministers come and Ministers go and nothing whatsoever happens. In relation to psychiatric services in Ireland for the past 30 years nothing has happened and that is why I feel the start must be made somewhere, irrespective of the odium which is heaped on the Minister of the day who endeavours to bring about that change.
I can assure the Senator that the patients in the hospital have already been assessed by a consultant psychiatrist employed by the health board. Seventy of the patients already are deemed to have a potential for rehabilitation to the community. It is interesting to note that I was the first person to bring this to the attention of the population in a public sense. I wonder if I had not made that point would anything ever have happened. The answer probably is “nothing” because with over 100 patients in the hospital well over the age of 65 I think admissions would still have been kept up to keep up the patient population of the hospital. That is not psychiatric treatment; that is something that is totally intolerable in any health service.
Eighty-eight of the patients are mentally handicapped in that institution. They should never have been there in the first instance. I am asking the co-operation of  the health board to get them out, to take them out in the best interest of persons who are mentally handicapped and who should not be with those who have serious psychiatric disorders. Nobody should be in a psychiatric hospital unless suffering from a serious psychiatric disorder. People should not be in psychiatric hospitals for social reasons, I submit that that is endemic within the system and I feel very strongly about it. Therefore, if one takes the two categories I have mentioned, namely those who are suitable for rehabilitation and those who are mentally handicapped that is half its population. That gives an indication of the potential that there is for transferring patients to the community.
I can assure the Senator that work is now being done, such as the building up of the acute psychiatric unit in Naas hospital. We have given the go ahead for the construction of this unit which will cater for the Carlow catchment area. That is being provided without delay. I already announced it within the past fortnight. The capital moneys required to enable this to be done will be available forthwith. Equally I want to build up — and I have not the slightest doubt that we will have the full co-operation of Senator Browne and his colleagues on the health board — the day care facilities in the Carlow area, the provision of residences for persons in the Carlow area who are capable of living reasonably normal lives in the community, out of the hospital, and for the provision of supervised hostels in the area. Then we will have the transfer of mentally handicapped persons  into the mental handicap services. We are going ahead and doing all that rapidly. The health board has substantial capital moneys which it is showing an extraordinary reluctance to release in some respects. I am sure the Senator will not ask me to elaborate on that. I am quite sure that those capital moneys can equally be put to the benefit of the patients concerned but if there is any great trauma in that regard the capital moneys from my Department will be readily made available jointly with the board. Furthermore, an assistant secretary from my Department will be in Carlow next week to further advance the situation to discuss the situation further and to advance it.
I would like to assure the Senator that I fully appreciate his concern and if my actions have concentrated minds I think it is because in this country such concentration of minds never occurs. We fudge, we fluff, we postpone, we defer any kind of decision which affects anybody and in the end the quality of life in our country, the quality of our health services and the care of those who have nobody to speak for them other than the politicians of the day suffer quite dramatically. Accordingly, I appreciate the raising of the issue by the Senator and I assure him that no patients or staff will suffer in this necessary transition to a far better psychiatric service.
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