Friday, 18 December 1987
Seanad Eireann Debate
An Leas-Chathaoirleach: I have notice from Senators Brian O'Shea and Paul Bradford that they propose to raise the following matter: (1) the need for the Minister for Health to rescind his decision to abolish the local health advisory committees; (2) to ensure the continuation and development of Mallow General Hospital's acute facilities and to insist that the necessary level of funding is provided to it.
The kernel of what I am here to propose tonight I suppose I can illustrate initially from my area of Waterford which is part of the South-Eastern Health Board area. We have lost five support hospitals and the voluntary hospital this year. Two of these hospitals were in County Waterford, the Lismore District Hospital and the County and City Infirmary in Waterford. On present trends it seems likely that the Dungarvan District Hospital is very much under threat in terms of the cutbacks which the South-Eastern Health Board must effect in hospital expenditure this year.
The health boards are monolithic regional bodies. When they were set up in 1971 the then Minister, later to be President of Ireland, Deputy Erskine Childers, introduced the local health committees, something of an extension of the old local county health authorities, in essence to maintain democratic connection between the smaller rural towns and the centre. At the last meeting of the health committee in Waterford, one very well respected councillor spoke to the effect that we were moving down a road of dictatorship, that the democratic base of local government and health is being eroded. The health committees have gone. We are told we will have a fairly substantial reduction in the number of VECs and there is speculation that we may see town commissioners and some of the smaller urban councils being abolished. That is a general point.
Essentially I am here tonight to demonstrate why the local health committees serve a very important role and should be maintained. Again I draw the illustration from my own area but I know that a somewhat similar pattern applies throughout the country. There are four electoral areas in County Waterford, each represented on the local health committee. There are three wards in Waterford Corporation, each represented also there. We have the professional staff. We have doctors who in some cases represent  hospitals. We have representatives of the public nurses and the psychiatric nurses. Let me say in all sincerity that in the local authoriries and committees I serve on the discussions we have had at the local health committees have been extremely constructive. In spite of fairly controversial times in the health area in the past few years, it is seldom that the discussion there descends into party political speeches. Vast areas of County Waterford have no representation on the South-Eastern Health Board and the various councillors, from each party, can promote the interests first of all of their town or genetal area.
There are other aspects to this. Quite a number of groups with specialised interests have emerged in recent years. To illustrate the point I am making, one problem that has been highlighted in Waterford local health committee is in regard to speech therapists and how we are under-supplied in that regard. In the main people who seem to need this help are mentally handicapped children and post-stroke patients. There has been some small improvement in that area because of representations made by the local health committee to the South-Eastern Health Board, but there are many voiceless and disadvantaged groups in all our areas and it is very important that there is a forum where their case can be put forward. I understand that in this type of representation not everybody can be met, and that is a real problem, but still it is vitally important that there is a forum where a case can be made, where it can continue to be pressed, and that we move along in this direction. It is important from the members point of view — I have to compliment the CEO of the South-Eastern Health Board because he has a very good attendance record at local health committee meetings — that when changes are made in conditions relating to the various community care schemes which are in operation the public representatives get factual information from the officials at those meetings. This means correct and solid information is being put out by the public representatives, the various voluntary  groups and the professions who in most areas would have prior knowledge.
In general, I believe the health committee in Waterford have been constructive. The community know various groups will make representations to the committee who will make recommendations to the South-Eastern Health Board, and there is a certain amount of interplay. For instance, when officials want to know what is the exact feeling in a particular area on a certain project, the public representatives, who have been put there by the people and who have the confidence of the people would have the best over-view. In small areas, for instance, identifying sites for new health clinics, or where a lease on a health clinic runs out, as happened a couple of times, the local knowledge can be very important. The public representatives can advise of a number of buildings in the area which might be suitable and an arrangement might be worked out.
In the health area we must, maintain the democratic input on as broad a basis as possible. I know that not all the recommendations coming from the local health committee in Waterford could possibly be met in one year, or over a number of years, but it is important that people realise they are not being forgotten and that there are people who are promoting their case. It is important that they read in local papers reports that indicate somebody cares about them and that their problem is not being neglected. For those reasons, local health committees should continue in operation.
Finally, on a point of clarification, the Minister's circular to the health boards stated that the functions of the local health committees were to be transferred to the health boards. Could he be more explicit? How can we maintain the direct input of the public representatives? I see a problem here. Public representatives in the main will no longer have a forum to pursue health issues. They can, at their local authority meetings, put down notices of motion and so on but these notices of motion will be dealt with by way of correspondence and answers will  come back. It is very important, in terms of the democratic operation of the health services, that the public representatives can put questions to the officials, can seek further clarification and pursue the matter further with the officials because if motions are being sent from local authorities, there will be long delays.
People will feel strongly about a particular issue in an area, and if it only gets an airing in a local authority the people will not be satisfied. The voluntary organisations have a direct input into the community care area. At the local health committee meetings they can question the officials about what is happening. They can say that a grant is being given to a certain organisation this year, but there are special circumstances which make this a more expensive year on that organisation and they would ask for further funding. My genuine fear is that we would be making many recipients of our services a bit more remote from what is happening. They will not feel they have as much impact of the democratic process as is the case at present.
I understand that the allocation to the Department is a basic problem and that the Minister is looking for areas in which to cut back. It would be unfair of me not to say that the Minister, personally, has brought a caring approach to this area and I understand the limitations he is under. I was interested to read last Sunday that he had become a Deputy before he became a councillor. I do not know if he has ever served on a local health committee, but I feel that this measure is a retrograde step. The savings in no way will represent the loss to the people. I ask him to reconsider this decision in the light of its enormous importance to various groups in our society. I would be particulary concerned about the groups serving the handicapped. There are many groups we can talk of here.
Mr. O'Shea: I had agreed to give eight minutes to Senator Bradford and I  thought you would call me to order. In conclusion, I would ask the Minister to reconsider this decision in the light of the points I have made.
Mr. Bradford: As a former member of a local health committee I would like to concur with all the sentiments expressed by Senator O'Shea. I would like to thank him for allowing me some of his time to raise the vitally important question of Mallow General Hospital. You will forgive me if I read from my notes because I want to say as much as I can in the little time available to me.
The case I wish to make here this evening for Mallow General Hospital is not one based simply on emotionalism as, I think we must admit, often occurs when we discuss the difficulties of a local hospital. Instead, it is based entirely on solid facts and figures which clearly indicate beyond any doubt whatsoever the cost effectiveness of this hospital, the excellent record it has of keeping within its budget, the fine tradition of treatment and care in the hospital and its vital importance to the north Cork region.
Mallow General Hospital at present has an allocation of 67 beds, 37 beds having been closed already. It serves a population in the north Cork area of 72,000 people. Even at the time when it had 103 beds its bed to population ratio was relatively low when you compare it with hospitals such as Portlaoise General Hospital which had 146 beds for a population of 53,000 — as you may well know yourself, a Leas-Chathaoirligh — and Tullamore Hospital which has 170 beds for a population of 60,000.
I would remind the House again that Mallow Hospital has 103 beds serving 72,000 people. In terms of its financial position it has done spectacularly well to live within the confines of a reduced budget from the Southern Health Board. It has been doing so for quite some time. For example, in 1985 with a budget of £2.7 million 2,821 operations were carried out in Mallow. The Tralee General Hospital, with a budget of £9.9 million, almost four times greater, carried out 5,200 operations, not even twice as many  despite their quadrupled budget. The number of operations at Mallow General Hospital has increased from 893 in 1975 to 3,200 in 1987, which demonstrates clearly its importance to the area. The number of general admissions in emergency cases dealt with has increased from 7,600 in 1978 to 14,070 in 1987. It demonstrates clearly its importance to the area.
The number of general admissions and emergency cases dealt with has almost doubled from 7,600 in 1978 to 14,070 in 1987. The Minister may recall the tragic Buttevant rail disaster of 1979. On that occasion the proximity of Mallow hospital and the outstanding work so quickly and effectively done there saved many lives. Without it the picture would have been far worse.
The average stay in Mallow hospital is six days and this is very favourable in comparison with other hospitals. On a cost per day basis, and this is a vital point, the same work can be done at Mallow hospital for 70 per cent of what it costs at the Regional Hospital in Cork. On that basis alone, sending patients from Mallow hospital to Cork hospitals is economic lunacy. The importance of the hospital to the north Cork area can be gauged from the fact that some of the patients attending there travel 30 and 40 miles because it is their nearest hospital. If they had to go to Cork they would have to travel up to 60 miles. We could be talking about life and death cases in those circumstances and many doctors in the Mallow area have publicly said that they would be willing to supply case histories of patients who would have died if it had not been for the proximity and availability of Mallow General Hospital.
Because of their dependency on it the people of north Cork have solidly supported their hospital. The Friends of Mallow Hospital Committee have raised tens of thousands of pounds for equipment for the hospital and, therefore, have a genuine stake in its future. Mallow hospital has proved its worth and value. It turned a deficit of £60,000 in April 1987 into a surplus of £44,000 this October.
 Sacrifices have had to be made by the staff. If every hospital in the Southern Health Board region and throughout the country had efficiency records similar or almost similar to Mallow hospital, the Minister's Department would not be suffering from some of the present financial difficulties.
Because of their present financial difficulties the Southern Health Board are now proposing to save £1.5 million by transferring the acute facilities at Mallow hospital to Cork hospitals and basically letting Mallow hospital grind to a slow death. It makes no economic sense whatsoever to do so. If the patients being treated in Mallow hospital are moved to Cork hospitals all the figures conclusively prove that it will cost each patient an extra 20 per cent approximately. What sort of saving would that be in both the short and long term? As well as that there will be the dreadful and dangerous spectacle of patients having to travel over 60 miles, many on bad roads, to Cork hospitals where, if they are lucky enough to survive the extreme, journey, they will be far removed from their friends and neighbours and the extra special personal attention available at a hospital such as Mallow hospital.
I realise the difficulties the Minister and his Department face. I am glad the Minister stated publicly a few weeks ago that he does not wish to see further closures of acute hospitals. I think it is time that the Southern Health Board were made aware of that view and were ordered to stop their plans for the closure of the acute facilities at Mallow General Hospital. When we are talking about the health service today we have to admit that it has to be run in the most cost effective fashion possible. There is clear evidence from the staff at Mallow General Hospital that they are willing to do this. They have proved their record and they should be allowed to continue to prove their record. In cases like this we are not talking about emotion we are talking about realism. If commonsense is allowed to prevail in a case such as Mallow General Hospital the hospital will be allowed to remain. I know that the  decision has to be taken by the Southern Health Board but because of the economics of the Southern Health Board at present councils in one area will be played off against councils in another area and the medical representatives in some areas will be opposed to counsellors in other areas.
The case for Mallow General Hospital is one which requires no further proof. I hope the Minister will insist that the Southern Health Board change their plan for Mallow General Hospital. That hospital has proved its worth and value and if commonsense is allowed to prevail, Mallow hospital will be allowed to serve the people of north Cork as successfully as it has done during the past number of years. I appeal to the Minister to do his utmost. The Southern Health Board are meeting next Tuesday to decide the future of the hospital and it is vital that the Southern Health Board management be made fully aware of the Minister's decision that no further cutbacks take place in acute hospitals. The figures speak in favour of Mallow hospital. The Minister has been asked to save hospitals where the figures spoke against them but in the case of Mallow hospital the figures speak clearly in its favour. I would appeal to the Minister to come down in its favour and do his utmost to ensure its future for the people of north Cork and their health.
Minister for Health (Dr. O'Hanlon): I will deal with Senator Bradford's points first. It is primarily a matter for the Southern Health Board to decide how they organise the services they can provide with the allocations made available for 1988. The board have not yet made any decision with regard to their budget for 1988. The management of the board have set out proposals on the measures which could be taken to ensure that their expenditure is kept in line with their allocation during the coming year. Officers of my Department have agreed with the boards of management that measures of the order proposed are necessary in order to deal with the shortfall in revenue in 1988.  It is now a matter for the board to decide if they agree with management's recommendations, including a proposed change of role in Mallow General Hospital. I understand that the Southern Health Board are meeting on Tuesday next to discuss a number of proposals and I will be awaiting the decisions made by the board.
On the question raised by Senator O'Shea, I am glad of the opportunity to respond to his statement. For some time now I have been convinced of the need to review the organisation of the health services, including the functions and management of health boards. My perspective on this need is multifaceted arising from my involvement in the delivery of health services as a general practitioner, as a member of a health board and as Minister for Health. When I was on the health board representing my medical colleagues, I had the honour of being on the local health committee representing the local authority.
The existing structure was proposed in the mid-sixties and the health boards came into operation, as Senators will be aware, in 1970 to meet the health and personal social service requirements at the time. The structures were also intended to address the projected requirements for future years as envisaged then.
There is no need to remind Senators of the dramatic changes which had taken place economically, socially and budgetary, since then. In addition, many developments have taken place in the intervening years in relation to health and health care which must also be taken into account in any proper assessment of the health care delivery system. In the light of all these factors and having regard to the limited resources which are currently available for health and personal social services I have indicated on several occasions that there is a need for an assessment of current conditions and more importantly the conditions which are likely to prevail to the end of the century. It behoves us all as public representatives to ensure that the publicly funded services in all spheres of national  life are regularly scrutinised to ensure that the structures that are in place and the service delivery system are effective and efficient and that they are addressing the current needs of the community.
In so far as the structures of the health services are concerned I am satisfied at this stage that there is no need for a change in the number of health boards. Concentration on an appropriate number of health boards deflects attention from improvements that are needed within the existing structures. A mere change in number does not address the need for change where deficiencies have been identified. Some time ago I initiated the process of the examination and review of the role, function and remit of the health boards with a view to introducing modifications where necessary. As part of the review the Government have been considering the role and function of local health committees which were established by regulations under the Health Act, 1970. As this House will be aware the principal function of a local health committee is to advise the appropriate health board on the provision by the board of health services in the functional area of the committee.
Senators will no doubt be aware of the questioning of people within the health sector, including members of local health committees, of the need to have such committees in the present circumstances. The focus of attention is centred on the statutory relationship between such committees and the relevant health board. The relationship is advisory, a health board are required merely to consider any advice tendered by a committee. They are not obliged to act on the advice so rendered. The provision of health and personal social services to the population and the functioning of the health board in an equitable manner remains the statutory responsibility of the health board.
The establishment of the health board structure in 1970 involved a radical change from the old health poverty system. Health boards became responsible for services in a number of counties. In those circumstances it was clear that initially there was a need for an advisory  input to the boards at county level; hence the local health committees were set up to provide that more localised knowledge. However, after 17 years, in which the boards have become well established and the services provided for the functional areas have become more cohesive, the need for local health committees must be questioned.
Another factor which must be taken into account is the cost of administering the local health committess. This cost involves not just expenses paid to members but also the substantial cost to health board managements in servicing them. At this time of financial restraint it is necessary to assess all aspects of health expenditure and in such an assessment the continuation of the committees must be queried. The resources that are saved will be applied to priority activities within each health board.
The Government have decided that arrangements should be made as soon as possible for the abolition of local health committees. I fully subscribe to the widely held view that there is a need for the involvement of the local community in the direction and the shape of the health services provied within a health board area generally and at local level specifically. The important position of local authority members, who by statute are in a majority on health boards, must be stressed in focusing on the planning and delivery of services within a board's functional area. While Senator O'Shea expressed concern that the input of local authority members would be diminished, it is important to recognise that local authority members, by law, make up the majority on each health board and, therefore, will continue to have the opportunity at health board level to make their input on behalf of their own particular county.
Senators will be aware of my recent initiatives in the area of health promotion which are now central to the improvement of community health. In that context I am considering the most effective arrangements or structures necessary to involve the local community in the positive promotion of good health within the  local community and throughout the country. The limited remit of local health committees and the current direction of community involvement in health requires a change in direction for a more effective co-ordination of effort. I am sure Senators will agree that the measures I have proposed are positive and necessary and will address current health policy developments in the interests of all.
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