Closing hospitals and the ‘ungovernability’ of Roscommon…

The people of Roscommon are a formidably independent bunch. They are under no illusions why they send TDs to Dublin. It is to defend the parish from the cutehoors and Jackeens of Dublin: no more; no less. No one puts the least store in the county council, since Jack Lynch had their teeth removed back in 1977.

Sure there are concerns about the state of nation and the knock on effects that has for the local economy, but their TDs know too that they are permanently on notice to quit if they don’t deliver.

Even their counterculture, cannabis-toking TD Luke ‘Ming’ Flanagan knows the value of a good local interest (aka populist) platform. His protective stance over turf cutting, for instance, does not exactly come with a Friends of the Earth approval tag.

I doubt the decision of Dennis Naughten of Fine Gael to vote with the Opposition (and subsequent loss of his party’s parliamentary whip) against his Minister’s decision to close the Accident and Emergency facility at Roscommon Hospital was taken willingly. But it was probably inevitable in light of his Minister’s rather bizarre (and with hindsight rather foolish) decision to pledge:

…to retain the Emergency, Surgical, Medical and other health services at Roscommon Hospital which are present on the formation of the 31st Dáil. Furthermore, in the event of the A&E being downgraded, we are committed to reinstating a 24/7 service, where feasible.

It should be noted too that the previous government may have been aware that Roscommon County Hospital was on the axing list as early as last September:

While Dr Reilly, who took over as Minister in March of this year, is unlikely to have had sight of this previous safety report, it is not known whether his predecessor, Mary Harney had seen it. The HSE did not make publicly available the September 2010 report, which was released to irishhealth.com under FOI.

Now, there is a strong clinical case to be made for the move. Patient outcomes are four times better for a number of acute conditions in Galway A&E. But Fine Gael was not making it before taking two seats out of Roscommon/South Leitrim. Nor, to be fair, was any other party. No one could credibly pitch that one to the voters and stand even a remote chance of getting in.

One of the reasons (and acutely understood by local people) for the differential in outcomes is a lack of investment in specialist staff at the hospital. What’s never cited, the likely outcomes for people living in Roscomon who have to get to Galway in the first place. Time and again people reiterate their fearful mantra of ‘dying on the road to Galway’.

As Peter and I noted back in February, despite the vast improvement in long distance road networks, roads west of the Shannon leave a lot to be desired:

Ten years ago a road-trip around Ireland would have lots of bumpy roads, traffic jams and long journey times, but this around it was all, well, bumpy roads, traffic jams, and long journey times. Ireland’s new motorways don’t help you much if you’re traveling between Cavan, Roscommon and Kilkenny – and these poor travel times are one of the main reasons why local folk would rather be treated in a community hospital, like in Roscommon, than take their chances on the road to a centre of excellence in Galway.

And there is the old county thing too. They are trying to rob us of another key asset (not mention an important centre of good employment where non agriculturally related work is relatively scarce) from Roscommon. First they come for A&E, but what will be next?

Of Fine Gael’s two Roscommon-South Leitrim TDs, Naughten was left holding the short straw on this issue. Roscommon town, where the hospital is based, is very much the centre of his electoral patch. Boyle publican Frank Feighan is removed from the town and so may calculate that his end of the constituency,will not be so keen to punish him for Dr Reilly’s apparent Ministerial fickleness.

Naturally enough, most political correspondents in Dublin are understandably resiling to the politics of Dublin, and more specifically those of Leinster House. But the undeniable fact is that no candidate standing for election in February in Roscommon-South Leitrim was in favour of the kind of expert opinion Minister Reilly is acting upon.

The refusal of the last government to publish last September’s report  has undoubtedly skewed the playing field, both laying a booby trap for the incoming administration and dodging an electoral bullet for their own unsuccessful candidate, Ivan Connaughton.

Such local trumping of the national interest by the local is one serious problem for governments of all stripes. It further underlines the need for the substantial beefing up of local democratically elected power at a time when many fear the resolve of all parties to ‘do-the-right’ on constitutional reform seems to be waning the teeth of the economic crisis and the irresistible urge of the opposition to make make political hay whilst the government’s caught out in a political downpour.

 

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  • pippakin

    I’m totally against pork barrel politics, absolutely totally against it, right up to the point where the government tries to take anything away from the west. If its a question of money let the bastards close a hospital in Dublin. Its a long way from Roscommon to Galway or Castlebar.

    Remember the people are dealing with a health service thast couldn’t arrange an emergency flight for a vital transplant! Piss ups and brewery’s spring to mind.

  • SK

    “If its a question of money let the bastards close a hospital in Dublin.”

    That’s a brilliant idea. Which one?

    Whatever the people of Roscommon feel about the cute hoors ™ in Dublin, they cannot accuse the HIQA of the same type of gombeenism. It might not be popular, but there is a logic to moving services from Roscommon to a larger site, and if the only retort Ming and pals have is “protect the parish!” then they have lost the argument.

    An independent body has decided that- statistically speaking- it would be better for patients if the ED at Roscommon were moved. Populism should not trump logic.

  • John Ó Néill

    Not a good few days for FG (or Labour).

    Yesterday the JLCs were thrown in doubt by a High Court judgement that ruled them unconstitutional (this may impact directly on the pay rates of about 200,000 low paid workers). At the same time, a whole battery of special advisers have been hired at off-scale rates by the government, including flunkies of both Fine Gael and Labour.

    Meanwhile, the Oireachtas Committee on Procedure and Privilege has busied itself drawing up a strict new dress code requiring business attire in the Dáil and Seanad (a move largely aimed at Mick Wallace and Richard Boyd-Barrett).

    If you can – listen to the podcast of the government Chief Whip Paul Kehoe’s interview on Breakfast on Newstalk from this morning (he’s on 50 minutes in, Richard Boyd-Barrett earlier at around 40 mins).

    I had figured this government would last about 18 months. I reckon, as Trichet might say, there should be strong vigilance that it might last only 12.

  • Republic of Connaught

    I feel sorry for the Roscommon people but they will just have to accept it. When the IMF enters a state well then you know difficult cutbacks have to be made. The problem for too many Irish people in glorious Connaught as elsewhere, is they want ‘themmuns’, to borrow a phrase from Ulster, to take the hits. I’m afraid in this case the Rossies will have to take one for the team.

  • Turgon

    Republic of Connaught ,
    “I’m afraid in this case the Rossies will have to take one for the team.

    I am sure many will see it that way but as SK points out if the outcomes are much poorer in the smaller hospital then in actual fact the people of Roscommon would be better served medically by going to a larger properly equiped hospital.

    Mick’s comment about drive times is incorrect. The ideas of a “golden hour” etc. are to best treatment. If the choice is between a drive of two hours to proper treatment or attempts at “stabilisation” in a local hospital the evidence is overwhelmingly clear that patients do better driven to the larger hospitals.

    Even if money was not an object one cannot have the small hospitals fully staffed. This is because the doctors nurses etc. there would see so few patients they would de-skill and the situation would be the same as before.

    This is why even in privately funded systems there are large centres and people travel much, much greater distances than they do in any part of Ireland in order to access state of the art health care and, hence, have better outcomes.

    The problem is that when people shout about keeping local hospitals open what a lot of people behind them and pushing them forwards are doing is trying to protect their little empires in the small local hospital or their job in the local hospital, or their political position by having kept the hospital open. There are lots of less altruistic motives behind people trying to keep small local hospitals open but it will always be dishonestly presented as about saving lives when in reality closing the small hospitals is what saves lives.

  • Republic of Connaught

    Agree with that, Turgon.

    The reason the health service didn’t reach optimum performance in the South was not for lack of money put in during the boom, but poor management at the top and too many Del Boys in the system more interested in lining their own pockets than anything else.

  • Of course Boyle residents won’t be much worried. Sligo is closer to them than Roscommon town. It’s not so much the roads west of the Shannon that are bad, but roads that go anywhere other than to and from Dublin. This has long been a problem in the Republic and recent road-building investments are no different. High-profile motorway investments mask a chronic lack of investment in regional and local roads. Even within the bounds of Galway city there are roads that you wouldn’t take an expensive car down for fear. The uncomfortable truth is that many (most?) local councils are too small to do their jobs properly.

  • michael-mcivor

    If there is going to be less hospitals but more drugs about-

    will ming be the man to ring about the street cure-

  • Mayoman

    Have a look here for how poorly the A&E in Galway is rated. http://lb.vg/31Npz (the ‘red light’ associated with ‘Emergency Department to Acute Admission Waiting Time’ means it is need of what the HSE call ‘urgent attention’). It is almost certainly already underfunded and under-resourced, and is now going to absorb a larger caseload.

    I am raising an eyebrow at the outcomes data.Would anyone be kind enough (if they know) to point me to where there is any detail on what/how outcomes were compared? .

  • SK

    “I am raising an eyebrow at the outcomes data.Would anyone be kind enough (if they know) to point me to where there is any detail on what/how outcomes were compared?”

    _

    Mayoman,

    Guidelines on HIQA site:

    http://www.hiqa.ie/publication/guidance-developing-key-performance-indicators-kpis-and-minimum-data-sets-monitor-health

  • RichyA

    I live over in London and here im all in favour of devolving greater power to local authorities and communities. Unfortunately in ireland, im of the opposite opinion. As set out in Fintan O’tooles book “Ship of Fools”, ireland has a politically underdeveloped culture. Too much naked, parish pump populism and a tolerance of corruption.

    look at local government in ireland with regard to town planning laws and im all in favour of centalising these powers more in Dublin…

  • Mayoman

    It may be lack of time to search the site properly, but I can’t find any data from HIQA that says that a person living in Roscommon with an acute need for A&E has a 4-fold greater chance of an adverse health outcome by being treated in Roscommon Hospital versus Galway. Have factors such as ‘time to treatment’ been incorporated? For example, from DeVon HA 2010.

    “Time to treatment for symptoms of ACS can be a matter of life and death. Data suggest up to half of patients with ACS experience sudden death prior to arrival in the emergency department (ED) 3. In addition, degree of myocardial necrosis is related to length of the ischemic episode 4”

    I just want to be sure that the clinical case for this closure is as strong as stated. On the other hand, if it is an economic one, let that be stated transparently too.

  • Blissett

    Im not sure if this is a feature in Roscommon, but certainly in Monaghan there was an issue around not so much the driving times, but the inability of the larger hospital to cope. How is Galway coping with its existing load, and how will it cope with however many thousands will be redirected from Ros to Galway?
    So while it may be true that centralised services deliver better outcomes, even with longer travelling times, if the larger hospital doesn’t have the beds etc to cope with the additional load from the closing/down sizing of services, thats probably not the case. This was very much the case in Monaghan in any case. It was like trying to fit a square peg in a round hole.

  • Mayoman

    Blisset, see my earlier comment for how badly the HSE are rating Galway in exactly that arena. http://lb.vg/31Npz

    My main point is not about ‘time to travel’ per se, but that I can’t find any info on hard clinical endpoints that supports the so-called clinical rationale for the closure. Outcomes are affected by multiple variables, and so far I can only find negatives on the basis of an already under-performing (not at the frontline staff level) A&E unit and a longer travel time. just two factors that would act negatively on outcomes. I have a suspicion that any ‘improvement’ is based on taking a cohort of patients in Galway versus a cohort in Roscommon, and not on the necessary multivariate analysis that would include all relevant factors.

  • Mick Fealty

    Turgon,

    I was reflecting somewhat on what people told Peter and I in Roscommon in February, not necessarily the facts of the matter. These could be more directly articulated by someone in politics, surely?

    It also seems to me that Reilly and Fine Gael have been blindsided by the HSE’s report on the hospital’s true state from last September.

    In Northern Ireland we’ve just witnessed another storm over the Housing Executive in which the previous minister chose not to share a report with the public (and by extension, the opposition) before the election.

  • Glensman

    It would have helped if they had have put Galway hospital in a half sensible place.
    They opted for the City Centre location of UCHG over Merlin Park.
    It’s not even the fear of dying on the road to Galway, getting to Galway is the easy part- it’s getting from the East side of the City to the West-side where the hospital is (and has massively insufficient parking).

    Speaking of empty promises, the road to Galway from Roscommon would be a lot faster if Claregalway and Tuam had have been bypassed as repeatedly promised.

    This Centre of Excellence lark can only work if they are placed in locations that are accessable to the population. I remember when Ballymena closed; Cushendall people said they would die on the road to Antrim. But they don’t. It’s only an extra 20mins away and it’s motorway…

  • kealanjflynn

    Events in Roscommon these past weeks show that politicians will never hesitate in making a step ladder of the people to get at a vote that could go to an opponent.

    The proximate political problem about the decision to axe 24/7 A&E at the County Hospital stems from the reckless promise made by the Fine Gael health spokesman Dr James Reilly to retain medical, surgical and other services, and to reinstate 24/7 A&E if necessary; and the fateful decision of the party’s election candidates to campaign on a prospectus that everyone knew was flaky and most knew simply could not be kept.

    The proximate problem facing the hospital, on the other hand, is that its legacy as a service-taker is now catching up with it. Ever since the Fitzgerald Report said that 9 in every 10 hospitals be closed over an 11-year period, Roscommon has provided only those specialist services the State was willing to support and no other services.

    Regardless of the party in power or the election promises they made to secure it, the long slow transformation of a small County Hospital into a glorified County Home has been relentless. And recent events suggest the momentum is almost unstoppable.

    It’s tempting to think that the wellspring of the hospital’s woes goes back to the pulling of the County Council’s teeth by Jack Lynch in 1977. In truth, those teeth were pulled when the Health Act 1970 stripped Councillors of their control over local health services and transferred it seamlessly to a new regional bureaucracy, the Western Health Board.

    While Fianna Fail and Fine Gael might have huffed and puffed about blocking the transition, in reality they could not and would not have done so. Politicians of every hue knew they had a fight on their hands but believed they might succeed in time; and they played the issue for political advantage so as to hold the ground with their opponents.

    The Department of Health faced them down when they tried to ‘save’ the hospital before the Health Board was set up in 1971. While the strategy bought time, it brought no new services. Throughout the 1970s, Comhairle na nOispideal steadfastly refused to sanction the consultants needed to develop full maternity and paediatric services at Roscommon. When the posts were finally approved in the early 1980s, they were never permanently filled because of the fiscal crisis that gripped and nearly sank the State.

    Comhairle was all-powerful in this period: it saw no point in spreading maternity and paediatric services in two hospitals; and so long as it had the power of appointment of hospital consultants, it was well-placed to resist local and national political pressures. The Hospital Action Committee emerged precisely because local people worried, correctly as it happens, that their Councillors and TDs were powerless to deliver the specialist medical, surgical, maternity and emergency services local people wanted.

    The Minister started a jihad when he decided to put a consultant-staffed psychiatric service in the mother-and-baby units of the County Hospital. Predictably, the politicians railed against it and the controversy itself led to the election of an Action Committee candidate to the County Council in 1985. Ironically, it was the delay in getting the psychiatric unit that encouraged the late Tom Foxe to stand for election in 1989!

    Foxe was credited with securing a number of improvements: the psychiatric unit that nobody wanted a few years before; a new medical unit that had since been sought by the Health Board; and a number of consultants that were needed to keep the whole facility functioning as an acute hospital. Enough to get him re-elected in 2002.

    But not enough, it seems, to prevent the standards watchdog, HIQA, from running the rule over the hospital a decade on. Whereas Comhairle resisted appointing new consultants because the workload might never be generated to maintain their skills, HIQA can now use the absence of a consultant skill-base to assert that the hospital is intrinsically (and perhaps objectively) unsafe. And that’s the noose that’s now getting ever tighter around Roscommon County Hospital, and which will surely strangle it.

    So, like many a politician in the constituency before them, Liam Naughten and Frank Feighan made a promise they shouldn’t have made, in their case didn’t need to make, and in any event couldn’t keep even if they wanted. This issue is about power and how it’s distributed. Voters want to believe their politicians are all-powerful, so the politicians have to maintain the illusion there is no miracle they can’t perform. It’s when they can’t deliver – because they don’t understand the balance of power – that they come unstuck.

    Locals are now seething about broken promises and the two TDs they believed – or were led to believe – had the clout to settle the issue are getting it in the neck, while the bodies with the real power – the HSE which pays the piper, and HIQA which calls the tune – escape unscathed. Let’s not even mention the overlords writing the cheques!

    Fianna Fail have been banished for the cuts they inflicted on local health and hospital services to feed the banks and satisfy the overlords, while Fine Gael worries about the fate that awaits it in Roscommon and elsewhere for the very same reason. And Ming – he’s doing as the others did for decades, playing powerlessly, praying for survival.