Portlaoise Hospital

Doctors in Laois set out their vision for the future of the Midlands Regional Hospital Portlaoise

Full text of the 'The Future of Acute Services at MRH Portlaoise The Local Stakeholder Perspective'

Conor Ganly

Reporter:

Conor Ganly

Doctors in Laois set out their vision for the future of the Midlands Regional Hospital Portlaoise

This is the full text of a plan published in September 2016 by hospital consultants and GPs in Co Laois as an alternative to HSE downgrade and loss of A&E, paediatrics, ICU, maternity

The Future of Acute Services at MRH Portlaoise

The Local Stakeholder Perspective

Medical Board Midlands Regional Hospital Portlaoise

Laois Faculty ICGP

MIDOC Members

September 2016

Contents:

Foreword i

Executive Summary ii

1. Background 1

2. Sustainability of Services 1

3. Policy Background 2

4. Previous Communications with the Hospital Group: Key Issues 5

5. Policy Formation: Community Involvement 6

6. Guiding Principles 8

7. Departmental Plans

7.1 Critical Care 9

7.2 Emergency Department 10

7.3 Obstetrics & Gynaecology 14

7.4 Paediatrics 16

7.5 Acute Medicine 18

7.6 General Surgery 20

7.7 Diagnostic Radiology 21

8. Conclusion 23

List of Recommendations 24

List of Signatories 28


Foreword

We, the undersigned members of the Hospital Board of Midlands Regional Hospital at Portlaoise, the Laois Faculty of the Irish College of General Practitioners and members of MIDOC, set out in this document our shared vision for the future of services at Midlands Regional Hospital at Portlaoise.

We do so in response to a draft plan for the future of services at MRH Portlaoise, that has been submitted to the Department of Health by the Dublin Midlands Hospital Group.

This plan was formulated without meaningful consultation with service users or regional health care professionals, and we believe, will result in severe curtailment of acute services in this part of the Midlands.

In the light of what we know of this plan and the risks it presents for our patients, and in light  of the community concerns that have been articulated at recent public meetings in Laois and KIldare, we, as Hospital Consultants and General Practitioners, see it as our obligation to set out our perspective on the future of acute services at MRH Portlaoise.


Executive Summary

The Dublin Midlands Hospital Group senior management team, in conjunction with a number of national clinical leads, has submitted to the Department of Health a draft plan for the future of acute services at MRH Portlaoise.

This draft plan, if implemented, would downgrade MRH Portlaoise to a Model 2 hospital and result in the closure of acute services including Paediatrics, Obstetrics and Gynaecology, Accident and Emergency and Intensive Care. Additionally, if implemented, the plan would severely curtail Acute Adult Medicine and General Surgery. If implemented, services that can effectively and safely be provided at MRH Portlaoise will cease to be provided there, and patients who currently rely on MRH Portlaoise will be forced to look elsewhere, in an already overcrowded hospital system, for care.

Such a plan does not provide for safe, effective or patient-centred care. Rather it repeats past mistakes. There is an ongoing crisis of capacity within the Irish health system. There are neither sufficient beds available for patients currently attending MRH Portlaoise elsewhere in the hospital system, nor sufficient ambulances to safely transport them to alternate hospitals. Additionally it is recognised internationally that attempting to centralise high volume essential services produces risks for patients and does not achieve cost savings or improve care. For patients in the Midlands, where the bed-stock is already low by national standards, and where there is no Model 4 or “hub” hospital, the risks of down-grade outweigh any argument that might be put forward in its favour.

We recognise the pioneering work of the Dublin Midlands Hospital Group in fostering the managed clinical network between MRH Portlaoise and the Coombe’s Women’s and Infant’s University Hospital. This initiative provides a template for safe, sustainable, and patient-centred care at MRH Portlaoise and should be extended across the range of clinical specialties.

We believe that the safe and correct way to proceed is to continue to provide acute services at MRH Portlaoise with appropriate support from the hospital group. We do not make an argument for the status quo. People in this area of the Midlands have seen their health care under-resourced. They deserve just provision for their healthcare.


1. Background

The Midlands Regional Hospital at Portlaoise is a Model 3 hospital. It is one of seven hospitals in the Dublin Midlands Hospital Group. It provides Emergency Medicine, Adult and Paediatric Medicine, Surgery, Obstetrics and Gynaecology, Diagnostic, and Allied Health services. In addition, there is an Acute Psychiatry Admissions Unit on site.

The hospital serves Laois and surrounding counties. Laois residents account for over 60% of inpatient discharges with the remainder of inpatient activity coming primarily from Kildare, but also including Offaly, Tipperary and Carlow. The nearest alternative Obstetric and Paediatric units are at a distance of greater than 50 Km from Portlaoise.

The Dublin Midlands Hospital Group senior management team, in conjunction with a number of national clinical leads, has over the last two years engaged in a process with the aim of setting out a plan for re-configuration at MRH Portlaoise. This process has been conducted at a remove from local stakeholders.

We understand that a process of meetings and consultations concerning MRH Portlaoise has concluded with a plan that remains in draft format. This draft has been submitted to the Department of Health.

We understand that this draft envisages a significant downgrade to services at MRH Portlaoise, including a cessation of Emergency Medicine, Intensive Care, Paediatric, Obstetric and Gynaecology, and Acute Surgical services.

2. Sustainability of Services

The sustainability of services at Portlaoise has been a concern for the CEO Dublin Midlands and the National Clinical Leads.

Some services provided at regional level may require re-configuration due to low frequency of demand. Low demand for services may result in levels of service provision that are either too limited to justify continuance or to facilitate maintenance of an adequate skill-base. In certain situations technological developments in healthcare may favour centralised provision of care. Such provision is in place nationally largely on a sub-specialty basis, for example patients with ST elevation myocardial infarction are transported to one of the primary PCI centres rather than to a regional unit.

The sustainability of services, however, may also be threatened by a lack of investment and a failure to provide adequate resources. When we examine statistics for MRH Portlaoise we see clinical activity that matches or exceeds that of many Model 3 hospitals. We also see funding levels that fall short, in some cases considerably short, of these comparable hospitals.

For patients, there is further injustice if past failure to invest in services is offered as a reason to deny future investment in their care. There is a risk of real harm to patients if services are disbanded without the provision of viable alternative options.

We believe that the vast bulk of care currently provided at MRH Portlaoise is sustainable into the future with appropriate resourcing and proper network support from the hospital group.

3. Policy Background: The need for new thinking.

In preparing this document we have reviewed:

‘The reconfiguration of clinical services. What is the Evidence’, The King’s Fund, 2014
‘National Standards for Safer Better Healthcare,’ Health Information and Quality Authority, 2012
‘Report of the investigation into the safety, quality and standards of services provided by the Health Service Executive to patients in the Midland Regional Hospital, Portlaoise’, Health Information and Quality Authority, 2015
‘Report of the National Acute Medicine Programme’, Royal College of Physicians of Ireland, 2010
‘A strategy to improve safety, quality, access and value in Emergency Medicine in Ireland’, National Emergency Medicine Programme, 2012
‘Securing the Future of Smaller Hospitals: A Framework for Development’, Department of Health & HSE, 2013
‘National Adult Critical Care Capacity and Activity Census 2015’, Acute Hospitals Division. Critical Care Programme & Health Service Executive, 2016
‘A National Model of Care for Paediatric Healthcare Services in Ireland’, National Clinical Programme for Paediatrics and Neonatology, HSE, RCPI, December 2015
‘Performance Diagnostic. Midlands Regional Hospital Portlaoise. HSE Dublin Mid Leinster’, Acute Hospitals Divison, 2014
‘Creating a better future together - National Maternity Strategy 2016-2026’ Department of Health 2016
‘The Medicine Needed for the Emergency Service.’ Royal College of Emergency Medicine & Royal College of Nursing 2016


The National Standards for Safer and Better Healthcare speaks of quality dimensions including: patient-centredness, safety, effectiveness, efficiency, access, and equity.

Re-configuration of acute general services within the Irish health service has focused on achieving centralisation. While there is scope within the documents provided by the clinical programmes for a more nuanced approach, reconfiguration to date has seen units that have provided a range of general services as Model 3 hospitals downgraded to Model 2 units. Services users who relied on these units are now required to look elsewhere for care.

The proposed downgrade to Model 2 status for MRH Portlaoise would result in a cessation of acute services including Paediatric and Maternity services.

The downgrade would force patients who are currently managed safely and effectively at MRH Portlaoise to seek care elsewhere in a system that does not have capacity to meet their needs.

We do not see how such centralisation of itself advances the values set out in the national guidelines. Of grave concern to us are reports in the international literature highlighting the considerable risks for services users inherent in such centralisation of essential high-volume services. Closer to home we note the problems of overcrowding and trolley-waits that have bedevilled health-care here in Ireland. Furthermore a policy of centralisation that is built on a concept of sustainability that depends in turn on historic under-funding will exacerbate inequality in health care. If this policy is accepted, communities who endure under-resourced healthcare will find that a failure to provide adequate funding in the past becomes the reason to deny adequate funding in the future.

The documents from the Clinical Programmes do not address the challenges of centralisation for a hospital with the scope and throughput of MRH Portlaoise. Experience to date with centralisation is limited to units smaller than Portlaoise (Roscommon, Navan, Nenagh and Ennis), none of which offered paediatric or obstetric services. There is no blueprint and no national experience to help us predict and manage the fallout from the proposed down-grade.

The concept of sustainability has been invoked to make an argument for this down-grade. Sustainability is however critically dependent on resourcing.

The past failure to provide resources at MRH Portlaoise cannot be put forward as the reason to justify not doing so now.

The issue of under-resourcing highlighted in the HIQA report of May 2015 must be addressed. It would however be a perverse response to a community’s needs, to suggest a further withdrawal of healthcare resource as a solution to the problem of under-resourcing. Such a policy, should it be generally adopted, would exacerbate the inequalities in healthcare funding across the state.

New thinking is needed nationally, along with a new set of solutions to support acute services in regional hospitals. This issue is not unique to MRH Portlaoise.

We believe that the pioneering developments at the Department of Obstetrics and Gynaecology at MRH Portlaoise provide a template as to how the hospital network generally can be re-configured to strengthen and support patient care in regional centres. A managed clinical network is in development, under the guidance of the Dublin Midlands Hospital Group, merging MRH Portlaoise and Coombe Women’s and Infants University Hospital. This arrangement aims to ensure that resources and expertise in both units can be drawn on to the benefit of patients. Under the auspices of this clinical network shared protocols, pathways of care and shared appointments have been implemented at MRH Portlaoise. This pioneering model ensures that access to care for patients attending MRH Portlaoise is on an equal footing with patients directly attending the tertiary unit.

This model of managed clinical networks provides a way forward for communities who rely on the regional hospital network for care. Among the deficiencies in the current conceptualisation of Model 3 and Model 2 units is the lack of integration between these units and tertiary centres.

A hospital model which is based on managed clinical networks offers the best way to ensure that patients have access to safe, high-quality and nationally-consistent care.

Such arrangements, in addition to augmenting the delivery of care at regional hospitals, can also drive efficiency in the health system nationally. When regional expertise is developed, the ability of regional units to provide subspecialty care will expand. As a result fewer patients will need transfer to tertiary units, and patients can return to regional units earlier after intervention at tertiary level. In this way, such arrangements can help to maximise the efficiency of tertiary hospitals.

We explain in this document how such clinical support within the hospital network combined with a linked-up approach to the individual clinical care programmes should be applied to plan a safe, effective and sustainable regional service at MRH Portlaoise.

4. Previous Communications with the Hospital Group: Key Issues.

We, the Laois Faculty ICGP and the Medical Board at MRHP, have communicated independently on a number of occasions with the CEO of the DML group and the relevant national clinical leads.

The Paediatric National leads have engaged in dialogue with the Paediatric team at MRH Portlaoise.

In a series of previous communications we have returned to three key issues:

The Accident and Emergency department at MRH Portlaoise is the busiest department outside the major urban centres. 12000 children and 24000 adults present each year to the department. Demographic trends suggest that this demand is likely to increase. Portlaoise has the highest proportion of children under 18 in the country. According to census figures the population of Laois has risen by 20% since 2006.
There is no alternative capacity within the health service to care for people who currently rely on MRH Portlaoise for acute care, neither is there ambulance capacity to transport patients to alternative locations for care. MRH Portlaoise provides care across a range of clinical specialities. No other paediatric nor obstetric unit exists in this region. In the event of a downgrade, women and children would need to seek care in maternity and paediatric units in Dublin - at some distance from home and in units that are already over capacity. While there exists regional adult units, each lacks the capacity to meet its current demands and people attending each endure trolley waits and severe overcrowding.

In the event of a downgrade to a model 2 hospital, acute services at MRH Portlaoise would cease. No paediatric or obstetric admissions can take place at a Model 2 unit. Additionally, ICU or A&E services cannot be provided at a Model 2 Unit. In the absence of ICU and A&E, acute medical or surgical services cannot be safely provided. A Model 2 hospital cannot safely admit patients who are ill and must transfer out patients who exhibit any level of clinical risk. Such an institution cannot contribute effectively to the acute care needs of this community.


5. Policy Formation - Community Involvement

HIQA in its national standards for Safer Better Healthcare stresses the need for person-centred care. The obligation this places on those who plan services is set out in Standard 1.1:

‘The planning, design and delivery of services are informed by service users’ identified needs and preferences’,

Planners are reminded that among the key features of services that meet this standard are:

‘1.1.3  Involvement of service users at key stages in the planning and design of healthcare services. Service users are kept informed of key decisions during this process and how their needs and preferences have been considered.

1.1.4  Provision of services at a time and place which takes into account the expressed preferences of service users, where this provision can be achieved safely, effectively and efficiently.’

The process of formulating this draft plan has not shown regard to these obligations. There has been no service-user or local stakeholder involvement in the formulation of the draft plan. The process has been characterised by a deficit of transparency.

A consultation process is promised, but this consultation is to begin only after the plan has been finalised.

There has been no consultation process with the communities in Laois and surrounding counties that will be impacted by the proposed down-grade.

6. Guiding principles

HIQA and the clinical programmes have set out principles to guide the provision and planning of healthcare.

A key distinction must be drawn between re-configuration and rationalisation of services. In a re-configuration process, the structures of care delivery are examined to see how they might better be arranged to improve outcomes and experiences for patients. This evidence-based consultative process has as its central concern the best interests and the preferences of service users.

Rationalisation of services is pursued for other reasons, most typically to drive down cost or make resource savings. Rationalisation may be required at times of financial constraint.

We submit that any rationalisation of healthcare should be shared equally across society rather than fall disproportionately on any section of the community.

In any event, international experience tells us that rationalisation of essential services does not produce a financial benefit for national health care organisations. Any cost savings accruing from a downgrade at MRH Portlaoise would be exceeded by the financial costs of ambulance transport and the costs of providing care elsewhere within the health system.

The starting point for reconfiguration must be the needs of the individual service user. Plans for healthcare in the Midlands need to answer the basic question: how is the individual who requires care to access that care? It is essential that capacity be in place within the service to accommodate and care for that individual and to provide emergency transport when it is necessary.

Clinical programmes recognise that healthcare capacity should be in place as near as possible to the communities they serve and that the care provided must reach an appropriate standard.

Where care cannot be provided locally, pathways need to be in place to support access to specialist care.

When planning the future of service provision, it must be recognised from international and national experience that the process of reconfiguration itself carries significant risks for service users.

We recommend that a code of practice be developed to guide the planning of reconfiguration within the hospital service.

We recommend that the views of service users and local stakeholders be sought and  demonstrably taken into account when reconfiguration is considered.

We recommend that concepts of clinical justice and fairness are considered when planning access to health services.

We recommend that re-configuration should occur only where it can be shown to be in the interests of patients.  

We recommend that where reconfiguration is required to improve the health resource available to a community then that reconfiguration should involve the least change possible from established services in order to minimise the risks inherent in the process.

7. Departmental Plans

7.1 Critical Care

Critical care helps people with life-threatening illnesses. In the absence of contingency for safe and effective critical care, acute clinical care cannot be provided.

The MRH Portlaoise Critical Care Unit is a Category 2 ICU. The unit can accommodate  either 4 HDU or 2 ventilated patients. The critical care unit is staffed by the anaesthetic department. The anaesthetic team also support the obstetrics, general surgery, cardiology and mental health services at MRH Portlaoise.

In MRH Portlaoise between 40-50 patients annually require the life-saving intervention of invasive ventilation. A further 200 adult patients receive ICU/HDU care.

The critical care team also carry out the initial stabilisation of critically-ill children prior to the involvement of the Paediatric Intensive Care retrieval team.

This critical care resource is an essential safeguard; were it to cease, acute care could no longer take place on site. The throughput of ventilated patients may be low by national levels, but few post-operative patients require ventilation in Portlaoise and these cases would account for most of the patients requiring such care in many units with similar overall activity to MRH Portlaoise.

The Acute Medicine Programme sets out two options for critical care support for a Clinical Strategy Programmes Division (HSE) Model 3 Unit (Section 17.9):

Category 1 ICU: ‘Invasive ventilatory support (48-72 hours), earlier transfer if severe critical illness’

Category 2 ICU: ‘General critical care, multi-organ failure support incl. CRRT'
(CRRT - Continuous Renal Replacement Therapy)

The Acute Medicine Programme further recommends:

‘For the safe and prompt regional or supra-regional transfer of critically ill patients within the hospital models system, a critical care retrieval team service is required.’

We recommend that the current Critical Care unit at MRH Portlaoise be re-configured as a Category 1 ICU.

As a Category 1 ICU, the unit would continue to provide life-saving treatment on a 24/7 basis, for patients who become critically unwell while in hospital or who present critically ill to the hospital. However the focus would change. No longer would the patient’s ICU stay in its entirety be expected to be completed at MRH Portlaoise. Rather, initial care, including stabilisation and establishment of ventilatory support, would take place at MRH Portlaoise with subsequent care taking place after transfer to a Category 2 or 3 ICU unit. This transfer would be sought should invasive ventilatory support be required for longer than 24 hours, or immediately if complex or interdisciplinary intervention was required or deemed likely to be required.

The anaesthetic team would continue to fulfil its current service commitments, in particular, for example, to the operating theatres, the surgical, maternity and paediatric departments.

We recommend that functioning reliable networks and pathways be established through shared appointments and protocol-led seamless patient transfers with a regional Category 2 or 3 ICU.

7.2 Emergency Department

The Emergency Medicine Programme describes the role of the Emergency Department (ED):

‘Emergency Medicine (EM) provides an essential service for patients and communities and fulfils a unique and crucial remit within the national healthcare system.’

‘EDs provide 24/7 access for undifferentiated emergency and urgent presentations across the entire spectrum of medical, surgical, trauma and behavioural conditions.’

The programme highlights the critical interdependencies between the ED, the in-house hospital teams and the wider network.

‘EDs require the on-site presence of core supporting specialties and services and must have seamless access to regional medical and surgical specialties and more complex diagnostic imaging facilities within an Emergency Care Network.’

The Emergency Medicine programme acknowledges that there is great uncertainty as to what might be seen as an optimum configuration for provision of Emergency Medicine services.

The authors recommend centralising:

‘only those services for which a benefit can be demonstrated, while providing as much care as can be provided safely as conveniently as possible for patients.’

The authors acknowledge that a safety benefit cannot be demonstrated in the literature for centralisation of services generally. There is however, an important exception in terms of major trauma (a trauma bypass both for adults and children is in operation for Portlaoise for some time now).

The authors quote The College of Emergency Medicine’s guidance on ED configuration for England. It states that:

‘Where the next nearest ED is more than 20 km away there is a strong argument for retaining an emergency service.’


(The Way Ahead 2008-2010 Strategic Guidance for Emergency Medicine in the United Kingdom and the Republic of Ireland.)

(The closest ED is at MRH Tullamore 40 Km from Portlaoise. Naas Hospital is 52 Km from MRH Portlaoise)

The authors point to international evidence indicating that hospital restructuring comes with the risk of increased ED overcrowding.

The overcrowding crisis in the Mid-West region, St Vincent’s University Hospital, the Saolta Group and OLOL Drogheda have followed the closure of much smaller ED units than the one apparently under threat at MRH Portlaoise.

The reliance on Accident and Emergency departments for urgent care has, in response to this over-crowding crisis, been questioned and alternative methods for patients to seek acute care have been proposed. International experts have concluded however that re-organisation of urgent care is confusing for the public and may make it difficult for patients in crisis to find the services that they need.

In Scotland,  ‘The Report of the Auditor General on Emergency Departments 2010’ warns that:

“the distinction between the role of EDs and Minor Injury Units is not always clear, making it difficult for staff and the ambulance service to know where to bring patients”.

The number of EDs per head of population is similar in the Republic of Ireland to that found in Scotland. Numbers of EDs per head of population in Northern Ireland exceed that in the Republic.

The Royal College of Nursing and the Royal College of Emergency Medicine in the United Kingdom offer this advice for health-care planners who attempt to curtail Accident and Emergency in the hope that patients might be directed to other services:

‘After more than twenty years of unremitting growth in attendances, the power of the A&E brand shows no sign of weakening. Instead of mounting endless initiatives in the hope rather than expectation that demand might in some way be curbed, the government of the day would be better served by planning for the reality of higher attendances and admissions.’

(The Medicine Needed for the Emergency Service. Royal College of Emergency Medicine & Royal College of Nursing)

The ED at MRH Portlaoise is a high-volume service. Attendance levels at 36,000 per annum are among the highest of any of the hospitals outside the major urban centres. In formulating a strategy for patients in the Midlands, planners must have regard for these figures and ensure that there is capacity to meet this demand.

There is however, no capacity within the region to accommodate people elsewhere who currently attend ED at MRH Portlaoise. TrolleyGAR figures for the first 6 months of 2016 show a crisis of capacity with trolley figures at MRH Portlaoise, MRH Tullamore, and Naas General Hospital all increasing.

The ED at MRH Portlaoise has suffered historically from under-resourcing. Under-resourcing that threatens the viability of this unit, notwithstanding the clear demand for the service.

The National Emergency Medicine Programme recommends that a type A2 ED be located at a DCSP Model 3 hospital. The core specialities and diagnostics recommended by the Programme are established on site at MRH Portlaoise to support a type A2 unit.

An A2 unit provides care 24/7 for patients with unselected undifferentiated emergency problems who self present or are brought by ambulance to the unit. According to the Programme ‘Unstable or higher acuity patients, whose care needs cannot be met at this unit can be transferred according to national protocols and by appropriate means to a designated networked hospital.’ Paediatric patients can attend A2 EDs and each should employ at least one Consultant with sub-specialty training in paediatric emergency medicine among the department’s staff.

In terms of staffing resource, the programme recommends:

‘Consultant in emergency medicine staffing levels should be such that it is feasible and sustainable to provide a Consultant presence in the ED from 08:00-20:00hrs on weekdays with a sessional commitment at weekends.’

‘There will be 24/7 Consultant in EM on-call cover for this ED.’

‘There will be a full range of appropriate therapy and Medical Social Worker services for this unit.’

We recommend that the ED at MRH Portlaoise be resourced and staffed to provide a type A2 Emergency Department in keeping with the DCSP Model 3 hospital.

We recommend that the ED is supported by a AMAU in keeping with the DCSP Model 3 plans for acute hospitals.

We note that key interdependent services as outlined in the Emergency Medicine Programme are available on site. We recommend that these services be developed as set out in sections 7.1, 7.3, 7.4, 7.5, 7.6, & 7.7 of this document.

We recommend that the ED at MRHP be integrated in the Emergency Medicine Network.

We recommend that protocols are developed to allow seamless access to services not available on-site at MRH Portlaoise.

7.3 Department of Obstetrics & Gynaecology

The obstetric department at MRH Portlaoise comprises a 29-bedded ward, an Early Pregnancy Assessment Unit, OPD, and a Special Care Baby Unit. The department is supported by the anaesthetic team. HDU care for obstetric patients is provided in the ICU at MRH Portlaoise.  Key interdependencies for the obstetric & Gynaecolgy department are with paediatric, surgical and medical units.

As there is no Obstetric & Gynaecology service in either Naas or MRH Tullamore, there is a large geographical catchment area for the service (Laois, Offaly, South Kildare, North Tipperary and parts of Carlow).

In all, 1606 babies were delivered at the unit last year. There is no capacity in the region or in units in Dublin to absorb these numbers in the event of a downgrade.

‘Creating a better future together - national maternity strategy 2016-2026’ outlines a vision for maternity services in Ireland where:

“Women and babies have access to safe, high quality care in a setting that is most appropriate to their needs; Women and families are placed at the centre of all services, and are treated with dignity, respect and compassion; parents are supported before, during and after pregnancy to allow them give their child the best possible start in life”.

The realisation of this vision requires that:

A health and wellbeing approach be adopted
Women have access to safe, high-quality, nationally-consistent, women-centred maternity care
Women’s choice be facilitated
Maternity services be appropriately resourced, underpinned by strong and effective leadership, management and governance arrangements, and delivered by a skilled and competent workforce in partnership with women.

MRH Portlaoise women’s services are attempting to realise this vision by participating in Ireland’s first Managed clinical network with the Coombe Women and Infant’s University Hospital  (CWIUH) under the guidance of the Dublin Midlands Hospital group.

This clinical network envisages a women-centred approach locally with streamlined access to more specialised care in the tertiary centre. The Managed clinical network has a steering group consisting of the CEO of DML hospital group, the Master /CEO CWIUH , the General Manager MRHP and the Clinical Director for Integration.

Appointments made to date under the auspices of this network have included; Clinical Director for Integration, Director of Midwifery, Two Consultant Obstetrician /Gynaecologists with joint appointments with MRHP and CWIUH, and two Consultant Neonatologists again with Joint appointments with MRHP/CWIUH/OLHC.

To date, access to ultrasound services has been greatly enhanced for women attending MRHP and a training programme for Midwives in MRHP in Ultrasound scanning is in progress in CWIUH. Such services will be provided locally in the future with access to specialised Fetal Medicine consultants using the NIMIS system.

Patient pathways in both hospitals have been developed and they have been reviewed by women attending the services and are in the process of being implemented.

Women’s services will be ultimately under the governance of CWIUH.

This first managed clinical network using the women’s services as a pilot offers an alternative to centralisation of services.

We recommend that this clinical network continues to be pursued at the Department of Obstetrics & Gynaecology MRH Portlaoise.

We recommend that this template for healthcare delivery be extended to other clinical departments at MRH Portlaoise to help ensure safe, high-quality, nationally-consistent services locally in addition to streamlined access to tertiary services.

7.4 Paediatrics

The hospital has a 25-bedded paediatric ward and an 8-bedded special care baby unit (SCBU).

Approximately 12,000 children present for emergency, unscheduled care each year to the hospital, 7,000 of whom are cared for directly by the paediatric medical team. The remaining 5,000 children are cared for by the ED and surgical teams. This overall figure has doubled in the past 15 years.

There are four Consultant Paediatricians who provide 24/7 on call to; the labour ward, Special Care Baby Unit, paediatric ward and the emergency department. Subspecialist interests of the paediatricians include: diabetes and endocrinology, respiratory medicine, neurodisability and neonatology.

As there is no paediatric service in either Naas or MRH Tullamore, there is a large geographical catchment area for the service (Laois, Offaly, south Kildare, north Tipperary and parts of Carlow). Paediatric services rely on anaesthetic (critical care), ED, radiology and surgical support.

A neonatal transport team is available 24/7 to ensure the safe transport of babies requiring tertiary neonatal care.

The Paediatric retrieval team is currently available 9-5, Monday-Friday for assistance in the transfer of children to Paediatric Intensive Care Units in Our Lady’s Children’s Hospital Crumlin or Children's University Hospital, Temple Street.

The Paediatric Early Warning Score (PEWS) and Irish Children’s Triage System (ICTS) have been implemented in MRH Portlaoise. The department has formal academic links with both University College Dublin and University of Limerick medical schools. It plays a vital role in the training of junior doctors including; General Practice, Paediatric (SHO and SPR) and emergency medicine trainees.

Downgrading Portlaoise hospital to a model 2 hospital will mean that safe acute paediatric services can no longer be provided or sustained. As a consequence there will be no maternity service.  

We believe that families and children who use the paediatric service deserve a well-resourced, safe and effective service so that care can be delivered locally and as close to home as possible, as per the paediatric model of care.

Two Consultant Neonatologists have been appointed to take up position in November 2016. The appointments are structured as part of the Managed Clinical Care Network with the Coombe Hospital. These specialists will divide their time on a structured basis between the Special Care Baby Unit in MRH Portlaoise, the Coombe Women’s and Infants University Hospital and Our Lady’s Children’s Hospital Crumlin.

Challenges for General Paediatrics at MRH Portlaoise include:

Consultant numbers remain below that recommended by the paediatric clinical programme / model of care.
Two separate points of access remain for children presenting acutely. Those with surgical issues are triaged in the main ED and those with medical paediatric problems are triaged on the paediatric ward
There is no social worker available in the hospital: this causes particular problems relating to child protection cases

We recommend that the general paediatric department at MRH Portlaoise be resourced according to the Paediatric Model of care.

We recommend that the paediatric team continue to provide 24/7 cover to the ED, Special Care Baby Unit, Paediatric ward and the labour ward.

We recommend that key supporting specialities of Critical Care Medicine, Obstetrics & Gynaecology, General Surgery, Emergency Medicine and Radiology be developed as set out in sections 7.1, 7.2, 7.3, 7.6 and 7.7 of this document.

We recommend that the paediatric ED be co-located with the adult ED to enable all children, whether presenting with a medical or surgical problem to have a single point of access and triage.

We recommend the commissioning of a paediatric assessment unit (PAU) to manage children who require a short stay admission (<12 hours).

We recommend that formal links between the National Paediatric Hospital Group continue to develop to allow shared care of sick children with complex medical problems and to enable more of that care to be delivered locally. We anticipate that the appointments of consultant neonatologists as part of the Managed Care Network with the Coombe Women’s and Infants University Hospital will strengthen and extend the level of care that can be delivered at MRH Portlaoise, facilitating both the return of children earlier from intensive care in major centres to the local unit and the transfer of children to those central units.

7.5 Acute Medicine

The hospital has a 39-bedded medical unit. This includes a 4-bedded CCU. There are five consultant physicians, who provide a 24-hour on-call service admitting unselected medical patients. Support services include cardiac diagnostics, cardiac rehabilitation, nurse-led heart failure, valvular heart disease, diabetes including rapid access diabetes, and general medicine clinics.

The national early warning score, and the national sepsis protocol have been implemented in MRH Portlaoise.

Medical inpatient attendances have increased from 3024 in 2008 to 4000 in 2015. Occupancy rates for the medical unit at MRH Portlaoise exceed 100 percent. TrolleyGAR figures show that unacceptably high numbers of patients requiring general medical care are accommodated on trolleys in ED. This year to date on average between ten and fourteen patients were boarded overnight on trolleys in ED at MRH Portlaoise (the corresponding figures in 2015 ranged between 4 and 9).

A bed-utilisation review in 2014 found that a complement of 46 medical beds minimum was required at MRH Portlaoise (current complement 39).

Challenges for general medicine at MRH Portlaoise include:

Workload exceeds available resources. MRH Portlaoise did not share in the expansion in consultant numbers in the Celtic Tiger years. The unit’s funding has been cut from an already low base in recent years. These years of cut-back have coincided with a sharp increase in activity.
There is a concentration of sub-specialty resource in the major urban centres. Beds in these centres are difficult to access for in-patients elsewhere in the system as ED patients at those units take precedence.
An AMAU awaits commissioning on site.
ICU care for complex medical patients is provided by in-house medical teams. The range of disciplines available in larger centres to care for people with complex illness is not available at MRH Portlaoise.
No consultant specialising in care of the elderly is in post at MRH Portlaoise.

We need to support this unit to provide a service for the patients it can efficiently and safely care for, while ensuring that patients have access to appropriate subspecialist care when required.

We reject the solution set out in the draft plan for acute medicine at MRH Portlaoise. Large numbers of patients rely on MRH Portlaoise for care, which can be provided there safely and effectively. In the unwelcome event that the hospital is downgraded, our patients will find themselves reliant on distant units that do not have capacity for them.

We recommend that the acute medicine at MRH Portlaoise be resourced according to the Acute Medical Programme (AMP).

We recommend that the in-house acute medicine team continue to provide 24/7 cover for the ED department at MRH Portlaoise.

We recommend that consultant numbers be expanded in keeping with the AMP.

We recommend that the commissioning of the AMAU be advanced.

We recommend that key supporting specialties of Critical Care Medicine and Emergency Medicine be developed as set out in sections 7.1 & 7.2 of this document.

We recommend a protocol-driven transfer policy for appropriate patients escalated to ICU level care, as set out in section

7.1. 

We recommend that the pioneering managed clinical network between MRH Portlaoise and the Coombe Women’s and Infant’s University Hospital be adopted as a template for sub-specialty care at the Department of Acute Medicine (See Section 7.3). This pioneering model ensures that access to care for patients attending MRH Portlaoise is on an equal footing with people directly attending the tertiary unit. Adoption of this template for healthcare delivery will help ensure safe, high-quality, nationally-consistent services at MRH Portlaoise. In addition the managed clinical network concept can streamline access to services at tertiary level. We recommend that a strategy of shared appointments and shared governance be pursued with a range of tertiary centres in general medicine. We recommend that physicians appointed to such positions have the bulk of their commitment at a tertiary unit. This tertiary unit would in turn provide network support for patients attending MRH Portlaoise in terms of access to diagnostics, treatments and MDT support. These physicians would attend MRH Portlaoise on a sessional basis to assist with the development of protocols, to provide consultation and OPD services, in addition to supporting the AMAU. Services such as respiratory medicine, dermatology, neurology and gastroenterology could all be augmented significantly for the benefit of patients attending MRH Portlaoise in this manner.

7.6 General Surgery

The surgical department at MRH Portlaoise provides emergency cover for patients presenting to the ED, in-patient, day-case and OPD services. The team of consultant surgeons provide a 24-hour on-call service. In addition to admitting adults and children who require acute surgical care, the surgical teams provide a consultation service for the medical, obstetrics and paediatric teams.

The surgical unit comprises a 24-bedded inpatient ward and a 15-bedded day ward.

There are 3 operating theatres which are shared with the Department of Obstetrics and Gynaecology and an Endoscopy suite.

Over 4,000 procedures are performed annually by surgeons at MRH Portlaoise

General Surgery at MRH Portlaoise is supported by the Dublin Midlands Hospital Group and patients requiring complex care have access to surgical services elsewhere in the network.

In common with all other centres that are not part of the cancer program, patients who require surgical resection of tumours identified at MRH Portlaoise are transferred to a cancer centre.

We recommend that the surgical unit be resourced according to the surgical programme.

We recommend that key supporting specialties of Critical Care Medicine and Emergency Medicine be developed as set out in sections 7.1 & 7.2 of this document.

We recommend a protocol-driven transfer policy for appropriate patients escalated to ICU level care, as set out in section 7.1. 

7.7 Diagnostic Radiology

The department of diagnostic radiology at MRH Portlaoise provides 24-hour access to plain films, ultrasound and CT. MRI scanning is provided within the hospital group. Images taken at the department are stored on the National Medical Image Management System (NIMIS). This system allows images taken at Portlaoise to be accessed by teams based elsewhere within the health system.

A rota of four consultant radiologists provide diagnostic support for the clinical departments at MRH Portlaoise, including the emergency department, on a 24 hour basis.

The diagnostic radiology department is in this way configured to meet the requirements set out for Type A2 EDs in the emergency medicine programme:

’24/7 immediate access to plain XR in a co-located, dedicated suite.
Immediate 24/7 access to CT and US.
Emergency MRI and Interventional Radiology access 24/7 within the HSE region via protocolised transfer/retrieval.’

Additionally the department provides direct access scanning for General Practitioners.

There are a number of challenges:

Consultant numbers remain below levels required to meet the workload at MRH Portlaoise. This workload is likely to increase with the commissioning of the AMAU. At present with 40,000 studies per year the recommended complement is 5 full time radiologists.
MRI scanning is provided off-site at MRH Tullamore. The single scanner at MRH Tullamore serves Longford Westmeath General Hospital in addition to MRH Portlaoisr and MRH Tullamore. The MRI provision for the region is not sufficient to meet demand and the waiting times for out patient scans are not acceptable. In addition off-site scanning complicates access to acute MRIs for hospital inpatients at MRH Portlaoise.

We recommend an expansion in consultant radiology numbers at MRH Portlaoise. We recommend that this be pursued through shared appointments.

We recommend that this policy of shared appointments in radiology be developed in tandem with shared appointments in other clinical specialties. These appointments should be configured to facilitate access for patients attending MRH Portlaoise to subspecialty Multidisciplinary Team (MDT) opinion.

We recommend on-site MRI scanning facility be developed at MRH Portlaoise.

8. Conclusion

This document sets out our vision for services at MRH Portlaoise. We do so in response to a process which has resulted in a draft report which has yet to be shared or discussed with stakeholders and service users.

The proposal that consultation with local stakeholders and service user should start after the report has been finalised is neither an adequate nor a reasonable method of ensuring that the voice and needs of service users guide the future for MRH Portlaoise.

Reconfiguration of health services in Ireland has involved the centralisation of services. The downgrade of MRH Portlaoise from a Model 3 to a Model 2, if implemented will result in the closure of the hospital’s acute services, including the centralisation of paediatric and obstetric services to Dublin hospitals. It will force patients who currently rely on care at MRH Portlaoise to look elsewhere within an already over-crowded system.

International evidence can be found to support centralisation of services only for patients with certain illnesses that require specific interventions. Centralisation of services otherwise creates many risks for service users. These risks are compounded in a context where there is no alternative capacity to care for patients who currently rely on MRH Portlaoise for care.

We believe that the safe and correct way to proceed is to continue to provide acute services at MRH Portlaoise. We have emphasised the interdependencies that are critical for maintenance of safe acute services at MRH Portlaoise. We recommend that the managed clinical network between MRH Portlaoise and the Coombe’s Women’s and Infant’s University Hospital provide the template for development across the range of specialities at MRH Portlaoise. We believe that our plan provides for safe, sustainable and effective care.

We do not make an argument for the status quo. People in this area of the Midlands have seen their health care under-resourced. They deserve just provision for acute and sub-specialty care according to the values of patient-centredness, safety, effectiveness, efficiency, access, and equity, as espoused in the National Standards for Healthcare.

Recommendations

A code of practice must be developed to guide the planning of reconfiguration within the hospital service.

The views of service users and local stakeholders must be sought and demonstrably taken into account when reconfiguration is considered.

Concepts of clinical justice and fairness must be considered when planning access to health services.

Re-configuration must only where it can be shown to be in the interests of patients.  

Critical Care

We recommend that the current Critical Care unit at MRH Portlaoise be re-configured as a Category 1 ICU.

We recommend that functioning reliable networks and pathways be established through shared appointments and protocol-led seamless patient transfers with a regional Category 2 or 3 ICU.

Emergency Department

We recommend that the ED at MRH Portlaoise be resourced and staffed to provide a type A2 Emergency Department in keeping with the DCSP Model 3 hospital.
We recommend that the ED is supported by a AMAU in keeping with the DCSP Model 3 plans for acute hospitals.
We note that key interdependent services as outlined in the Emergency Medicine Programme are available on site. We recommend that these services be developed as set out in sections 7.1, 7.3, 7.4, 7.5, 7.7 of this document.
We recommend that the ED at MRHP be integrated in the Emergency Medicine Network.
We recommend that protocols are developed to allow seamless access to services not available on-site at MRH Portlaoise.
Department of Obstetrics & Gynaecology

We recommend that the clinical network between MRH Portlaoise and the Coombe Women’s and Infant’s University Hospital continues to be developed.

We recommend that this template for healthcare delivery be extended to other clinical departments at MRH Portlaoise to help ensure safe, high quality, nationally consistent services locally in addition to streamlined access to tertiary services.


Department of Paediatrics

We recommend that the paediatric department at MRH Portlaoise be resourced according to the Paediatric Model of care.

We recommend that the paediatric team continue to provide 24/7 cover to the ED, Special Care Baby Unit, Paediatric ward and the labour ward.

We recommend that key supporting specialities of Critical Care Medicine, General Surgery, Emergency Medicine and Radiology be developed as set out in sections 7.1, 7.2, 7.5, 7.6 and 7.7 of this document.

We recommend that the paediatric ED be co-located with the adult ED to enable all children, whether presenting with a medical or surgical problem to have a single point of access and triage.

We recommend the commissioning of a paediatric assessment unit (PAU) to manage children who require a short stay admission (<12 hours).

We recommend that formal links between the National Paediatric Hospital Group will continue to develop to allow shared care of sick children with complex medical problems and to enable more of that care to be delivered locally.

Acute Medicine

We recommend that the acute medicine at MRH Portlaoise be resourced according to the Acute Medical Programme (AMP).

We recommend that the in-house acute medicine team continue to provide 24/7 cover for the ED department at MRH Portlaoise.

We recommend that consultant numbers be expanded in keeping with the AMP.

We recommend that the commissioning of the AMAU be advanced.

We recommend that key supporting specialties of Critical Care Medicine and Emergency Medicine be developed as set out in sections 7.1 & 7.2 of this document.

We recommend a protocol-driven transfer policy for appropriate patients escalated to ICU level care, as set out in section 7.1. 

We recommend that the pioneering managed clinical network between MRH Portlaoise and the Coombe Women’s and Infant’s University Hospital be adopted as a template for sub-specialty care at the Department of Acute Medicine.


General Surgery

We recommend that the surgical unit be resourced according to the surgical programme.

We recommend that key supporting specialties of Critical Care Medicine and Emergency Medicine be developed as set out in sections 7.1 & 7.2 of this document.

We recommend a protocol-driven transfer policy for appropriate patients escalated to ICU level care, as set out in section 7.1.


Diagnostic Radiology

We recommend an expansion in consultant radiology numbers at MRH Portlaoise. We recommend that this be pursued through shared appointments.

We recommend that this policy of shared appointments in radiology be developed in tandem with shared appointments in other clinical specialties. These appointments should be configured to facilitate access for patients attending MRH Portlaoise to subspecialty Multidisciplinary Team (MDT) opinion.

We recommend on-site MRI scanning facility be developed at MRH Portlaoise.

List of Signatories

Dr Averil Atkinson, General Practitioner, Portlaoise

Dr Derry Bergin, General Practitioner, Mountmellick

Dr David Booth, General Practitioner, Portlaoise

Dr Annette Brennan, General Practitioner, Mountmellick

Dr Sinead Burke, General Practitioner, Portlaoise

Dr Michelle Byrne, General Practitioner, Portlaoise

Dr John Paul Campion, General Practitioner, Rathdowney

Dr Maria Carroll, General Practitioner, Portlaoise

Dr John Connaughton, Clinical Director, Consultant Physician, MRH Portlaoise

Dr Eamon Cosgrove, General Practitioner, Mountrath

Dr Julie Cunningham, General Practitioner, Clonaslee

Dr Michael Cushen, Consultant Palliative Care, MRH Portlaoise, MRH Tullamore

Dr Miriam Doyle, Consultant Obstetrician & Gynaecologist, MRH Portlaoise

Dr Ethelda Ellis, General Practitioner, Portarlington

Dr Hosam El Kininy, Consultant Obstetrician & Gynaecologist, MRH Portlaoise

Dr Seamus Fitzgerald, General Practitioner, Borris In Ossory

Dr Sean Fleming, Chair Medical Board, Consultant Physician/Cardiologist, MRH Portlaoise

Dr Paul Gallagher, Consultant Paediatrician, MRH Portlaoise

Dr John Geraghty, General Practitioner, Portlaoise

Dr Ligia Gherlea, General Practitioner, Mountmellick

Dr Oxana Gradinar, General Practitioner, Mountmellick

Dr Conor Grimes, General Practitioner, Stradbally

Dr Rizwan Gul, Consultant Paediatrician, MRH Portlaoise

Dr Anna Gullane, General Practitioner, Portlaoise

Dr Adrian Honan, General Practitioner, Portarlington

Dr Deirdre Honan, General Practitioner, Portlaoise

Dr Simon Honan, General Practitioner, Portlaoise

Dr Roberta Jianu, General Practitioner, Mountmellick

Mr Shahid Kaimkhani, Consultant Surgeon, MRH Portlaoise

Dr Anna Kavanagh, General Practitioner, Abbeyleix

Dr Peter Kemple, General Practitioner, Abbeyleix

Dr Asad Khan, Consultant Physician, MRH Portlaoise

Dr Huma Khosa, Consultant Radiologist, MRH Portlaoise

Dr Pyeh Kyithar, Consultant Physician, MRH Portlaoise

Dr Robert Lawlor, General Practitioner, Portlaoise

Dr  Andrew Lavin, General Practitioner, Portarlington

Dr Maeve Lee, General Practitioner, Portlaoise

Dr Sinead Lynch, General Practitioner, Mountmellick

Dr John Madden, General Practitioner, Abbeyleix

Dr Vivek Mahadev, General Practitioner, Mountmellick

Dr Suvarna Maharaj, Consultant Emergency Medicine, MRH Portlaoise

Dr Masud Ur Rehman, Consultant Anaesthetist, MRH Portlaoise

Dr Jacqueline McBrien, Lead Department of Paediatrics, Consultant Paediatrician, MRH Portlaoise

Dr Sharon McDonald, General Practitioner, Portlaoise

Dr Caitlin McFadden, General Practitioner, Portlaoise

Dr Conor Meehan, Consultant Radiologist, MRH Portlaoise & MRH Tullamore

Dr Anne Marie Miller, General Practitioner, Stradbally

Dr Sean Montague, General Practitioner, Portarlington

Dr Shonagh Mooney, General Practitioner, Portarlington

Dr Judith Murray, General Practitioner, Portarlington

Mr Farrukh Naseem, Consultant Surgeon, MRH Portlaoise

Dr Ciara O'Boyle, General Practitioner, Portarlington

Dr Michael O’Connell, Clinical Director for Integration, Coombe Women’s and Infant’s University Hospital, Consultant Obstetrician & Gynaecologist, Coombe Women’s and Infant’s University Hospital

Dr Patrick O’Dwyer, General Practitioner, Mountrath

Dr Frank O'Hara, General Practitioner, Portarlington

Dr Ailish Phelan, General Practitioner, Mountrath

Dr David Rabinowicz, General Practitioner, Durrow

Dr Nagabathula Ramesh, Lead Department of Diagnostic Radiology, Consultant Radiologist, MRH Portlaoise

Dr Jayant Sharma, Lead Department of Medicine, Consultant Physician/Endocrinologist, MRH Portlaoise

Dr Mary Sheehan, General Practitioner, Clonaslee

Dr Shoba Singh, Clinical Director Department of Obstetrics & Gynaecology, Consultant Obstetrician & Gynaecologist, MRH Portlaoise

Mr Amir Siddiqui, Lead Department of Surgery, Consultant Surgeon, MRH Portlaoise

Dr Olive Strumble, General Practitioner, Portarlington

Dr Muhammad Tariq, Consultant Paediatrician, MRH Portlaoise

Dr Barry Warde, Lead Anaesthesia, Consultant Anaesthetist, MRH Portlaoise

Dr Nora Whelan, General Practitioner, Stradbally

Dr Gerald White, General Practitioner, Portlaoise

Dr John White, General Practitioner, Portarlington

Dr Anne Whitford, Consultant Anaesthetist, MRH Portlaoise