The Fine Gael-led Government is facing having to make a €100 million policy u-turn on Portlaoise hospital, in the wake of the leaking of a plan which proposes a complete downgrade of services at the Laois facility.
'Consensus' has been reached, according to the newly leaked plan entitled 'Development of an Action Plan for a New Model of Clinical Service Deliver in the Dublin Midlands Hospital Group'. The plan states that Portlaoise hospital, despite being one of busiest hospitals in the Dublin and Midlands, should be downgraded to a Model or Category 2 hospital.
Under the proposal, all emergency, maternity, paediatric and intensive care services would be removed. Hospitals in Dublin, Kildare and Offaly will pick up the slack. Under Dublin Midland Hospital Group (DMHG) estimates the plan could cost nearly €100 million in capital investment alone.
The DMHG say a realistic timeframe for implementation is four years.
It is claimed that the plan has expert backing but has only been reviewed by the HSE. A picture is painted that all that is awaited is the green light and cash from Government.
The proposal has been with the Minister for Health Simon Harris, for more than a year. He has yet to endorse or reject the plan but has asked for revisions. The latest leaked version dates to September this year.
However, the downgrade to Model 2 status would mean a u-turn on a policy adopted in 2011. At the time Minster for Health James Reilly stopped downgrade and kept Portlaoise as a Category 3 hospital. The latest downgrade road map has been in the works since 2015. However, it is fundamentally no different than a proposal dating back six years when several small hospitals, such as Roscommon, were downgraded.
The plan was submitted to Minister Harris in December 2016 and revised in September this year. It has never gone out for public consultation. The DMHG, HSE and Department of Health have refused to publish or give details.
However, confirmation that it was likely to call fo downgrade came recently with a linked outline five year strategy for hospitals in Dublin, Kildare, Laois and Offaly which was leaked to Laois TD Brian Stanley.
Its contents are confirmed in this 160 page new document leaked to the Sunday Business Post. The newspaper is charging the public a €19.99 subscription to access the document.
The proposals affect hospitals in Portlaoise, Tullamore, Naas, Tallaght, St James's and the Coombe.
In the plan's foreword Dr Susan O'Reilly, outlines the background and the support for the 'Development of an Action Plan For a New Model of Clinical Service Delivery in the Dublin Midlands Hospital Group'.
"I am pleased to share the Phase 1 design of how we propose to deliver clinical services for the Dublin Midlands Hospital Group."
She says the design is 'unanimously agreed' by the Consultant Clinical Leads of the National Clinical Care Programmes who acted as an advisory group. Although, she adds that the action plan has only been "reviewed" by the HSE Senior Management Team.
Once agreed in principle by the Department of Health and Minster for Health, Dr O'Reilly says the proposed design will enter a 'detailed and complex implementation planning process (phase 2) which will clearly set out the key actions and timelines for successful implementation'.
The executive summary sets out more background and the roadmap. It begins with Portlaoise and outlines its current status as a Category 3 hospital with an Emergency Departement (ED/A&E). The report says funding has increased from €44.9 million to €57.7 million for this year.
It gives the background to the plan being the HIQA investigation that followed the maternity scandal. That report issued in 2015 called for a plan for the hospital.
The new plan says National Clinical Programme leaders met over several months to to deliver sustainable high quality care at Portlaoise and other hospitals in the group.
It says there is a lot of evidence that patient outcomes are better in high volume settings, while there is "no evidence" to commission or continue commissioning acute care in low volume settings. It adds:
"In low volume hospital setting, the volume of activity does not match the resource allocation input. Hence there is clear inefficiency".
It does not mention, when making this claim, that nearly 40,000 patients accessed A&E in Portlaoise in 2016. A higher figure than Naas for Tullamore. But it continues:
"In the modern day, it is not justifiable to misallocate or or continue to misallocate scant healthcare resources to a known low volume setting," it said.
The plan sets out an option appraisal. It says that the population base accessing Portlaoise hospital is too small to generate sufficient volumes of clinical practices in critical care, complex surgery and anaesthesia.
The options were:
1 Sustaining the Midlands Regional Hospital as a Model 3 acute general hospital.
2 Continuation of 24/7 obstetrics and paediatrics in a Model 2 acute general hospital.
3 Coversion to Model 2 hospital necessitating relocation of acute paediatric services and obstetrical deliveries to other hospitals in the region.
"The consensus view for all National Clinical Programme Leaders is that the Midland Regional Hospital Portlaoise will become a Model 2 hospital consistent with the National Policy Doument: Securing the future of Small Hospitals," says the plan.
It says a Model 2 hospital enables the delivery of services in areas of ambulatory (outpatients) care, whih includes chronic disease management and day surgery, diagnostics and rehab.
There will be a 12/7 GP referral Medical Assessment Unit with the 'intent' to progress to a 24/7 service and a 12/7 local injuries unit. The focus will be on developing integrated care with GP and Community Health.
The plan outlines an end to 24/7 A&E. It says ambulances already bypass the hospital for major trauma, stroke, heart failure and major fractures. However, it says that there is a risk that care will be delayed for patients who present independently if the A&E is open.
As a result it says that the Emergency Department be transferred to other Dublin Midlands Hospital Group hospitals and that all ambulance calls be triaged to the the most appropriate setting.
This cut will be contingent on developing the Medical Assessment and Local Injury Units.
As for the care of pregnant women in obstetrics, the plan says all deliveries and neonatal services will be delivered by the Coombe Women and Infants Hospital in Dublin or nearest unit. This would be subject to substantial theatre and delivery capacity development at the Coombe. Outpatient care will still be provided in Portlaoise.
As for children the report says paediatric emergency and inpatient services cannot be safely provided in a Model 2 hospital. So, when Portlaoise is downgraded, all patients aged 5 or older will be seen at the the Midland Regional Hospital Tullamore except for patients aged five years or older who will attend the local injuries unit.
A new Paediatric Emergency Department will be established in Tullamore. The Offaly hospital will also provide both urgent and elective paediatric mdicine and surgery services.
Anesthetics in Portlaoise will be refocused on day-case elective surgery which will go up in volume once phase two has been developed and implemented.
As for ICU and critical care, the report says that the very low volume at Portlaoise is not sustainable and will be discontinued. If a patient needs critical care, he or she will be stablised and transferred according to the plan.
In surgery, the plan finds that there is a low volume and low complexity of cases at present. It says it would be 'preferable' for all surgical presentations except minor injuries to attend hospitals with higher volumes of surgical services.
As to the related health care planning considerations, the plan says the National Ambulance Services estimate that it will take two years to have sufficient sat trained to support 'growth in capacity'. It is admitted that the required training of staff and investment must be achieved prior to change to model 2 status.
On mental health, the plan will ensure appropriate support and clinical pathways between Tullamore and St Fintan's Mental Health Services in Portlaoise.
As for Prisons with more than 1,000 inmates, the report says mental health, addiction and chronic disease management are the dominant health care needs. The plan says Portlaoise hospital will continue to provide services to the prisoners and the low volume of ambulance deliveries will go to other hospitals in the group.
As for implementation and investment, the plan says that health services transformation requires capacity developments to provide appropriate facilities and staff. It says a high level plan describes the proposed capital developments.
It is claimed that €20 million would have to be invested into Portlaoise to expand outpatients and other departments. The Coombe requires €20 million while Tallaght and Naas require €15 and 1.8 million respectively. Up to €40 million is projected to be needed in Tullamore.
The cost of extra staffing and ambulance services is not outlined in the summary.
The plan says staffing will not fall in Portlaoise and patient numbers will increase.
The report says it will take a minimum of four years to implement the plan subject to capital funding. It says the time frame is realistic.
"The future for the Midlands Regional Hospital Portlaoise will be the evolution of a large Model 2 hospital in provision of a broader scope of elective, day surgery and endoscopy, extended ambulatory services in medicine, general paediatrics, surgery and antenatal and postnatal obstetrics as well as a growth in integrated medical care between a new medical assessment unit, inpatient services, GP and community services which will offer a broad range of medical services and both chronic and disease management and care of the elderly," said the plan.
Nowhere in the executive summary does the plan refer to any public consultation with the people of Laois, Dublin, Kildare, Offaly and other counties that use the services of hospitals in the Dublin Midlands Hospital Group.