Dublin midlands hospital group claims downgrade mistakes will not be repeated in Portlaoise

Dublin midlands hospital group claims downgrade mistakes will not be repeated in Portlaoise

Portlaoise hospital.

The HSE's Dublin Midlands Hospital Group claims it has learned the lessons of the past and that any changes made will not be made without planning and investment.

In a long statement the DMHG say that in recent weeks, there has been a lot of coverage concerning the future of Portlaoise and the proposed action plan. It says that unfortunately, much of that has taken place without the formal publication of the proposed action plan. Repeating the sentiments of a letter already to staff, the group say this was "very regretful".

The DMHG issued the statement to provide an understanding of its process, data and evidence that informed the proposed action plan’s recommendations. 

The statement does not mention that maternity, paediatrics, emergency and other services will be pulled from the hospital. It does not mention that the plan would see the Midlands Regional Hospital regraded as a Category 2 hospital.

"From the outset the hospital group and Portlaoise hospital would like to state unequivocally, the approval of proposed action plan submitted to the Department of Health in December 201 is a policy decision for the Minister for Health," it says.

The group claims it 'should be clear' that the development of the Action Plan was mandated by HIQA which in recommendation 7C of their report on the hospital May 2015, directed the HSE to:“Publish an action plan outlining the measures and timelines to address the safety concerns and risks at Portlaoise Hospital, to include both general and maternity services...”

The statement says the HSE and the DMHG convened a consultative group. Led by Susan O Reilly and Dr Colm Henry, HSE National Clinical Advisor and 10 national leads for the HSE Clinical Care Programmes the HSE National Clinical Leads in Emergency Medicine, Critical Care, Surgery, Acute Medicine, Transportation Medicine, Paediatrics and Neonatology, Obstetrics and Gynaecology, Anaesthesia and the National Ambulance Service;

The statement says "the business intelligence data" informing the expert group was provided by Portlaoise hospital and the HSE nationally.

Independent data and analysis of the population demographics and expected trends and independent review of national and international evidence for the provision of acute emergency care are referenced.

It is claimed initial consultation and engagement to inform the Action Plan included meetings with clinicians and management at the Hospital, General Practitioners, the Prison Service, Community Health Services, HSE National Directorates Primary Care, Mental Health.

The lead author of the plan is Dr Susan O'Reilly, DMHG CEO. She says she wishes provide further information.

“I welcome the opportunity to provide further understanding to the process undertaken. I appreciate the situation is not ideal given our inability to proactively publish this proposal but I have to respect the process. This involved very detailed and thorough engagement with the Department of Health.

"The Department of Health have considered the proposal and the key drivers for change, including the data and evidence that informs our proposals. I have every confidence the Minister is considering it in detail and will provide a clear position in the coming weeks.

“With the completion of the action plan, this mandate has now been fulfilled.”

“Since the publication of the Sunday Business Post, 12th of Nov, it has been my priority to firstly communicate with all staff in Portlaoise. I firmly believe we need to have these conversations so the debate on this matter is informed clearly.

"Unfortunately, this could lead to uncertainty for our patients and the public who are attending Portlaoise Hospital today. I have a very clear message for these patients. There are no changes at Portlaoise Hospital today. Portlaoise Hospital will not close.

"If the proposals are adopted by government, it will take at least 4 years to implement. I have every confidence in the clinicians and management providing services here today who are doing their very best in a very challenging situation. Nevertheless, provision of low volume complex services remains challenging.

"Many commentators over the last few weeks have questioned the need for a plan. We all agree, there is a need for a plan. The key driver is stated clearly in the two HIQA Reports published about General and Maternity Services at Portlaoise Hospital. Specifically, in December 2016, HIQA again highlighted significant patient risks at the hospital and found that:

She references "The governance arrangements in the Emergency Department remained largely unchanged and continue not to be in line with the HSE’s National Clinical Programme for Emergency Medicine.

She also says that the Intensive Care Unit still does not meet the minimum requirements for critical care as set out by the Joint Faculty of Intensive Care Medicine of Ireland. In 2015, the HIQA Portlaoise Investigation Team was not assured that critical care services were sustainable in Portlaoise Hospital, and this situation has remained unchanged.”

 “In the days since the action plan was leaked to the media, a number of inaccuracies have been stated about the plan and its proposals. It would be both remiss of me not to address these inaccuracies, particularly to my colleagues who assisted in drafting this plan, and to the staff of MRHP,” she said.

The statement also investment at the hospital:

There has been significant investment at MRHP in recent years, including:

Capital: €7 million already spent on developing new Medical Assessment Unit and endoscopy equipment;

Current: MRHP’s 2017 budget is €57.7 million, a 28% increase on its 2012 budget of €44.9 million. The increase principally supports additional clinical staff; in 2017 there are 670 whole time equivalent (WTE) positions (775 members of staff), an increase of 21% from the 2014 base of 552 WTEs (600 members of staff). Since 2014 it says MRHP has been well funded for its current volume and complexity of clinical services

Future: The action plan provides for a further investment of €20 million at the hospital. This investment will be spent on expanding outpatient services.

The statement also references Capacity building

It claims that lessons have been learned from other downgrades.

"Unlike previous reconfiguration proposals and plans in other areas the DMHG are not repeating mistakes of the past. No changes can take effect without substantial planning and investment at other hospitals and in ambulances services in the group. This is estimated to take about 4 years.

"The DMHG has already prioritised funding for Portlaoise, Naas, Tallaght Hospital and the Coombe Women & Infants University Hospital for essential capacity for all group services. The Action Plan proposed investment in Tullamore to provide appropriate ED and inpatient capacity for future reconfiguration.

"The Hospital Group do not want any decisions taken at Portlaoise to impact negatively on any of our hospitals who are already extremely busy. This is why the proposals consider existing capacity challenges. The Department of Health bed capacity report is also a welcomed development and will inform future planning need," said the statement.

Remarking on the need for further consultation, Dr O’Reilly said: “It is recognised equally that further consultation and engagement is required so all interested parties can really understand the complexities of what is being proposed. 

"This plan was thoroughly considered, reviewed and analysed to ensure that the final draft puts forward what we believe to be the best and most appropriate plan for the long-term sustainability of MRPH, and in the best interests of patients and the community.

"We welcome the Minister prioritising the review of our proposal and giving a clear commitment to have a clear position on Portlaoise Hospital.”

Projected investment across DMHG (2018 – 2022) 

The DMHG prioritised a number of capital developments required immediately for capacity growth and critical care. These include investment in:

Midland Regional Hospital Portlaoise (Up to €20 million) to expand outpatient and elective medical, surgical, obstetrical and paediatric services;

Coombe Women and Infants University Hospital (€20.5 million) replacement of ageing theatres and delivery suites and inpatient capacity expanded;

Tallaght Hospital (€15 million) plans for a larger critical care unit;

Naas General Hospital (€18 million) for expanded elective and day care services; and

Midland Regional Hospital Tullamore €40 million projected to increase capacity at the hospital.
Patient activity at MRHP

The statement also includes an analysis of HSE Hospital In-Patient Enquiry (HIPE) data details the pattern of patient activity at MRHP:

On analysis of inpatient and day ward admissions for emergency or elective services (HIPE) across our hospitals we know that MRHP provided fewer than half of these services to county Laois residents (45%);
For Offaly residents MRHP provided services for 3.6% and for Kildare resident services were provided to 5%;
Despite the combined counties of Laois, Offaly and Kildare being 384,865, the catchment utilising inpatient and day case services is (54,167) based on our analysis;
The other 55% were admitted to other hospitals in Dublin and Tullamore for emergency and elective care; and
This data highlights the challenges of providing low volume complex services to a small catchment population.
Catchment population and demographics

The Statement says that the DMHG has accounted for the increase in population of 4.7% from 2011 to 2016 in its action plan. It does not reference a 20% growth from 2006 to 2011.  

However, what stands out most clearly is the changing demographic age profile within the Midlands region:

The number of over-65s has increased by almost 22% since 2011; while
Based on current trends, a projection of population growth in the region up to 2030 indicated that those aged under 65 will increase by 7% over the period but those over 65 years old will increase by 65%.
This ageing population trend informed the proposals within the action plan; particularly the need for services designed and equipped to deal with their needs. These include increased chronic illness, longer length of stays due to complex health conditions, and the need for a more diverse range of services.

ED attendances

Portlaoise hospital in 2016 reported 39,212 visits to the emergency department. Its says 21,400 attendances by adults which comprised 19,605 new visits and 1,795 returns.

It says there were 10,898 new paediatric patients and 597 paediatric return visits. Of these, 6,813 paediatric visits were medical in nature were cared for in the paediatric medical ward for assessment and treatment.

For the paediatric surgical attendees there were 4,681 of which the majority of which would have been dealt with for injuries in the main adult emergency department but a number that might present with abdominal pain would be admitted to the paediatric ward after being assessed in the ED. These should all count as emergency attendances.

For obstetric and gynae ED attendances there were 2481 new visit and 875 return visits.Early Pregnancy Unit which is open approximately 9am-5pm 5 days a week, 1717 women attended this unit.

Maternity Assessment Unit saw 1639 women principally with antenatal issues

Staffing and recruitment

The DMHG says the hospital continues to experience a significant difficulty in recruiting and retaining staff, particularly specialised clinical staff. As a result, the hospital is heavily reliant on agency and locum staff. This is unsustainable over the long term:

Staff numbers across MRHP have increased over the last three years, with a 21% overall increase in staffing since 2014;
There is 26.2 WTE consultant staff at MRHP, 19% who are employed as a locum.
There are 286.8 WTE nursing and midwifery staff at MRHP with 28.25 vacant positions.
There is 112.4 WTE allied health professionals and 4 vacant positions.

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