Oireachtas Joint and Select Committees

Tuesday, 18 February 2014

Joint Oireachtas Committee on Health and Children

Closure of Mount Carmel Hospital: Discussion

2:30 pm

Photo of Jerry ButtimerJerry Buttimer (Cork South Central, Fine Gael)
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We are having two sessions today to discuss issues surrounding the recent closure of Mount Carmel Hospital. The second session will be at 3.45 p.m. with the Minister for Health and representatives of the Health Service Executive, HSE. In this session I welcome Mr. Philip McAnenly, industrial relations officer for the Irish Nurses and Midwives Organisation, INMO, east coast region, and Ms Phil Ní Sheaghdha, director of industrial relations, INMO. I thank them for attending.
We have received apologies from Deputies Sandra McLellan and Robert Dowds and Senator Imelda Henry, who could not be present. I ask members to turn off their mobile telephones or to switch them to flight mode as they interfere with the broadcasting equipment and the broadcasting of the committee's proceedings.
By virtue of section 17(2)(l) of the Defamation Act 2009, witnesses are protected by absolute privilege in respect of the evidence they are to give this committee. If they are directed by the committee to cease giving evidence in relation to a particular matter and they continue to so do, they are entitled thereafter only to a qualified privilege in respect of their evidence. They are directed that only evidence connected with the subject matter of these proceedings is to be given and are asked to respect the parliamentary practice to the effect that, where possible, they should not criticise or make charges against any person, persons or entity by name or in such a way as to make him, her or it identifiable. Members are reminded of the long-standing parliamentary practice and rulings of the Chair to the effect that members should not comment on, criticise or make charges against either a person outside the House or an official by name or in such a way as to make him or her identifiable.
We invited representatives of the National Asset Management Agency, NAMA, to the meeting but, as is clear from the written correspondence, the agency has declined to attend the committee's meeting this afternoon. It has furnished the committee with documents relating to this discussion.
I invite Mr. McAnenly to make his opening remarks.

Mr. Philip McAnenly:

Mount Carmel Hospital opened in 1949 but was acquired in 2006 by an investor. On 24 January last, this investor petitioned the High Court to appoint a liquidator to take possession of the assets of the company. The High Court appointed provisional liquidators on 24 January to effect the full cessation of the business of the hospital. This resulted in the loss of 382 jobs and the closure of 130 beds. Adjacent hospitals, including St. James's Hospital, Tallaght hospital and St. Vincent's University Hospital, all had high numbers of patients admitted to their emergency departments at the time the hospital closed. In fact, today there are 419 patients admitted in hospitals without a bed. The National Maternity Hospital, the Coombe hospital and the Rotunda Hospital, the three Dublin public maternity hospitals, have consistently reported that they are operating at 30% above their capacity. In recent months, Mount Carmel Hospital had been treating a large number of patients from public waiting lists. In addition, the HSE had contracted 25 beds to alleviate overcrowding in acute hospitals.

To give the committee some factual information, a number of investors made a bid recently to buy the hospital as a going concern. One bidder had concluded a due diligence exercise and had take-over funding in place. Linked to this, St. James's Hospital had agreed to manage and operate Mount Carmel Hospital on behalf of this investor. The interest of St. James's Hospital is important for a number of reasons. First, it would allow the hospital to transfer patients and services to Mount Carmel Hospital and thereby create capacity for the planned new children's hospital on its site in Dublin 8. Also, St. James's Hospital planned to reduce its waiting list numbers with the extra bed and theatre capacity opened up by the usage of Mount Carmel Hospital's facilities. Following NAMA's rejection of this bid, these opportunities have been lost.

With regard to occupancy, throughout 2013 bed occupancy increased at Mount Carmel Hospital from a low of 20% in March to near full capacity at the end of the year, prior to the hospital being liquidated. The higher occupancy was mainly as a result of the HSE contracting 25 beds to relieve the chronic overcrowding that has plagued acute hospitals in the region. These hospitals are repeatedly in the news for having a chronic over-crowding problem. In particular, Tallaght hospital, Beaumont Hospital and Connolly Hospital immediately benefited from the access to these 25 additional beds. St. James's Hospital and the Mater hospital also stood to benefit within weeks. The 25 beds were contracted by the HSE because the public health service is unable to cope with current demands for health care. This additional capacity has now been lost.

As regards waiting lists, 2,300 public patients were prioritised to be taken off waiting lists and have their operation promptly carried out at Mount Carmel Hospital. A total of 1,100 public patients, including children, had their operation carried out, with a further 1,200 public patients having scheduled appointments for operations. Many of these individuals had been waiting three years for an appointment. Our Lady's Children's Hospital, Crumlin, Letterkenny Hospital, Naas Hospital, Sligo Hospital, Tallaght hospital and St. James's Hospital all benefited from this waiting list initiative. The 1,200 people have now been returned to public waiting lists with little, if any, prospect of having their procedure completed. The 1,100 patients now return to an over-crowded public hospital system for their follow-up care and outpatient appointment. This additional capacity is now also lost.

Recent statistics show that there are 60,000 people waiting on public waiting lists for operations. The members have been furnished with figures which are submitted by the HSE to the health sector trade unions' at the bi-monthly national joint council meetings. The latest figures confirm that nursing whole-time equivalents, WTE, employed in the public services have reduced by more than 5,000 since March 2009. This reduction records a loss of almost 1,000 posts since December 2012 alone. I point this out in the context of a number of nurses and midwives now going into the jobs market and finding it almost impossible to rebuild their careers elsewhere. The reductions were effected by the moratorium on recruitment during a period of continued increased demand for our public health services. The members of the committee have the waiting list figures for each of the hospitals.

I will now outline the immediate cost to the Exchequer. The Social Insurance Fund will meet the cost of all the redundancies. At a conservative estimate, this will cost the public finances between €6 million and €8 million. In addition, with 328 workers applying for jobseeker's allowance, at a conservative estimate it will cost the Exchequer approximately €4 million per year. It should be borne in mind that an additional 64 staff are currently at the Labour Relations Commission in talks with the employer regarding redundancy, so we expect there will be a further hit to the public finances in respect of jobseeker's allowance. The loss of VAT and PAYE receipts to the public finances is conservatively estimated to be €7 million per year.

It has been widely reported that the aforementioned bid failed due to it being approximately €2 million below what NAMA was prepared to accept. It would appear that 382 jobs have been sacrificed for a balance of €2 million, while the public finances suffer by €17 million immediately, and a potential ongoing cost of €11 million per year thereafter. A considerable number of public patients will have their operations delayed. Our public health care system will come under additional pressure as a result.

Mount Carmel Hospital made a loss of approximately €1 million in 2013 on a turnover of €28 million to €30 million. Staff accepted a number of cost saving measures in 2012 and 2013 as a result of the pain and hardship of the Haddington Road agreement being extended to those employees. The effect of that will not flush through the system until 2014.

This would probably have resulted in the hospital breaking even or showing a profit.

We have a number of recommendations we would like the committee to consider. There should be an examination of why the public finances have been allowed to suffer a significant hit when this could have been avoided by modest funding of Mount Carmel Hospital. The hospital site should be re-opened immediately as a health care facility to relieve the chronic overcrowding in our public hospitals. Preferential transfer arrangements should be put in place for staff at Mount Carmel Hospital to ensure their service is reckonable in the public superannuation scheme. Staff who secure a job in the public system should not be subject to the altered career-averaging superannuation provisions.

There seems to be a perception and misconception at large that Mount Carmel Hospital was a maternity hospital. Maternity services formed a very small part of the overall services. Of the 130 beds at the facility, only 25 were provided for maternity services. A significant part of the work included general surgery, orthopaedic work, ear, nose and throat work, and paediatric surgery.

2:40 pm

Photo of Billy KelleherBilly Kelleher (Cork North Central, Fianna Fail)
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I thank Mr. McAnenly for his presentation. I am delighted the Irish Nurses and Midwives Organisation has come before the committee. We will also have a discussion with the Minister and the Department of Health. We requested that NAMA come before the committee but it declined. It has furnished us with some documentation which does not throw much light on what we would like to find out about the offers put on the table and how much it would have cost to secure Mount Carmel Hospital as a going concern and private entity or to have it taken over by the State and placed in the public hospital system.

I do not know what we can do about Mount Carmel Hospital. We all know where it is. It is closed and being wound down. Documents have been transferred in recent days and it is ceasing to exist as a hospital as we speak. It is still important that we find out how much it would have cost to maintain the hospital if due diligence were done by the Department of Health and HSE on whether it would have been an asset for the State in the provision of health care.

I visited Mount Carmel Hospital a number of weeks ago and one could sense the staff were very deflated. They were shattered. Caesarean sections were taking place when I was there. It was a very vibrant and alive hospital. What I found amazing when examining the figures was the number of public patients being treated there under the National Treatment Purchase Fund. These patients will now go back on the waiting list and the National Treatment Purchase Fund is shopping around, examining other private health providers such as the Beacon Hospital and the Mater Private Hospital to see whether they can fill the void. This is why I cannot hold out much hope for the hospital itself. We felt we should try to find out exactly why it closed and whether it was a simple case of liquidation because it was no longer viable or if other avenues were available.

I wish to convey my sympathies to the staff. It has been a part of the community of south Dublin and part of the broader health system for many years. I represent a Cork constituency and people came from throughout the country for specific treatment in Mount Carmel Hospital, referred through the National Treatment Purchase Fund or private health insurance.

It does not make much difference now, but how it was handled by NAMA, the courts and the liquidator and how they informed the staff was very disappointing to say the very least. We should put on record that sending out a press release or informing the media before staff and management is distasteful. It happens all too often in this country that the last people to be told are the staff. A press release is sent out from a PR organisation to inform people their livelihoods have been taken away and it is not good enough. This was badly handled.

Mr. McAnenly stated Mount Carmel Hospital was not just a maternity hospital and this was also brought to my attention when I was there. A large volume of other procedural traffic also went through it. When one considers this, what must now happen will put huge pressure on the public hospital system in the greater Dublin area, and other private hospitals will have to be contracted to take up the void. We have not thought this through. If it came down to €2 million or €3 million, based on analysis done on the cost of social welfare and other Departments, it would raise very serious questions on what effort the Department of Health or HSE made to see whether it could be rescued as a going concern and brought into State ownership so it could continue to provide a service.

The development of the national children's hospital at the St. James's Hospital site is a key issue. I am not an expert on planning, architectural design or engineering but the development of a massive infrastructural development at such a tight site will cause huge dislocation to St. James's Hospital. It will have a major impact on the workings of St. James's Hospital for a number of years while it is being constructed. Mount Carmel Hospital could have taken the overflow or surplus during this construction. Even at this late stage, this needs to be explored. If we cannot reverse what has happened, it should still be seen as a medical facility to complement the public health system in the greater Dublin area.

I do not know what we can do for the staff of Mount Carmel Hospital at this late stage. They have our sympathy. I thoroughly believe it is appropriate to bring the witnesses and other stakeholders before the committee to hear what they have to say about why the facility was allowed to close.

Photo of Caoimhghín Ó CaoláinCaoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)
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I join the Chairman in welcoming Mr. McAnenly and Ms Ní Sheaghdha and I thank them very much for attending and representing the INMO. We will have an opportunity to engage with the Minister directly after this meeting. What the witnesses have shared with us will be very helpful in preparing for it. I join Deputy Kelleher in expressing disappointment that NAMA did not feel it appropriate to come before the committee. It is most regrettable. NAMA certainly has questions to answer and we will have to explore them in another way.

The lamentable end result of all of this is we will lose a health care facility. I am not a champion by any means - far from it - of private health care provider entities but nevertheless one must recognise in the situation we are in this was a health facility with 130 beds, 382 staff, expensive medical equipment and extensive premises which are now to all intents and purposes closed down. It is most unwise.

I thank the INMO for ably representing its membership in the nursing and midwifery staff. The staff themselves only learned of what was intended through the media. They have been laid off without proper notice. A number of them have decades of service in Mount Carmel Hospital and other facilities.

I noted the remarks Mr. McAnenly made in his presentation on NAMA. I ask him to elaborate on the role of NAMA in all of this. To my mind, it has looked at this as an asset securing loan acquirement in cold balance sheet terms with no consideration whatsoever of what the facility was about. I wonder where stood its social responsibility, which it most certainly has or is supposed to have, I understand, as part of its terms and responsibilities.

In the closing remarks of his opening submission, Mr. McAnenly indicated that Mount Carmel was not solely a maternity hospital. Nothing makes that point more strongly than the fact that only 25 of the 130 beds were designated for maternity work. The witnesses should provide an outline of the range of other activities that were catered to at Mount Carmel. I note Mr. McAnenly mentioned that approximately 2,300 patients were actually facilitated from the public domain within the facility at Mount Carmel. The patients' procedures and needs were addressed there having been acquired through the HSE's activities and engagement with Mount Carmel on an annual basis. What proportion of patients at Mount Carmel were public patients referred from the public health system? Do the witnesses have such a figure to hand or can they indicate what it might be as a proportion of Mount Carmel's past throughput?

My last question pertains to the important issue of the current prospects for the staff. Members of the Joint Committee on Health and Children are aware that not all 382 employees are members of the Irish Nurses and Midwives Organisation, INMO, as they represent a range of service providers, as well as ancillary and support staff. How many of the 382 are nursing staff who are members of the INMO? What are the prospects for this significant number of highly trained and in many cases long-serving health care providers? I already have told the Minister that in the event of Mount Carmel being a shut and done deal, such people, with their experience and expertise, should be re-engaged within a health system that really needs their services. There is evidence aplenty, not merely anecdotal, of the shortage of nursing staff in maternity midwifery. Tragic situations were recently exposed in respect of which nursing and midwifery staff have been crying out since 2006 for additional staff at the Midland Regional Hospital, Portlaoise. While displacement will be part of the experience of these nursing staff, surely within the HSE service overall there must be facilitation to absorb them because the need is there and no one desires for them to be obliged to look to employment opportunities overseas. I will leave it at that and thank the Chairman for the opportunity.

2:50 pm

Photo of Jillian van TurnhoutJillian van Turnhout (Independent)
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I also extend a welcome to the witnesses. I will not repeat the comments of my colleagues, Deputies Kelleher and Ó Caoláin, other than to agree and to declare an interest. I was born in Mount Carmel myself and had my tonsils out there. Consequently, I have had some experience of the facilities. However, as stated by my colleagues, the manner in which this decision was communicated is a subject of concern and I certainly have taken note of the INMO's recommendations. Mr. McAnenly raised some really valid issues and in addition to Deputy Ó Caoláin's questions about the staffing, what arrangements are in place? Are arrangements in place for transferring or picking up on expertise? As I have heard different communications, it would be really useful for the joint committee to have clarity in this regard. Another question that has not been raised previously pertains to the hospital's current infrastructure and facilities. At what level are the facilities? Did the hospital need a major overhaul or are these facilities fully operational? I seek to understand what is the infrastructure that has been left there. I again refer to the manner in which the news was communicated to the local area, the staff and to everyone concerned. I cannot imagine what the week in question was like for those who were pregnant and had been booked in to attend Mount Carmel. I thank the witnesses for their attendance today and certainly look forward to hearing their answers.

Photo of Colm BurkeColm Burke (Fine Gael)
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I will be brief. I thank the witnesses for their attendance and, like my colleagues, acknowledge it is a difficult time for staff who made a huge commitment there in the provision of health care for many years. It is not easy for anyone who is dedicated and committed to his or her job to suddenly find one's employment changes overnight without any warning. I have examined the affidavit filed in the High Court and the financial position does not appear to have been great for some time. Were staff aware of the difficulties that existed or were they kept completely in the dark? The aforementioned affidavit indicates there appear to have been losses from 2007 onwards. The figures being given here in the affidavit, which I presume was filed, indicate annual losses since 2007 that vary between somewhat more than €1 million and €1.5 million. Three different figures were given in the end, which add up to approximately €43 million in liabilities. Were the staff aware of the difficulties? Was there any warning of such difficulties or was this all kept in the dark without any prior warning? If that was the position, it was very unfair. One problem that exists at present for everyone in private health care is there now is a lot of competition in that sector. Another issue is the number of people with private health insurance is decreasing. However, from a staff point of view, was there any pre-warning with regard to the financial difficulties that existed? As for re-organisation since 2007, was there consultation about creating efficiencies in order that the maximum number of jobs could be maintained throughout that period over the past six or seven years?

Photo of Jerry ButtimerJerry Buttimer (Cork South Central, Fine Gael)
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I now call Deputy Mathews.

Photo of Peter MathewsPeter Mathews (Dublin South, Independent)
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Would the witnesses like to address some of those questions?

Photo of Jerry ButtimerJerry Buttimer (Cork South Central, Fine Gael)
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No, the Deputy should go ahead. I will chair this meeting.

Photo of Peter MathewsPeter Mathews (Dublin South, Independent)
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I thank the Chair for allowing me to attend this meeting.

Photo of Jerry ButtimerJerry Buttimer (Cork South Central, Fine Gael)
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All Members of the Houses are entitled to attend the committee. It is not the Chairman's gift, as the Deputy is entitled to attend and participate.

Photo of Peter MathewsPeter Mathews (Dublin South, Independent)
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I merely wished to take the opportunity to thank the Chairman, as I like to be friendly. I do not believe I have attended a meeting of this joint committee previously. My apologies; I attended the committee last May, as the Chairman knows only too well.

Photo of Jerry ButtimerJerry Buttimer (Cork South Central, Fine Gael)
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The Deputy has not been here subsequently.

Photo of Peter MathewsPeter Mathews (Dublin South, Independent)
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Exactly. I met Mr. Philip McAnenly almost immediately following the announcement of the closure and he kindly briefed me fully on pretty well all the information that has been presented here. I remembered it point by point. The question that Senator Colm Burke raised is easily answered because it was public knowledge that Mount Carmel Hospital, which was controlled by Gerard Conlon, paid a huge price to the sisters for the hospital. Interest charges alone on that sum of money would have hung a huge albatross around its neck. In fact, the operating loss of slightly more than €1 million in the past year, given the subdued levels of occupation, almost constitute an achievement when one considers what the interest charges would have been. If one takes a rate of 4% on the guts of €60 million, which we believe was the initial figure when the loans were advanced, that amounts to €2.4 million alone in interest charges. While interest did fall with the reducing European Central Bank rates and so on, it does not take rocket science to know that the over-mortgaged or over-loaned position of the bank was the problem, not the operational matters.

I wish to double-check with the witnesses a statement by the Minister, Deputy Reilly, that the demand for maternity services, relatively speaking, has peaked and is falling as the birthrate falls. While this is known to all, there had been an orderly transition to other types of medicine. In fact, my own dear father died in Mount Carmel in March 2010 after two years of highly caring nursing.

All my children were born there.

Mr. Jimmy Sheehan, who is perhaps the leading expert on hospital operational management across any type of hospital, was involved at the establishment of the hospital in 1949 to 1950. I spoke to him only 15 days ago before he went to America and from where he has just returned, having visited the best children's hospitals in the United States with a view to making a contribution on a reconsideration of the siting of the national children's hospital. We have to stand back at this point from the nitty-gritty of decisions and look at the overview. I agree that on the face of it, 382 staff going on to jobseeker's allowances will be a cost of in the order of €7 million a year to the Exchequer. There is a once-off cost of approximately €9 million for the call on the State fund and a further shortfall in the minds of NAMA as to the acceptability or otherwise of the offer which I know was fully funded and I know had been discussed with the previously mentioned Mr. Jimmy Sheehan. He understands the operational aspects, having been a founder member of Blackrock Clinic, the Hermitage Clinic - in which he is no longer involved - as well as the Galway Clinic and other hospitals. It is a great shame and even at this stage we should have clear light on what were the key areas of decision-making. What was the offer? Why was €2 million considered to be a shortfall that would trigger a loss of €17 million in the first year of closure? Why was the whole transition to different types of medical procedures and medical nursing in the hospital stopped in its tracks? In my view, there is a big question mark and it is not satisfactory.

3:00 pm

Photo of Jerry ButtimerJerry Buttimer (Cork South Central, Fine Gael)
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Thank you, Deputy Mathews.

Photo of Peter MathewsPeter Mathews (Dublin South, Independent)
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Deputy Billy Kelleher raised a Topical Issue matter in the Dáil-----

Photo of Jerry ButtimerJerry Buttimer (Cork South Central, Fine Gael)
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The time is against us, Deputy.

Photo of Peter MathewsPeter Mathews (Dublin South, Independent)
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What is the time pressure here, Chairman?

Photo of Jerry ButtimerJerry Buttimer (Cork South Central, Fine Gael)
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Speaking times are decided.

Photo of Peter MathewsPeter Mathews (Dublin South, Independent)
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What is the pressure?

Photo of Jerry ButtimerJerry Buttimer (Cork South Central, Fine Gael)
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We have another meeting with the Minister and we need to turn the committee time around.

Photo of Peter MathewsPeter Mathews (Dublin South, Independent)
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Maybe we can discover the questions that need to be put to the Minister on this matter.

Photo of Jerry ButtimerJerry Buttimer (Cork South Central, Fine Gael)
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I ask the Deputy to please conclude; he has spoken for five minutes.

Photo of Peter MathewsPeter Mathews (Dublin South, Independent)
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I feel I have been bundled into a corner.

Photo of Jerry ButtimerJerry Buttimer (Cork South Central, Fine Gael)
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The Deputy has spoken for five minutes, which is the same length of time as the party spokespersons of the main political parties.

Photo of Peter MathewsPeter Mathews (Dublin South, Independent)
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I am revisiting some of the key elements of information and asking whether there were other bits of information that should now be examined and questioned. I suggest we should drill into it. My sister is a nurse in Mount Carmel and the hospital has been there since 1950. I remember being there with the Minister in 2012 when new machinery was being installed in one of the operating theatres. That is only a year and a half ago.

Photo of Jerry ButtimerJerry Buttimer (Cork South Central, Fine Gael)
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I thank the Deputy.

Photo of Peter MathewsPeter Mathews (Dublin South, Independent)
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I will keep asking "Why?"

Mr. Philip McAnenly:

I will answer the questions as they were presented. Deputy Kelleher asked about the offers. My information on that matter comes from what has been made public and is in the media. I understand there were two serious bids, one by a company called Centric - I read in the newspapers that it may be interested again to some extent.

Photo of Jerry ButtimerJerry Buttimer (Cork South Central, Fine Gael)
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Has there been discussion with Mr. McAnenly since that revelation has been made?

Mr. Philip McAnenly:

No, there have been no further discussions. The second bid is more serious; Mr. Mulchrone and Mr. Barry had an interest in bringing together a number of new services to the hospital and a number of new consultants were going to bring work to the hospital. In addition, I understand a bid of €14 million was made. Of that €14 million, some €10 million was going to be paid for creditors, including the Revenue Commissioners who were happy with the payments being made to them. The remaining €4 million was to be paid to NAMA. I understand that before Christmas NAMA was prepared to accept closer to that figure but subsequently, in the two to three months later, it decided to reject the bid of €4 million. It would appear that €2 million was the sum required to continue the hospital funding and that was based on 2013 figures when the occupancy level of the hospital fell to 20%. In the weeks prior to the liquidation of the hospital, the occupancy was almost at full. The figures I am presenting of a loss of €1 million based on a €28 million to €30 million turnover are somewhat skewed. It may have been more accurate if we had looked at figures for the final six months or the final quarter of the year which would have shown a more accurate picture of how profitable or viable the hospital could have been, based on closer to full occupancy.

Photo of Billy KelleherBilly Kelleher (Cork North Central, Fianna Fail)
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Deputy Mathews referred to the interest rate payment. Is that included in the operating loss figures?

Photo of Peter MathewsPeter Mathews (Dublin South, Independent)
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Of course it would be.

Photo of Jerry ButtimerJerry Buttimer (Cork South Central, Fine Gael)
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Sorry, Deputy-----

Photo of Billy KelleherBilly Kelleher (Cork North Central, Fianna Fail)
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It should be included in normal accountancy practice.

Mr. Philip McAnenly:

In answer to the question as to why the hospital was not closed, I would ask why was the hospital not saved. There are very compelling and persuasive reasons as to why the hospital should have been saved along with the 482 jobs that have been lost. Only the catering jobs remain and these are currently in the conciliation services of the Labour Relations Commission.

There is a national public interest issue at stake. This is not about patients in one part of Dublin. I refer to the waiting lists in Letterkenny, Naas and Sligo hospitals as well as in larger Dublin hospitals which are struggling with well-documented capacity problems. These hospitals all obtained immediate relief when the HSE purchased 25 beds in Mount Carmel to relieve the overcrowding. Patients who no longer required acute hospital care and attention could be moved to Mount Carmel for the next phase of their care. The other concern of a public interest is the impact this is likely to have on the development of the already delayed national children's hospital. St. James's Hospital is on the record as stating that it needs the capacity at Mount Carmel Hospital to create the new site because adult beds would be lost in the creation of the new children's hospital. The decanting of adult beds to Mount Carmel would solve the problem for St. James's.

I ask what level of joined-up thinking took place across a number of Departments and publicly funded bodies such as NAMA, which should have had an interest in ensuring that almost 400 jobs were saved and that adults who cannot afford the private health system would be able to access immediate care and have their operations and procedures carried out promptly.

The HSE prioritised the most sick children and adults from its waiting lists to be treated in Mount Carmel Hospital. A total of 1,100 patients had their procedures completed and they would require further outpatient care but they must return to an overcrowded, overburdened public health system that cannot cope with them. The only reason they were treated in Mount Carmel Hospital was because the public health system could not look after them.

Deputy Ó Caoláin asked about the input of the HSE and the Department of Health. The level of co-ordination between HSE and the Department and the board of St. James's Hospital is worthy of further examination. I am not sure if there was liaison between the board of St. James's Hospital and the Minister's office but I believe there should have been with regard to the potential risk to a number of patients on public waiting lists. A number of elderly, confused patients were immediately transferred into the 25 contracted beds. They were transitioned from Beaumont and Tallaght hospitals into Mount Carmel Hospital, with a consequent aggravation of their confused state.

They were then transitioned out of the hospital. That all took place within two to three weeks. The trauma families suffered as a result of that did not seem to be considered in the decision to liquidate the hospital.

The price value of the asset, on which the Deputy also touched, is very important. We believe NAMA should have an interest other than simply considering the price value of the asset. The issue here was much broader than that. Without going over ground that has already been covered, the issues are the same as those on which we have already touched.

The type of work that was being carried out at Mount Carmel dispels the myth that it was a private maternity hospital. A full range of general surgery was being carried out there, including orthopaedic surgery, ear, nose and throat work, general surgery and paediatric work. As per the figures in my submission, 2,300 patients were booked off the HSE public list and 1,100 patients had already had their procedures done. That was for part of the year; in a 12-month period those numbers would possibly have been significantly higher. As the HSE may have taken a greater interest in this hospital, the numbers would have significantly increased as well, which would have done a great service to the public patients in the public health service.

Of the 328 staff, 205 are nurses and midwives, and a small number of the 205 are midwives.

3:10 pm

Photo of Caoimhghín Ó CaoláinCaoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)
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How many of those staff are there? Is it 205?

Mr. Philip McAnenly:

They number 205 out of the 328 staff. There were 54 catering and catering support staff employed at the hospital and they are currently engaged in a conciliation process at the Labour Relations Commission in an attempt to save some of those jobs.

Photo of Jerry ButtimerJerry Buttimer (Cork South Central, Fine Gael)
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In respect of those 205 staff, can Mr. McAnenly give a breakdown of the number who were permanent and the number who were part-time?

Mr. Philip McAnenly:

It is 205 persons, not 205 wholetime equivalents.

Photo of Jerry ButtimerJerry Buttimer (Cork South Central, Fine Gael)
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Yes.

Mr. Philip McAnenly:

It was not a teaching hospital and tended not have the same turnover of staff as one would find at teaching hospitals. They would have been largely permanent staff. In response to the Deputy's question regarding the chances of the staff rebuilding their career elsewhere, unfortunately, it is almost zero because there is a recruitment ban in the health service. The moratorium on recruitment provides for some grades being exempt from the recruitment ban but unfortunately nursing and midwifery are not exempt grades. The Government may consider in the medium term temporarily lifting that ban on recruitment not only because of the difficulties those 205 nurses and midwives now face, but because of the well-chronicled and well-reported difficulties that the public health service is currently suffering. We need only consider the number of patients who were on trolleys last night.

Photo of Jerry ButtimerJerry Buttimer (Cork South Central, Fine Gael)
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We are dealing with a different topic now.

Mr. Philip McAnenly:

I would also point out that while these nurses, midwives and other staff are unable to secure jobs elsewhere or to access work, the public purse is currently paying an inflated rate for agency staff and for staff at the overtime rate of pay. We have a ready-made solution on our hands to immediately make a cost saving for the public health service.

Photo of Jerry ButtimerJerry Buttimer (Cork South Central, Fine Gael)
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Were agency staff employed in Mount Carmel?

Mr. Philip McAnenly:

No.

Photo of Jerry ButtimerJerry Buttimer (Cork South Central, Fine Gael)
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None at all.

Mr. Philip McAnenly:

What they tended to use were bank staff - staff with an "if and when" type contract. Those staff would have enjoyed quite regular roster lines and would have had frequent access to a minimum number of hours.

In regard to Senator van Turnhout's questions-----

Photo of Jerry ButtimerJerry Buttimer (Cork South Central, Fine Gael)
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Senator van Turnout had to leave to attend another meeting and she passes on her apologies.

Mr. Philip McAnenly:

Does the Chairman want me to deal with those questions?

Photo of Jerry ButtimerJerry Buttimer (Cork South Central, Fine Gael)
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Yes.

Mr. Philip McAnenly:

Senator van Turnhout asked questions around the quality of the facilities. It is interesting to note that in the history of health care provided at Mount Carmel Hospital there was never one incident of MRSA, which has plagued our health services elsewhere. Since 24 January, I have spent up to 14 hours per day on-site at the hospital trying to support staff and going through the redundancy procedures, etc. It is vexing to see the excellent facilities that are there. As nurses, both I and my colleague have worked in public health care facilities over the years that were not a patch on what we have seen in Mount Carmel. It is a fantastic facility. The buildings are pristine, with many single rooms and two-bed rooms, all en suite and all available today for use by the public, yet they have been closed.
Senator Burke asked if staff were made aware of the financial situation at the hospital. Each of the unions involved, including our union, would have worked very closely with both the previous management of the hospital and the interim management since NAMA acquired the assets to effect cost savings to try to ensure the future of the hospital. We would have introduced all the cost-saving measures civil and public servants endured under the Haddington Road agreement. Staff would have worked the additional hours for no added pay. Staff would have lost premium earnings, as did staff in the civil and public service. All those cost-saving measures were introduced in an effort to secure the future of the hospital.
In addition, we engaged with management in effecting a round of redundancies at the hospital last year but we were moving in a direction that led us to believe, and we were being informed by the interim managers, that we were moving closer and closer to a break-even point with every passing day. We were looking forward to 2014 when the full values of those cost savings would be measured in the annual budget and where we would have been operating a hospital that would have had close to 100% occupancy. We have no doubt based on the accounts and the figures that were presented to us regularly and at the monthly - and sometimes more frequently than that - meetings with management that the hospital would have moved into profitability in 2014.
Deputy Mathews mentioned that the Minster has repeatedly stated that the birth rate has peaked. That may be the case and that may be for reasons due to legislative changes over the years, but it is also a fact that the masters of each of the three Dublin maternity hospitals have repeatedly reported that they are operating at more than 30% above the optimum level or their desired or ideal capacity level. It is a red herring to refer to declining birth rates.

Photo of Peter MathewsPeter Mathews (Dublin South, Independent)
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I asked for clarification on that and I thank Mr. McAnenly for that clarification.

Mr. Philip McAnenly:

It is a red herring to refer to a declining birth rate or what might happen in the 2027 or 2057. It is more important that we listen to the masters of each of the three Dublin maternity hospitals in regard to capacity problems they have been encountering for a number of years without relief.

Photo of Peter MathewsPeter Mathews (Dublin South, Independent)
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Mr. McAnenly made the point that 105 beds were non-maternity.

Photo of Jerry ButtimerJerry Buttimer (Cork South Central, Fine Gael)
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Out of respect for the witness, allow him to complete his response.

Mr. Philip McAnenly:

With regard to the 30% overcrowding in the three Dublin maternity hospitals, the additional births that will take place in each of those hospitals on foot of the closure of Mount Carmel will have immediate implications in terms of cross-infection, higher rates of infection and simply even the dignity of patients - mothers and babies - in those areas that are already overcrowded. This will worsen a very difficult problem.

Photo of Jerry ButtimerJerry Buttimer (Cork South Central, Fine Gael)
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I thank Mr. McAnenly for his response. I call Deputy Kelleher and I believe he is aware that we will have to finish at 3.45 p.m.

Photo of Billy KelleherBilly Kelleher (Cork North Central, Fianna Fail)
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Yes. I thank the witnesses for their presentations and the responses to the questions. The key issues are probably areas on which they cannot give us information in terms of what exactly was on offer. We will have to explore that perhaps through written correspondence with NAMA or others, while respecting the legislation that underpins this.

Photo of Jerry ButtimerJerry Buttimer (Cork South Central, Fine Gael)
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We asked NAMA to come before the committee.

Photo of Billy KelleherBilly Kelleher (Cork North Central, Fianna Fail)
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I accept that.

Photo of Jerry ButtimerJerry Buttimer (Cork South Central, Fine Gael)
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There is extensive correspondence from NAMA on that. It states, first, that NAMA has no role in relation to either the formulation or implementation of public health policy and it believes it would be inappropriate for any officer of NAMA to comment on Government policy in this area; and, second, NAMA is precluded under sections 99 and 202 of the NAMA Act, similar to restrictions on other lenders, from commenting on the financial affairs of individual debtors or even on matters relating to their properties or such assets.

Photo of Billy KelleherBilly Kelleher (Cork North Central, Fianna Fail)
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I respect NAMA's right to state that, but we certainly were not asking NAMA to come in to comment on Government policy; we were asking it to comment on the fact that it consented with the owner, Mr. Conlon, to go to the High Court to liquidate the hospital. That is the key issue. We wanted to find out whether a certain number of millions of euro would have sustained this entity to the point where it would have reached profitability.

The joint committee must explore this issue and if representatives of the National Asset Management Agency are unwilling to come before us, we should write to it seeking further information about what was on offer. The Mulchrone-Barry offer proposed a sum of €10 million for creditors, including the Revenue, of which the State would obviously recoup some money, and an additional €4 million. Given that the hospital is still for sale, the key issue is what will happen to it and if it will continue to operate as a medical facility. One must also ask whether it was intentionally liquidated to tidy up legacy issues, for example, staffing, thus allowing it to be placed on the market as a medical facility without legacy issues attached. We must keep an eye on that issue because if that was the case, NAMA was complicit in that approach.

3:20 pm

Photo of Peter MathewsPeter Mathews (Dublin South, Independent)
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A figure of €14 million would be the right price. I know that from experience.

Photo of Jerry ButtimerJerry Buttimer (Cork South Central, Fine Gael)
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Deputy Mathews does not often attend our meetings but we would like all Members to adhere to a model of behaviour. He should not interrupt.

Photo of Billy KelleherBilly Kelleher (Cork North Central, Fianna Fail)
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We should explore this issue further with the National Asset Management Agency, if necessary in writing in the event that representatives of the agency are unwilling to come before the joint committee to answer questions.

Photo of Jerry ButtimerJerry Buttimer (Cork South Central, Fine Gael)
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Once our deliberations have concluded, members may decide how to proceed when we meet in private on Thursday morning.

Photo of Caoimhghín Ó CaoláinCaoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)
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Have we passed the point of rescue? Are front-line providers of specialist services, for example, the surgical teams and consultants working at the facility, still in a state of limbo? Are they available and willing to resume responsibilities or are they lost in the system or beyond?

Photo of Colm BurkeColm Burke (Fine Gael)
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The letter from the National Asset Management Agency states neither of the two bids was viable and both were heavily conditional as they involved low up-front payments and deferred unsecured payments. Were staff given details of the two proposals at any stage?

Photo of Jerry ButtimerJerry Buttimer (Cork South Central, Fine Gael)
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Did NAMA make direct contact with the Irish Nurses and Midwives Organisation or other organisations representing workers? Did representatives of the INMO meet representatives of NAMA?

Mr. Philip McAnenly:

No.

Photo of Colm BurkeColm Burke (Fine Gael)
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Was the INMO aware of the conditions of purchase?

Mr. Philip McAnenly:

I will deal with Senator Burke's questions first. While it was reported in the media that a number of caveats were attached to the Mulchrone-Barry bid, the media did not carry any reports on the Centric Health bid, which was, I understand, made by two consultants. It was reported that the Mulchrone-Barry bid failed, inter alia, because it included too many caveats. It should not be unusual to find caveats attached to bids where a hospital is in the process of an orderly wind-down. This was not the liquidation of a factory, block of apartments, hotel or restaurant. The hospital was fully occupied on 24 January when the owner petitioned the High Court to liquidate the asset. I imagine that if any investors were buying a hospital which was almost fully occupied and fully operational, it would be normal to expect some caveats attached to any bids for the facility.
We have not had any discussions with the National Asset Management Agency. NAMA did not engage with us about the welfare or future of the employees or the timeframes under which it was funding the liquidation.
To respond to Deputy Ó Caoláin's question, it is not too late to rescue the hospital. The liquidator was appointed on 24 January and two thirds of the staff were made redundant on 31 January. The majority of the third remaining were made redundant on 7 February. Between 15 and 20 staff are decontaminating areas of the hospital where they are still employed. Few of these staff have been successful in securing an interview with a prospective employer, not to mention getting a job offer.
When one pays attention to the public media, it is clear that work could be transferred to the 130 beds. This would provide significant comfort to the public health service in terms of people who are ready to move from an acute hospital setting to a step-down type setting that would be more appropriate to their needs, including health care needs. Mount Carmel is ideally located and, with a little imagination and innovation, the hospital could be opened again very quickly.

Photo of Peter MathewsPeter Mathews (Dublin South, Independent)
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An offer of €14 million for a hospital that might make €1 million per annum once it recovers to normal levels of activity would give a return of 7%. Without studying the issue in great deal, that appears to be roughly the right price. Mr. McAnenly is correct that there will be caveats. My experience, having spent 20 years in this business, is that one would expect caveats. The big elephant in the room that must be explained is the decision not to accept a bid which would have averted a cost to the State of €17 million. When one adds the €14 million bid to the €17 million cost, the total cost is €31 million.

Mr. Philip McAnenly:

The cost is estimated to be €19 million.

Photo of Peter MathewsPeter Mathews (Dublin South, Independent)
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That gives a total cost of €33 million. That is the elephant in the room which must be analysed.

Photo of Jerry ButtimerJerry Buttimer (Cork South Central, Fine Gael)
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I thank the witnesses for their attendance. This has been an enlightening meeting. In the second part of the meeting, we will be joined by the Minister for Health, Deputy James Reilly, and representatives of the Health Service Executive. The witnesses are more than welcome to observe proceedings from the Gallery.

Sitting suspended at 3.50 p.m. and resumed at 3.55 p.m.

3:30 pm

Photo of Jerry ButtimerJerry Buttimer (Cork South Central, Fine Gael)
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We will resume in public session for the second part of our deliberations. I welcome the Minister for Health, Deputy Reilly, and the assistant secretary at the Department of Health, Ms Tracey Conroy. I also welcome Ms Joan Regan of the Department of Health and Mr. Ian Carter, national director of acute services from the Health Service Executive. I thank Mr. Ray Mitchell from the HSE. I also welcome Ms Eileen Finn from the INMO. We already had a discussion with the Irish Nurses and Midwives Organisation and as part of our deliberations in this second meeting, we will hear from both the Minister and Mr. Carter.
I remind members to turn off their mobile telephones or switch them to flight mode. I welcome back Deputy McLellan and thank her for being here, as I note she had another engagement in the Chamber. Senator van Turnhout sends her apologies as there is another meeting that she must attend.
By virtue of section 17(2)(l) of the Defamation Act 2009, witnesses are protected by absolute privilege in respect of the evidence they are to give this committee. If they are directed by the committee to cease giving evidence in relation to a particular matter and they continue to so do, they are entitled thereafter only to a qualified privilege in respect of their evidence. They are directed that only evidence connected with the subject matter of these proceedings is to be given and are asked to respect the parliamentary practice to the effect that, where possible, they should not criticise or make charges against any person, persons or entity by name or in such a way as to make him, her or it identifiable. Members are reminded of the long-standing parliamentary practice and rulings of the Chair to the effect that members should not comment on, criticise or make charges against either a person outside the House or an official by name or in such a way as to make him or her identifiable. I call the Minister for Health.

Photo of James ReillyJames Reilly (Dublin North, Fine Gael)
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I thank the Chairman and members of the committee for inviting me here today to discuss the closure of Mount Carmel Hospital.

I recognise fully that the loss of the hospital has come as a blow and, to some, a shock. It created some uncertainty for patients and prospective patients, and the HSE stepped in quickly to ensure a seamless transfer to other maternity services where required. Understandably, it has been difficult for staff to come to terms with job losses, particularly those who have spent the best part of their careers working at the hospital. I acknowledge that and, on a personal level, I am disappointed that a suitable buyer could not be found for the hospital. However, let me be clear that a State purchase of the hospital as a going concern was never a viable option.

Following an approach from NAMA, my Department undertook a high level examination in order to assess the feasibility of HSE purchase of the hospital. It immediately became clear that the purchase of Mount Carmel, as a standalone low-volume hospital, would be contrary to Government policy on maternity services. Current Government policy on maternity services is based on the premise that for optimal clinical outcomes, maternity services should be co-located with adult acute services or tri-located with adult and paediatric services. The benefits of co-location and tri-location are clear and accepted internationally. Co-location allows the mother access to a full range of medical and support services should the need arise, such as cardiac and vascular surgery, intensive care facilities, haematology services and psychiatric services. Tri-location ensures immediate access on-site to paediatric services when foetal or neonatal surgery or other interventions are required. The availability of these services helps ensure the delivery of an optimum safe service for mothers and their babies.

I assure the committee that Government policy on maternity services is evidence based. The model of stand-alone maternity hospitals is not the norm internationally and is no longer recognised as international best practice for future service development. Where other countries have reconfigured, the move has been to co-location and tri-location. In Ireland too, we are moving in that direction. Last May, I announced the Government's intention to relocate the National Maternity Hospital, Holles Street, to the St. Vincent's University Hospital campus at Elm Park. We also propose to provide a new maternity hospital on the St. James's campus, alongside the new children's hospital, and thus we will have a tri-located maternity, adult and pediatric facility. In the context of our move to the provision of bi-located and tri-located facilities, the acquisition of Mount Carmel as a stand-alone maternity hospital would represent a retrograde step.

I should also put on record my reservations regarding the low volume of births in the hospital. Best practice, and the development of excellence in patient care and safety, is predicated on a high volume of patient throughput. On the international front, there has been a clear move to close smaller maternity units and consolidate services into larger hospitals. As a doctor and as Minister for Health, my primary concern must be the provision of safe high-quality care to patients. Patient safety issues are issues on which we will not compromise. I assure the committee that the provision of maternity services in a small stand-alone maternity hospital or in a maternity unit within a non-acute setting does not constitute best practice or represent safest practice, and clearly does not provide the level of safety and quality that our patients need and deserve.

In considering the option to purchase Mount Carmel as a going concern, my officials examined the potential impact of the closure of the hospital on maternity service capacity in the greater Dublin area. The reality is that there has been a significant reduction in birth rates in Dublin, and in the rest of the country, in recent years. It is also relevant that the Central Statistics Office, CSO, projects that birth rates will continue to fall, at least until the early 2020s.

The latest draft information available from the HSE indicates that there were 25,877 births in the three Dublin publicly funded hospitals in 2013. Since the peak in Dublin in 2010, the number of births in Dublin public hospitals has reduced by over 1,900 births. In Mount Carmel in 2012, the most recent full year for which figures are available, there were 1,323 births, some of which were from outside the Dublin area. Thus, we can be confident that our maternity services have the capacity to deal with the additional demands on their services arising from the closure of Mount Carmel. This is borne out by the fact that within hours of the announcement regarding the liquidation of Mount Carmel, the three Dublin maternity hospitals made it clear that they had the capacity to treat maternity patients who had planned to give birth in Mount Carmel and invited mothers to be to contact them to arrange their transfers.

As Minister, I have responsibility to the taxpayer to ensure public money is used prudently. In view of the evidence of falling birth rates and the consequent falling demand for maternity services, allied to the need to provide maternity services where possible in co-located or tri-located hospitals, I am firmly of the view that the purchase of Mount Carmel as a going concern cannot be justified. Any available funding would be more appropriately used to resource our current maternity services to enable them to continue to provide safe, high-quality services rather than acquire a facility whose operation would be contrary to Government policy. There may, of course, be other potential uses for the hospital - for example, as a step-down facility or a short-term transitional facility for older people – and these options may be worth exploring. However, if we want to acquire the hospital for other such purposes, it would not make sense to purchase it as a going concern because, by so doing, we would expose the HSE to all contingent liabilities.

My Department, in conjunction with the HSE, is currently developing a national maternity strategy. This will provide the strategic direction for the optimal development of our maternity services to ensure that women have access to safe, high-quality maternity care in a setting most appropriate to their needs. Developing the strategy will provide us with the opportunity to take stock of current services and identify how we can improve the quality and safety of care provided to pregnant women and their babies. The strategy will ensure that, in the future, our services will be fit for purpose and in accordance with best available national and international evidence.

It would be unwise in advance of considerations regarding the future models of maternity service provision to make any decisions on maternity service capacity in any part of the country. I am aware that the HSE is continuing to work with the Mount Carmel Hospital group to ensure a seamless transfer of patients to alternative hospitals. We would endeavour to support staff in their efforts to find alternative employment. In that regard, I am pleased to note that some of the staff have already been offered employment and other hospitals.

There has been much commentary on the closure of Mount Carmel Hospital. It holds a special place in the hearts of many people, particularly those who have had their babies there. They are understandably sad that the hospital is closed. However, in considering the option to purchase the hospital, I had to make an evidence-based decision. The position is that the acquisition of Mount Carmel as a stand-alone, low-volume maternity hospital would not be in line with current policy on safe and high-quality maternity services. In view of falling birth rates, there is no evidence of a need to acquire additional service capacity. Buying the hospital as a going concern would, therefore, have unnecessarily exposed the HSE and the State to very obvious and significant financial risks. I am satisfied that we have taken the right decision and that we have done so for the right reasons. However, I must express again my concern for those who have worked in the hospital over the years and who provided such great service. We will do all we can to ensure that we find a place for them in our health services elsewhere. I am assured by Mr. Carter that, in respect of the former patients, including those who were in the hospital until recently, we have managed a seamless transfer in almost all instances. That work continues.

3:40 pm

Photo of Billy KelleherBilly Kelleher (Cork North Central, Fianna Fail)
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I thank the Minister for his response on this issue. A point that sticks out in his statement is that the hospital was seemingly assessed solely on the basis of its being viewed as a maternity hospital. There seems to be no further expansion of thinking in terms of capacity. We understand that best international practice in terms of maternity services points to tri-located or co-located services, at the very least. However, was there any due diligence procedure or assessment of the broader issue of the elective surgical procedures the hospital was providing? Quite a large number of public patients were contracted to the hospital through the NTPF and the special delivery unit in recent times. From March 2013 until the closure earlier this year, there was almost full occupancy. Therefore, there was quite a large throughput of non-maternity procedures. Nowhere in the Minister's statement did he refer to examining services beyond maternity services. One should bear in mind that only 25 beds in the hospital were being used for maternity purposes. The rest were used for elective surgery cases in respect of specialties and disciplines right across the spectrum. When the high-level examination to assess the feasibility of the HSE purchasing the hospital was carried out, did the high-level group engage in any due diligence exercise on the broader issues? Was the group just sent in to assess the maternity services alone? We will have to have some clarity on that.

I do not expect the Minister to wave magic wands in this particular area. Every Minister is obligated to ensure that taxpayers' money is spent wisely and efficiently. I will receive the usual reminders from the Minister on taxpayers' money being spent wisely, or otherwise, but one should consider this in the context of the fact that the Government is ramping up the purchase of elective surgery from the private providers. In recent days and weeks, we have seen a large increase in the purchase of orthopaedic services. There is certainly an issue of capacity in the public hospital system.

If one carries out any analysis of specialties in all elective areas in the public hospital system, leaving aside the emergency and maternity services, one realises there is a capacity issue. Consequently, we are purchasing from private providers continually. Am I missing something? Day in, day out, we are referring people to private hospitals for orthopaedic and many other services. Why is it the case if there is not a capacity issue in the public hospital system? One must bear in mind that commitments were made about new hospitals in the north east and all that flows from that.

Photo of James ReillyJames Reilly (Dublin North, Fine Gael)
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Not by me.

Photo of Billy KelleherBilly Kelleher (Cork North Central, Fianna Fail)
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People close to the Minister, therefore. There was a view that a new hospital was required for the north east given the downgrading of Navan hospital and Our Lady of Lourdes Hospital, Drogheda, which complemented Beaumont and others to the north of Dublin.

Photo of Caoimhghín Ó CaoláinCaoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)
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And Monaghan. Do not let the Minister off the hook.

Photo of Billy KelleherBilly Kelleher (Cork North Central, Fianna Fail)
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Monaghan also.

Photo of Jerry ButtimerJerry Buttimer (Cork South Central, Fine Gael)
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Deputy Ó Caoláin will get his chance; he should not worry.

Photo of Billy KelleherBilly Kelleher (Cork North Central, Fianna Fail)
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I will carry my burdens as well. We are talking about a 130-bed hospital. It had a very good track record, not only in the early maternity area. Even accepting that it is not Government policy or best international practice to have stand-alone small maternity units, the issue of elective surgery must be considered. Such surgery was being provided continually. One should also bear in mind that the vast majority of the elective surgical procedures concerned public patients contracted through the NTPF or the special delivery unit. When the Minister addressed us today, he did not make reference to that other than by making reference to the issue of maternity services. Could we have clarity on that?

Although the Government states there is joined-up thinking and that silos have been removed, and while there are buzzwords floating around, any quick analysis of the actual cost to the State in terms of job losses and the consequent impact on the social welfare budget and the subsequent loss of revenue, combined with an analysis with regard to NAMA, debt write-down, interest rates, and purchase of the facility as a going concern demonstrates we are down, demonstrates it is no longer a question of tens of millions of euro but of a few million euro here or there.

Did the Department look at the offers that were put on the table, including the Barry proposal and the Centric proposal? Did the Department have any discussions with NAMA about how this service could be maintained for a period? Unless NAMA can tell us otherwise - even though it has decided not to come to the committee - it seems to be accepted that the projections were that it would reach profitability towards the end of this year. Perhaps we can get some clarity on that.

The key issue is whether this high-level group's examination to assess the feasibility of a HSE purchase of the hospital was just based on maternity issues alone.

3:50 pm

Photo of Caoimhghín Ó CaoláinCaoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)
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As the Minister well knows I have no particular fondness or brief for private health care. I have made that patently clear to the Minister over the years. However, I have to recognise that in the context of the current configuration of the hospital network, Mount Carmel was playing an important and useful role. The loss of its facilities is therefore a loss to the structure of delivering hospital and acute services.

In his contribution the Minister spoke of Mount Carmel as if it was wholly and solely a maternity facility. He only spoke of it in that context and at no time did he allude to the range of other services that it has provided. I understand that they include: orthopaedics; ear, nose and throat; paediatrics; and a range of surgical procedures that were carried out at that hospital. Only a proportion of the 130 beds in the facility were designated for maternity purposes.

As regards the role of NAMA in all of this, my understanding was that it had a social responsibility but it does not appear to have employed it in this particular instance. I am told that St. James's Hospital had plans for Mount Carmel and envisaged the transfer of patients and services from St. James's, thus increasing capacity at the latter hospital, while the site designated on that campus was being developed for the new national children's hospital. Are there consequences arising from the NAMA decision concerning Mount Carmel and the development of the children's hospital?

The Minister also said he envisaged a new maternity hospital on the same St. James's campus alongside the new children's hospital. I have not had the opportunity to visit the site and can only accept what the Minister has told me. Other voices that are familiar with it would even question that it has the capacity to take a new national children's hospital, let alone a maternity hospital in tandem at the same location. Perhaps the Minister could elaborate on that.

I am also anxious to know about the HSE's engagement with NAMA. This is very important. I am told that the HSE had discussions with NAMA without briefing St. James's, even though the HSE and the Minister would know that St. James's had a specific interest in the Mount Carmel facility. In the course of those discussions the HSE representatives sought to present themselves as speaking on behalf of St. James's. Will the Minister revisit all of this with NAMA, the HSE and St. James's so that we can establish the full truth and the full facts concerning the various engagements that took place, including St. James's with NAMA and the HSE with NAMA? Why was there not the same overlap in terms of the HSE and St. James's? There appears to be a significant deficit there in terms of engagement. That is coming directly from sources within these entities, particularly St. James's.

Will the Minister comment on the view that has been repeated time after time that the Mount Carmel facility was expected to return to profit this year? All the indicators suggest that is the case, so could that not have prompted a different response to the one that materialised?

At our meeting immediately prior to the Minister's attendances, the INMO's representatives made a number of recommendations and would like us to press the Minister on them. One of the recommendations is to re-explore with NAMA why it did not take on board the health care implications of the decision to move as they did against Mount Carmel, rather than solely the financial considerations. The Minister has not ruled out the reopening of the site as a health care facility, while indicating other roles it might have. Will he please elaborate on that? Can the Minister have discussions with St. James's to see if it can conclude its plans to operate the site, as it had developed them? I am told that it had intended to do so.

Of Mount Carmel's 382 staff, some 205 were nurses. The Minister said he was pleased to note that some of the staff have already been offered employment in other hospitals. My understanding was nursing and midwifery were not among the exempted grades. Will the Minister indicate what numbers and what hospital sites we are talking about? With the ongoing employment embargo how is it possible? If Mount Carmel is not going to resume providing services as heretofore, can we ensure that the displaced nursing staff and other staff will be facilitated within the network of hospital sites?

Will the Minister take on board preferential treatment arrangements for staff at Mount Carmel to ensure, as the INMO wishes, that their service is reckonable in the public superannuation scheme? I would be grateful for the Minister's replies to those questions.

Photo of Colm BurkeColm Burke (Fine Gael)
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In his presentation, the Minister mentioned the hospital being used as a step-down facility. Have we advanced that research at this stage? A recent report indicated that people with dementia who are returning home had an average stay in hospital of 22 days, whereas those who were getting nursing home places had an average stay in hospital of 59 days. In view of that, there is an urgent need to examine step-down facilities. Have we made an advance on this issue concerning Mount Carmel? The figure of 59 days is more than eight weeks in hospital, so there is a huge cost factor to the State. A stay in hospital costs roughly a minimum of €6,000 per week. In that context, perhaps Mount Carmel could be used as a step-down facility for the greater Dublin area.

4:00 pm

Photo of James ReillyJames Reilly (Dublin North, Fine Gael)
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On Deputy Kelleher’s points, I referred in my speech to other considerations. We have discussed the maternity end of this because Mount Carmel was the only private maternity hospital, whereas there are many other private hospitals dealing with the general medical care. It is important we deal in facts. In 2004, there were 16 private hospitals in the Republic of Ireland. Today, there are 21. There is plenty of capacity. The National Treatment Purchase Fund and the SDU, special delivery unit, used Mount Carmel to ensure outpatients did not wait untimely lengths for treatment and there were plans to use it again. There is no shortage, however, of capacity in the private sector to take up the slack. Apart from that, Mount Carmel provided medical paediatric and surgical services in a range of areas including orthopaedics, ophthalmology, gynaecology, endoscopy and ear, nose and throat. As I said, there are plenty of other providers to cover that capacity.

During 2013, the HSE secured additional treatment capacity in Mount Carmel, as well as in other public and private hospitals. However, the number of treatments outsourced to these facilities represents less than 1% of the total number of annual scheduled outpatient appointments and less than 0.5% of the total number of inpatient and day-case appointments undertaken nationally. Obviously, there is no shortage of capacity and there is no need for any concern in that regard. The HSE will continue to avail of the support and services offered by other public and private facilities where capacity is required and available. It is considered that other hospitals will be in a position to take the proportionate cases previously outsourced to Mount Carmel.

We will explore the use of the site as a step-down or short-term transitional facility for older persons. It will take some time to do that, however. The HSE is already examining it but at this stage it is not clear whether Mount Carmel can offer what is needed. To establish this would require a full assessment including appropriateness of accommodation, availability of staffing, ability to provide the required services to be determined, as well as outcomes, costs and timescales to commence the delivery of services. It is certainly part of our desired armamentarium that we want to have such facilities in highly populated areas where people can continue their recovery having had their acute medical condition addressed, rather than sitting in a hospital bed at great expense, as Senator Burke pointed out. It is important they would get the type of service they need because historically they did not. Once their medical treatment was over, that was it. They did not get the physiotherapy, occupational therapy or speech and language therapy they needed that could have resulted in many of them living an independent life at home. Sadly, if the opportunity passes, then they are destined for long-term care which all members will agree is not acceptable. As we all know, no matter how nice a place is, there is no place like home.

Discussions with NAMA were raised. The Department and the HSE would have had discussions with NAMA. However, it is a business decision by NAMA as to what it does with this facility. The hospital was losing money on a weekly basis. Contrary to what several members claimed that it was on target to make a profit at the end of this year, my understanding is that it was on target to lose over €1 million. This could not be sustained.

I do not believe the VHI should be determining the market. If a private hospital comes on-stream that has the appropriately qualified staff and facilities, there is no reason it should not be insured to treat insured patients. However, if it goes out of business, it has to be a matter for it. The VHI cannot be expected to support it, nor the Government. As I pointed out already, we had only 16 private hospitals in 2004 while today we have 21 plus Mount Carmel. It would not be fair to say that private medicine is disappearing off the face of the health landscape.

It was claimed that concerns have been expressed about the national paediatric hospital which we are not discussing today. However, I want to set down a marker in this regard. The Government has made its decision and it is not resiling from it. Those voices of concern want it built elsewhere. I am happy that the Government has made the right decision and that St. James’s is the right place for the hospital. It has more than enough space to accommodate the hospital planned, as well as the maternity hospital. Neither is there any planning danger with the expansion of this site and the additional grounds bought at another location.

Deputy Ó Caoláin referred to the recruitment embargo affecting midwifery services. We always said the embargo would be operated in a flexible fashion to get the right skills mix. Last year, we recruited over 700 nurses to the health service. Those with particular expertise in theatre, ICU and midwifery are much sought after. I believe the nurses in Mount Carmel with these skills will be quickly taken in by other hospitals. We also have 200 more general practitioners in the GMS than we had four years ago, as well as 200 more consultants. The health service is trying to get its skills mix right and focus on the right people delivering the right care in the right place at the right time to the right sort of patient. In other words, this is about treating the patient at the lowest level of complexity that is safe, timely, efficient and as near to home as possible.

We do have a problem in urban areas with delayed discharges and patients not being able to get the precise treatment they need to recuperate properly while other acutely ill patients are unable to access a bed because it is occupied inappropriately. This is to the detriment of the patient who is delayed. This is what we are addressing through the frail elderly programme put in place by the clinical probes.

Photo of Billy KelleherBilly Kelleher (Cork North Central, Fianna Fail)
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Has the Department done an analysis of what is required for step-down and transitional facilities in the greater Dublin area? There are still difficulties in some hospitals with regard to discharges, meaning people are in hospital for too long. Mount Carmel had surgery and post-surgery facilities. One would assume it could cater for step-down and transitional care with little conversion or capital expense, other than the purchase of it. With HIQA’s further assessment of step-down facilities and community nursing homes, there could be pressure on beds in the greater Dublin area in a year or two. Has the Department or the HSE looked at Mount Carmel providing a solution to these imminent problems?

Photo of Caoimhghín Ó CaoláinCaoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)
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On St. James' interest in the Mount Carmel facility, I asked specifically about HSE discussions with NAMA that had not been advised to St. James’s. I have been advised that the HSE voices endeavoured to present themselves as speaking for St. James’s. There is a serious matter there.

I have asked the Minister whether he will address this matter and explore the detail of this with NAMA, the HSE and St. James's Hospital. Will the Minister inform himself in respect of the interest of St. James's Hospital specifically allied to the development of the new national children's hospital and be supportive of any interest that St. James's Hospital would have in the Mount Carmel facility?

In his address, the Minister said "we would endeavour to support staff in their efforts to find alternative employment." How is that being done? What type of supports are being offered to staff who had formerly worked in Mount Carmel and now find themselves out of employment? Does the Minister have the facts regarding the staff who have already been offered employment in other hospitals? How many of them are there? What hospitals are we talking about? It would be very informative and worthwhile to share that with the committee.

4:10 pm

Photo of James ReillyJames Reilly (Dublin North, Fine Gael)
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In response to Deputy Kelleher, we are very much interested in and open to the idea of Mount Carmel becoming a step-down facility. The HSE is looking into that. I do not like alluding to it as a step-down facility. What is envisaged if we were to purchase it is a facility that would have some transitional long-stay services but would focus more on rehabilitation and on getting people back home. If older people who are frail and become ill are in bed for even 48 or 72 hours, they can stiffen up and lose a lot of function and it takes quite a bit of effort to get them mobilised again. It can be done and in a large number of cases, people can go home and continue to live independent lives, albeit with certain supports.

The Deputy used the word "assume" and, of course, I am reminded of my son who when he was 14 explained what "assume" can do to one. It can make an ass out of you and me. We are not assuming anything. We will examine it and have very clear idea of what is involved in transposing this into the sort of facility that we feel best serves the health services' requirement to serve our citizens.

In respect of St. James's Hospital and NAMA, I must lay down a marker. The HSE has the right to negotiate in these situations - not individual hospitals. We could end up with a situation where St. James's, St. Vincent's and Tallaght have their eye on it. I know that St. James's might have had an interest in it and still does but it does not have funding to run it the way it was as a going concern. Things remain on the table from the point of view of this facility being used again as a health facility. No one hospital will have a say over how that is done or used. The HSE as a national entity and the Department of Health will determine the policy in respect of how to best serve the people of the greater Dublin area in respect of a facility of this nature - not one single hospital. I lay down that marker loud and clear, particularly given the situation we have had in respect of section 38 agencies and their non-compliance with public pay policy.

Deputy Ó Caoláin was asked about staff and how they are being supported so perhaps Mr. Carter from the HSE could give him a précis on that.

Mr. Ian Carter:

For the past three weeks, there has been direct engagement from at least three hospitals with Mount Carmel, in particular looking at midwives, theatre nurses, etc. That dialogue was still ongoing recently and has been fairly proactive in terms of securing potential people to transfer to St. James's, St. Vincent's and Our Lady of Lourdes Hospital, Drogheda. There is still live debate with those individual nurses. Can I give the Deputy an exact number of people who have definitely been offered contracts at this stage? The answer is "No" but as I said, there has been quite strong engagement for the past three weeks.

Photo of Caoimhghín Ó CaoláinCaoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)
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Regarding the latter comment, it is nothing to do with any of these other section 38 and section 39 issues. It relates to how St. James's will be able to facilitate its ongoing work responsibilities while the construction of the new national children's hospital would be underway. That was the primary interest it had in Mount Carmel. That is something that surely the Minister would be either already informed of or interested in.

Photo of James ReillyJames Reilly (Dublin North, Fine Gael)
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I am fully informed of and very interested in it, which is why I am fully informed of it. I am fully informed of the fact that there is a 50-bed unit in Inchicore to which St. James's has access in order to address the issue referred to by the Deputy. I am also fully informed of the fact that there is planning permission for an eight-storey building in order to allow for the decanting of services off the site to clear it and that this was achieved in eight weeks, which is great credit to the people in St. James's. However, I stand over what I say. The HSE is the authority here - not any individual hospital or hospital management. The HSE must act in the best interests of all of Dublin, not just one particular catchment area. That is not a thing I say lightly but I will not apologise for saying it either.

Photo of Caoimhghín Ó CaoláinCaoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)
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It is not only a Dublin facility nor would it be.

Photo of Jerry ButtimerJerry Buttimer (Cork South Central, Fine Gael)
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That concludes our deliberations. I thank the Minister, Mr. Carter, Ms Conroy and Ms Regan for coming before us. I also thank the representatives of the Irish Nurses and Midwives Organisation for being here earlier.

The joint committee adjourned at 4.36 p.m. until 9.30 a.m. on Thursday, 20 February 2014.