Margaret Conlon (Cavan-Monaghan, Fianna Fail)
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I thank the Ceann Comhairle for the opportunity to speak on this very important issue both for the people I represent in County Monaghan and myself. For the past 30 years the people of Monaghan have had the dark cloud of an impending hospital closure hanging over their heads. In the 1980s, the Minister for Health at the time, Barry Desmond, used the famous phrase that he wanted to close and dispose of the hospital. That was not what we wanted then and it is certainly not what I want now.

I want to see an enhanced role for the hospital in Monaghan in providing services which it is competent in delivering and which the people would have faith in using. Monaghan's medical unit is second to none under the expert guidance of the consultant, Dr. McMahon, and it should continue to provide such services.

I have no objection to changing for the better and standing still is not an option. If change is something to be embraced and not feared, it must be managed properly. Since I was elected and before that, I have believed that in order to effect change in a real way one has to work within the system. However, the level of engagement and consultation with the HSE has been disgraceful and with the proposed changes as of 22 July, the level of meaningful discussion has been unacceptable.

I never at any time made promises on the hospital which I felt I could not deliver and I always knew this would be an uphill battle. Nevertheless I pledged to do my best. Although I was tempted many times to use the media to create the impression of over-the-top activity on my behalf, I never chose to do so. I regret that the system has failed me and the HSE has moved on without any involvement or input from me.

Since being elected I have endeavoured to do my best and I will continue to do so. The proposed measure as the HSE sees it is "a replacement with a safer, superior alternative" but I do not see it that way. The HSE are masters at changing the goalposts when it suits.

The medical assessment unit in Cavan is working well but there is chaos in Our Lady of Lourdes Hospital in Drogheda, with patients on trolleys and long waiting times for assessment and admissions. There was nobody on a trolley in Cavan yesterday or today but Drogheda is more than making up for that. There are patients on trolleys today and there were patients on trolleys yesterday. I can guarantee that there will be patients on trolleys tomorrow. Is that a better service? I think not.

I have always been consistent in saying that systems must be in place, bedded in, tried and tested so that people can have confidence in any newly reconfigured services. I am disappointed that over the past few weeks there has been much political game playing and scurrilous personal attacks; there is no place for such abuse in any debate. I regret that we came to that level.

Tonight I appeal to the HSE not to proceed as proposed on 22 July as it is too soon. Not everything is in place and there has been a lack of consultation and engagement by the HSE. It has not had the full benefit of the wisdom of GPs and Dr. McMahon and other stakeholders. If the HSE treats the GPs in the same manner as the elected representatives, it is no wonder it has no engagement.

My major fear is that the HSE will not have all its i's dotted and t's crossed by 22 July and something will go wrong to compromise patient care and safety. I will hold Professor Brendan Drumm and the management of the transformation team in the north east responsible and accountable for any failings or shortcomings that have a negative impact on any patient. I guarantee that I will watch their every move every step on the way.

Seymour Crawford (Cavan-Monaghan, Fine Gael)
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I thank the Ceann Comhairle for allowing this issue to be discussed by the four Deputies from County Monaghan. I am very disappointed that the Minister for Health and Children, Deputy Harney, did not see fit to be here tonight. I hope this Minister of State will give us a positive reply.

I welcome the statement in The Irish Times by Deputies O'Hanlon and Conlon indicating that they are against the transfer of services on 22 July 2009 but what have they done in the past few months and years to change the decision of the Minister for Health and Children, Deputy Mary Harney, and the present and previous taoisigh, who worked with the HSE to remove the services from Monaghan General Hospital? The Minister did everything possible to close down the hospital before by using the tragic death of Pat Joe Walsh, who should never have been removed from the hospital in Drogheda. During the period when the hospital was off-call, up to 17 lives were lost.

Who is charge of the health service and runs the budget? Has she any role in how that is administered? If she does not, is there any role for Deputies in Government at all? We have heard Deputy Conlon say that she has worked hard behind the scenes but the Minister is in charge and not Professor Drumm. Professor Drumm is answerable to the Minister.

Earlier I submitted questions to the Minister and I hope the replies are available. Has the transfer of services from Monaghan General Hospital been discussed and agreed as safe with Monaghan GPs? Has it been discussed with consultants in the hospital? What evidence does the Minister have that what is being done is safer and better than the service currently available? Can primary care teams deliver a replacement service and is there any in place in Monaghan?

Will the Minister comment on why the advice of Teamwork is being ignored when it was paid to provide such advice? It clearly indicated that the services at Monaghan should not be removed until the new regional hospital is in place. Does the Minister accept that the current project is being spearheaded by management structures without any medical expertise?

Some €17 million was spent on Monaghan General Hospital in repair and restructuring. I make no apology for reminding the House that on the day the Minister for Agriculture, Fisheries and Food, Deputy Smith, officially opened the two brand new, state-of-the-art wards, I organised a protest at the gates - in which I was supported by the party I represent, Fine Gael, Sinn Féin and the Monaghan General Hospital Alliance - because we learned that at the same time that these wards were being opened, a top-quality female medical ward was being dismantled and state-of-the-art beds were being dumped in storage. This meant that 25 beds were removed from service.

The new proposal put forward by the HSE, which is supported by those who represent the main Government party - including the Minister for Agriculture, Fisheries and Food, Deputy Smith, and Deputies O'Hanlon and Conlon - is that the two wards opened in September 2007 be dismantled, at a cost of €6 million, and be turned into two 13-bed units for rehabilitation and respite.

I beg the Minister for Health and Children, at this late stage, to intervene with the HSE in order to put a stop to the lunacy of taking our hospital off call. This hospital is capable of providing a good service and closing it is unwise, unsafe and unjustified. The four Oireachtas Members who represent the constituency were recently brought to see the new state-of-the-art ambulances at the paramedic unit that is due to replace the hospital. However, I must highlight the fact that in the past number of weeks it took an ambulance 45 minutes to reach the site of an accident at Knockatallan. This accident involved a lorry and took place on the main national primary route which runs from Donegal to Dublin. The paramedics were contacted first but the ambulance arrived before them.

We have been promised that the new service will be state-of-the-art. Deputies O'Hanlon and Conlon should ask the Taoiseach who is in charge of the HSE. That organisation is not completely without attachment to the House. We must ensure that it is accountable to the Dáil.

Rory O'Hanlon (Cavan-Monaghan, Fianna Fail)
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This matter relates to patient care; it is not about party politics or any other agenda. I did not oppose the transfer of services in circumstances where I accepted that a better and safer service was being provided. This is not the case with regard to the announcement of 8 June.

Monaghan General Hospital has an excellent acute medical service, which provides for approximately 80% of patients' needs. I recognise that major improvements have taken place in the provision of services in our region. I refer, for example, to the medical assessment unit in Cavan and the enhanced ambulance service, to which Deputy Crawford referred, in Monaghan and Castleblaney.

What is being implemented will result in patients travelling 30 to 50 miles and I am not satisfied that sufficient additional facilities have been put in place in Cavan or Drogheda to cope with the increased numbers that will come from County Monaghan. Where an appropriate level of service can be provided at Monaghan General Hospital, then it should be provided. It is important to recognise the level of services that will continue at Monaghan General Hospital. The two wards to which Senator Crawford referred will be used in an extremely efficient manner to, for example, facilitate patient rehabilitation.

Seymour Crawford (Cavan-Monaghan, Fine Gael)
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The ward in Cavan has been closed.

Rory O'Hanlon (Cavan-Monaghan, Fianna Fail)
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A wide range of outpatient services, including day surgery, ear, nose and throat services and a number of investigative procedures, will continue to be provided. More people attend outpatient clinics than are admitted to hospital.

I urge the Minister for Health and Children to ensure that an adequate CT scanner is put in place at Monaghan General Hospital. It is important that the hospital should have all the state-of-the-art facilities necessary to assist in the provision of services. I made that point to Professor Drumm last night when Deputy Conlon and I discussed the issue with him at a meeting which lasted an hour and a half.

We must move forward from where we are and not from a point at which we would like to be. Medical patients, particularly elderly people who are affected by conditions such as pneumonia, asthma, strokes and mild heart attacks, should continue to be treated at Monaghan General Hospital because this would mean that they would be near to home and their relatives. In order to achieve this, I would like the Minister for Health and Children to request the Health Service Executive, which has the ultimate responsibility in this area-----

Seymour Crawford (Cavan-Monaghan, Fine Gael)
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It is the Minister who has that responsibility.

Rory O'Hanlon (Cavan-Monaghan, Fianna Fail)
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The operation of the services is the responsibility of the HSE, not the Minister. It is time we moved away from adversarial politics-----

Seymour Crawford (Cavan-Monaghan, Fine Gael)
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What happened at Roscommon?

Rory O'Hanlon (Cavan-Monaghan, Fianna Fail)
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-----and stopped blaming the Minister for things for which she has no responsibility.

Seymour Crawford (Cavan-Monaghan, Fine Gael)
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I tried to do that for years and it did not work.

Rory O'Hanlon (Cavan-Monaghan, Fianna Fail)
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What we should do is come together in order to achieve a resolution.

I ask that the Minister for Health and Children request that the Health Service Executive work with elected representatives, those who represent the hospital staff, GPs and patient representatives in order to consider the options that exist in order to ensure that the level and quality of health care will not be compromised. We must ensure that the elderly people to whom I refer will continue to be treated at Monaghan General Hospital.

Caoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)
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On this morning's Order of Business, the Ceann Comhairle characterised the axing of services at Monaghan General Hospital as a constituency matter. With respect, I must correct the Ceann Comhairle and say that it is a national matter with consequences for hospitals throughout the country. Monaghan is the blueprint for this Government's policy of slashing services in local hospitals. What it is doing to Monaghan now it plans to do to other hospitals in Dundalk, Navan, Nenagh, Ennis, Tralee and Cork, with still more likely to follow. These are ultimately political decisions.

I have been reliably informed from within the HSE that the Taoiseach, Deputy Cowen, and the Minister for Health and Children, Deputy Harney, were closely involved in the decision to axe these services from 22 July next. Let us consider the timing involved. The HSE signalled that these services were to go in November 2008. It then decided that the closure would not happen until the start of this year. Finally, a date in early summer was identified as apt for their disappearance. However, the local and European elections loomed and the axe was hidden until polling day passed. That axe was merely being sharpened and, lo and behold, two days before the Dáil goes into recess until September, the announcement was made that it will finally fall on 22 July.

This represents nothing short of a health care disaster for the people of counties Monaghan and Cavan and areas beyond. It flies in the face of all appeals from front line health care workers - including nurses, GPs, consultants and support staff - and from people of all political affiliations and religious beliefs. From 22 July, lives will be at risk, day and night, because we will lose vital hospital services, including emergency services and inpatient medical care. Lives were lost when Monaghan General Hospital was off call for emergencies in the past and now another fatal date has been set.

Deputies Conlon and O'Hanlon pointed out that all the promised support services due to be put in place before the axing of acute care at Monaghan have not, in fact, been put in place. That is true but I will return to those Deputies in a moment.

Even if all the promised supports were put in place, this would still not make the execution of Monaghan General Hospital acceptable or safe. In the HSE's confidential so-called transformation planning document of April 2008 - I revealed this fact at the time - "rehab/respite/step-down" facilities are described as "alternatives to acute inpatient care". Of course, they are no such thing.

The decision announced yesterday represents an attack on the health services by this Fianna Fáil-Green Party Government and a betrayal of the people by the members of Fianna Fáil who represent Cavan and Monaghan, namely, Deputies Conlon, O'Hanlon and Smith. Deputies Conlon and O'Hanlon shed crocodile tears here this evening but this morning they voted with the Government and could not bring themselves to abstain in the vote I called in order to allow all Deputies to register a protest at what is being done to Monaghan General Hospital. The Deputies opposite had an opportunity to make a difference but the vote was defeated by 70 votes to 68.

Margaret Conlon (Cavan-Monaghan, Fianna Fail)
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That was a vote on the Order of Business. It had nothing to do with Monaghan General Hospital.

Rory O'Hanlon (Cavan-Monaghan, Fianna Fail)
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It was a vote on the Order of Business.

Caoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)
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If the Deputies had abstained, the Government would have been defeated in the vote.

Margaret Conlon (Cavan-Monaghan, Fianna Fail)
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There was no vote on Monaghan General Hospital

Caoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)
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As a result, the issue of Monaghan General Hospital would have been catapulted to major national attention.

Deputy Conlon mentioned scurrilous attacks. I wish to refer to just one such attack which I heard this evening on the "Drivetime" programme on RTE radio, when Deputy O'Hanlon actually had the gall to blame those courageous people who have campaigned in defence of the hospital for the removal of services. Apparently, we should all have remained quiet while our betters decided what was best for us. Those days are long gone. Deputy O'Hanlon and his colleagues should hang their heads in shame because their inaction has helped bring about this mortal attack on a hospital that has served generations of the people of County Monaghan and served them well.

The Minister for Health and Children is not present in the House.

She, like the Taoiseach, had escaped before the announcement was made yesterday and Professor Brendan Drumm had wrapped up his opportunity the previous morning before the Joint Committee on Health and Children. As for the Minister of State, who is the messenger of the Minister-----

Charlie O'Connor (Dublin South West, Fianna Fail)
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Excuse me Deputy-----

Caoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)
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I will conclude on this point.

The Minister of State and her colleagues on the Government benches must deliver a single clear message to the Minister for Health and Children and to the Taoiseach. They should make no mistake about it and should not become relaxed on this issue because this fight is not over.

Áine Brady (Kildare North, Fianna Fail)
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I am replying to this Adjournment matter on behalf of my colleague, the Minister for Health and Children, Deputy Mary Harney.

At the outset, I note the fundamental objective of Government health policy continues to be to maximise the health status of the population. The Government is committed not only to ensuring the delivery of the best quality health services possible, but to doing so in an effective and efficient way. Ensuring patient safety is paramount in order that people can have confidence in the services and the best possible patient outcomes can be achieved.

The transformation programme for the north-east region involves widespread and fundamental change. It is designed to build a health system that is in line with the model of care emerging internationally. This can be achieved by centralising acute and complex care in order that clinical skill levels are safeguarded by ensuring access to a sufficient throughput of cases. This was highlighted, along with crucial patient safety and quality of care issues, in the 2006 Teamwork report to the HSE. The Teamwork report demonstrated that the service configuration in the north east was unsustainable. I am glad to have the opportunity this evening to explain clearly what the changes will involve and to offer reassurance that they can bring significant improvements in the services available.

As part of the transformation programme for the north-east region, all acute medical services will be transferred from Monaghan hospital to Cavan hospital on 22 July 2009. As part of the Cavan-Monaghan Hospital Group, Monaghan hospital will continue to play an important and expanding role in the provision of non-acute health services to the people of counties Cavan and Monaghan.

As the newly appointed clinical director for the Cavan-Monaghan Hospital Group, Dr. Hayes, stated on radio yesterday, there have been significant improvements in acute hospital services provided to Cavan and Monaghan over the past five to ten years and this transfer is part of the ongoing development of the services for the people of the area. He made the point that the Cavan medical assessment unit provided better, safer and significantly easier access to acute hospital services in the Cavan-Monaghan area.

Seymour Crawford (Cavan-Monaghan, Fine Gael)
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Tell that to the people.

Áine Brady (Kildare North, Fianna Fail)
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A medical assessment unit, MAU, which is consultant-led, opened in Cavan hospital on 30 March 2009. It provides a fast-track alternative to the emergency department for patients who require an urgent medical assessment. Patients can be referred directly by their GP to the medical assessment unit. Since the introduction of the MAU, the average waiting time for full medical diagnosis has reduced from eight hours to three hours. This unit is assessing patients and putting in place appropriate treatment plans that include admission to a medical bed. However, the reduction in diagnosis times is facilitating an increased level of discharges. As a result, this MAU has freed up bed capacity in Cavan hospital.

A new 24-hour observation ward, which is managed by emergency department consultants, has further reduced the Cavan hospital inpatient bed requirement. This observation ward will also reduce surgical admissions in Cavan. An admissions lounge, which is a new six-bedded ward, is now also in place in Cavan hospital. It is aimed at ensuring that no patient from the MAU, observation ward or emergency department will be obliged to wait on a corridor.

Seymour Crawford (Cavan-Monaghan, Fine Gael)
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Great.

Áine Brady (Kildare North, Fianna Fail)
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This ward is close to the MAU and the observation ward. If a patient in either of these services requires admission, he or she will be transferred to this ward until a bed in the main hospital becomes available.

My Department is informed by the HSE that it has no plans to close the Pathways rehabilitation unit service.

Seymour Crawford (Cavan-Monaghan, Fine Gael)
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It has been closed for months.

Áine Brady (Kildare North, Fianna Fail)
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However, because of a number of recent staff retirements at the Pathways unit, patients from the unit are currently being accommodated in the Lisdaran unit for the elderly, which is located within the same building. These patients are receiving the same level of intensive rehabilitation therapy within the Lisdaran unit-----

Seymour Crawford (Cavan-Monaghan, Fine Gael)
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Total and absolute rubbish.

Charlie O'Connor (Dublin South West, Fianna Fail)
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Please, Deputy.

Áine Brady (Kildare North, Fianna Fail)
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-----as they had received prior to their relocation from the Pathways unit.

Seymour Crawford (Cavan-Monaghan, Fine Gael)
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I was there and saw it.

Áine Brady (Kildare North, Fianna Fail)
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In the meantime, the HSE is trying to source staff nurses with a view to restoring the service at the unit as soon as possible.

Seymour Crawford (Cavan-Monaghan, Fine Gael)
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Does the Minister of State expect Members to believe that?

Áine Brady (Kildare North, Fianna Fail)
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As the Deputies will be aware, the Pathways unit has been playing a key role in providing an intensive rehabilitation service to patients from counties Cavan and Monaghan who are recovering from an episode of acute illness such as stroke, amputation, a road traffic accident or acquired brain injury.

Under the new arrangements, Monaghan hospital will have a minor injuries unit. This unit will now treat adults and children over the age of five years who present with minor injuries between 9 a.m. and 9 p.m. seven days a week. These minor injury patients will receive the same service in Monaghan hospital as they do on the other sites with a targeted turnaround time of one to two hours. Day surgery, medical day services and X-ray diagnostics will remain at Monaghan hospital. Outpatient services in medical, surgical, ear nose and throat, diagnostic urology, paediatrics, obstetric and gynaecological specialties will also stay at the hospital. Furthermore, 26 rehabilitation and step-down beds will be retained in Monaghan.

My Department is informed by the HSE that it is committed to putting in place an appropriate computed tomography, CT, service at Monaghan hospital. Having carried out a detailed option appraisal, the HSE established that best value can be obtained by putting in an upgraded CT scanner rather than reusing the former Cavan hospital scanner, which is in storage at present.

Seymour Crawford (Cavan-Monaghan, Fine Gael)
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That has been the case for ten years.

Áine Brady (Kildare North, Fianna Fail)
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An upgraded scanner will require less infrastructural works, will incur lower service charges, will include a free parts replacement guarantee and will allow advantage to be taken of a trade-in discount on the existing scanner. The HSE is extremely mindful of the relatively low volumes of scans likely to be a feature of this service and will tailor both the service configuration and the clinical governance arrangements accordingly to ensure that any issues related to expected volumes are appropriately managed. As a minimum, this will involve the CT service at Monaghan hospital operating within an overall single radiology department for Cavan and Monaghan hospitals, with appropriate rotation of radiography CT staff between the main CT service at Cavan hospital and the Monaghan hospital site to ensure skill levels and clinical competencies are maintained. It is anticipated that this service will operate within existing staffing levels and should be operational by late September or early October.

I wish to assure the House that there will continue to be a significant role for each of the acute hospitals in the region. Rather than operating largely independently of each other as at present, they will come together to enable the provision of a comprehensive integrated service. We need to recognise that the way in which hospital services are provided is changing rapidly and a growing proportion of care can be provided on a day basis without the need for overnight stays. I appreciate that people are concerned about services to deal with those who fall seriously ill or who are involved in an accident in areas further away from Cavan hospital. Pre-hospital care is the key to quality emergency and trauma management, regardless of hospital configuration. There always will be people who live considerable distances from any hospital and the key is to ensure that pre-hospital services are put in place that enable life-saving treatment to be provided quickly to such patients.

Medical evidence demonstrates that stabilising a patient should commence as rapidly as possible for someone who has suffered significant trauma. In the case of a road accident, this should happen at the roadside and be carried out by advanced paramedics. All the evidence demonstrates that people with severe injuries are best dealt with in large hospitals with a range of specialist teams to deal with serious injuries to different parts of the body. Ambulance services for Monaghan and Cavan already have been enhanced to include an additional emergency ambulance. This is in addition to two existing emergency ambulances based at Monaghan ambulance station. An intermediate care vehicle will also be based there for the transportation of non-emergency patients between hospitals. Advanced paramedics have also been deployed in a rapid response vehicle on a 24-hour, seven day a week basis to provide the population of Monaghan with access at the scene to life-saving treatments including blood and anti-clot treatment.

Ten posts were identified to deliver a significantly increased number of care packages in the community. Nine staff are in place at present, with the tenth person expected to be put in place shortly. These care packages will support the Cavan and Monaghan hospitals, further relieving the pressures on acute hospital services in the area. The HSE is managing the change process in Cavan and Monaghan through a network of subgroups. The HSE has stressed the importance of the involvement of all relevant stakeholders in this process and the HSE has sought the participation of general practitioners on a number of the subgroups particularly in respect of the development of the medical assessment unit in Cavan.

The sub-groups are being supported by specialist risk advisers to ensure that the change process is managed smoothly and, in particular, with a view to ensuring that any associated risks or challenges are identified and addressed in advance of any service changes. The HSE has reiterated that it has and will continue to seek engagement with GPs on this issue. Last week, the HSE held two sessions with GPs and work will continue to help ensure the GPs involvement, which is required for a well-integrated service linking hospitals and the community.

The HSE is due to issue an information leaflet to all households in Monaghan shortly to advise them of the minor injury unit. Advertisements are due to be placed in local newspapers in Cavan and Monaghan next week to remind the public of the new arrangements. The emergency unit consultants wrote to GPs in Cavan-Monaghan, on behalf of the HSE, on 7 July 2009 to outline the referral process and the inclusion and exclusion criteria to them for the proposed minor injury unit at Monaghan Hospital.

It is frequently alleged that the Government and the HSE want to downgrade smaller hospitals, principally to save money. This is not so. There is an abundance of expert medical advice that small hospitals with low patient volumes should not continue to provide complex care.

Seymour Crawford (Cavan-Monaghan, Fine Gael)
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We were never offered that.

Áine Brady (Kildare North, Fianna Fail)
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Patient safety, as a guiding principle for change, is aimed at achieving the best outcomes for patients. The best outcomes for the population will be achieved when complex care is provided in specialised centres where all of the necessary expertise, which is maintained by way of day-to-day experience in treating a range of patient's problems and facilities, is immediately available. At the same time, the changing nature of health service delivery is such that smaller hospitals can meet much of the demand for less complex services, especially those that are increasingly done on a day case basis.

Seymour Crawford (Cavan-Monaghan, Fine Gael)
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On a point of order, Mr. Mulvaney told us it was a political decision.

Charlie O'Connor (Dublin South West, Fianna Fail)
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I am not in a position to take any further contributions.

Caoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)
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The Government needs to re-examine this.