Caoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)
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73. To ask the Minister for Health his views on the smaller hospital sites; the steps he will take to establish the real potential of smaller hospitals that have lost critical services over the past decade; in view of the impossible footfall presenting at many of the larger hospital sites, if he is providing serious consideration to the restoration of services to smaller hospitals, thereby alleviating overcrowding elsewhere; and if he will make a statement on the matter. [36738/14]

Caoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)
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I ask the Minister, who has demonstrated some new thinking regarding his new portfolio of responsibilities, if he has had time to form a view or decide on an intent regarding the great and under-utilised resource that is our network of smaller hospital sites across the State. Such hospitals are still in service, though their number has significantly reduced in recent years.

Leo Varadkar (Dublin West, Fine Gael)
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The Government’s decision to establish hospital groups, where small and larger hospitals work together, was informed by two reports, the hospital groups report and the smaller hospitals framework.The hospital groups will provide an optimal configuration of services, with benefits relating to safety, quality, access and cost. Every hospital, large and small, will play a vital role in their group.

The smaller hospitals framework defines the role of the smaller hospitals and outlines the need for smaller hospitals and larger hospitals to operate in partnership as a single hospital group. It also defines the need for the smaller hospital to be supported within the group in terms of education and training, continuous professional development, recruitment of high quality clinical staff and safe management of deteriorating and complex patients.

The framework outlines in detail the wide range of services that can be provided in smaller hospitals, the services that can be transferred from larger to smaller hospitals and commits to the expansion of less complex services in these hospitals, such as day surgery, ambulatory care, minor injury units, medical assessment units, screening, other medical services and diagnostics. It is envisaged that smaller hospitals will provide more, rather than fewer, services, with more flexibility so that patients are the ultimate beneficiary of the reforms.

The initial focus is on getting the hospital groups up and running as single cohesive entities. In 2015, each hospital group will be asked to develop a strategic plan to describe how they will provide more efficient and effective patient services, reorganise these services to provide optimal care to the populations they serve and how they will achieve maximum integration with other groups and all other health services, particularly primary care and community care services. Alongside the work done at hospital group level, work will be done at a national level on the best configuration for certain national specialties.

Small hospitals have a bright and busy future providing a wide range of existing and new services, but it will not be possible for every hospital to be a centre of excellence or specialist centre for everything. We need to be honest with people about that. Separately, I foresee many services moving out of hospitals and into primary care in line with clinical programmes strategy.

Caoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)
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I thank the Minister for his reply. I support a policy of having more, rather than fewer, services. As in so many areas in this country we go overboard in following the lead of others in other jurisdictions in comparable matters, and that has been the experience of many people in many reconfigured arrangements currently in place. I could instance several such cases. We have heard today of the situation in Limerick regional hospital where overnight an exceptional number of patients were kept in wholly inappropriate settings. That cannot go on unchecked.

We have to recognise that there are other options. There are alternatives, in cases where certain ailments are present, to transporting such patients by ambulance to a so-called centre of excellence and bypassing existing facilities which have the capacity, trained staff and competency to deal with such situations. This has been acknowledged to me by hospital management and practitioners in critical hospital sites across the State.

I appeal to the Minister as a new mind with a fresh approach, as he has demonstrated in other areas, to look seriously at the potential of smaller hospitals to relieve the distress presenting at so many of the larger sites.

Leo Varadkar (Dublin West, Fine Gael)
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When it comes to reorganising services, we must always bear in mind that medicine, best practice and clinical science are always changing. There will never be an end point when it comes to reorganising services and we will always be adapting them. What we need in the health service is not disruptive reform but evolutionary reform, which means more things moving from hospitals to primary care, more specialist centres being centralised and more services moving from large central hospitals to smaller ones. I had the opportunity to visit Roscommon on Saturday where I spent a few hours in the hospital. I was impressed to see that there were services in the hospital which were not available in Blanchardstown, where I live, including, for example, a minor injuries unit where one can be seen in less than an hour with a laceration, broken bone or other injury of that nature. It also has a medical assessment unit to which a GP can send a patient during the day for assessment by a consultant. That is a good example of a smaller hospital providing the services those of us in Cork or Dublin would love to be able to offer our constituents.

To perhaps answer the Deputy's question a little better, when I look at trolley and overcrowding numbers across the hospital system, it is evident to me that one may have a great deal of overcrowding in three or four hospitals and none in ten or 11. It is not always down to resources, but is sometimes the result of management. It is clear that more beds are required in Limerick and a plan is in place to provide a new emergency department there. Between now and then, there will be difficulties; perhaps, some work might be moved back out to Ennis or Nenagh in the interim to alleviate the pressure.

Caoimhghín Ó Caoláin (Cavan-Monaghan, Sinn Fein)
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I welcome the Minister identifying both of the sites he has just mentioned. I had not intended to refer specifically to any of the hospital sites for fear of leaving one out. The Minister has identified immediately what might be done in relation to University Hospital Limerick. There are many other examples. There is international evidence of increasingly poor outcomes, including increased mortality, in relation to the closure of accident and emergency departments and their over-centralisation. A recent study in California has demonstrated as much and it is reflected across a whole range of studies conducted globally. We need to recognise that is the case. It is estimated by some of the Minister's colleague practitioners in front-line hospital employment that up to 90% of some of these emergencies, particularly in the older age group, do not require a transfer to larger hospital sites with a range of specialty supports. One could be dealing with pneumonia or a range of other things that could be provided for and dealt with clearly on the smaller hospital sites to which I have referred and which are still open, working and capable of dealing with these issues. It would also be hugely welcomed by the individuals concerned because they are closer to their homes and accessible by their families, with all of the better and speedier outcomes that come as a consequence.

I ask the Minister to look at all of these matters. I speak from experience; it is not something I am reading about. I live in a community that lost the greater number of its services at Monaghan Hospital, a fine institution that is way under-utilised in terms of its potential. I urge strongly the Minister's review of the area.

Leo Varadkar (Dublin West, Fine Gael)
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There will be a job to be done in educating the public and, to a lesser extent, GPs about where patients should go and when. Ideally, an older patient with pneumonia should be referred by his or her GP to a medical admissions unit, if there is one available. He or she should not - at least not during the day - be calling an ambulance to take him or her to an emergency department. The same applies to minor injuries. Where there is a minor injuries unit available, a patient should go to it rather than the emergency department. Certainly, he or she should not be calling an ambulance. There is a significant job to be done to change mindsets around this issue.

In some countries ambulance crews can discharge patients from the ambulance and not take them anywhere if they do not need to go to a hospital. Similarly, ambulance crews have more autonomy in deciding where they take the patient, and there are many such systems that can change in time.

Any decision to reconfigure services among the hospitals in Limerick, Nenagh and Ennis is a matter for the hospital group to decide, not me. Unfortunately, that group is running very much over budget. It is the one running most over budget among all the hospital groups, and that is a matter of concern in itself.