What happened in Monaghan this week could happen elsewhere soon if urgent action isn't taken, argues Dr Muiris Houston, Medical Correspondent
A lot has been written and said about the poor state of our public health service. Not surprisingly, a certain amount of reader and listener "fatigue" sets in, and human nature being what it is, we begin to switch off from the bad news. However, in the light of the tragic death of a premature baby girl, hours after she was delivered in an ambulance en route to Cavan from the Monaghan hospital where maternity services have been shut down, it is time to tune in again. What was Monaghan this week could soon be your local health service.
The North Eastern Health Board (NEHB) is the cockpit for change in our hospital system. The region has traditionally been served by five acute hospitals: Cavan, Monaghan, Dundalk, Drogheda and Navan.
In the regional development plan drawn up by the NEHB, only Cavan and Drogheda will retain a full range of acute services. The remaining three hospitals are due to be "reconfigured", in the language of health administrators; those of a more cynical persuasion use the word downgraded.
In essence, the three hospitals will lose their capacity to provide acute medical, surgical and obstetrics services and will become long-term care units, with a small range of planned procedures and investigations taking place in each. Reconfiguration makes a certain amount of theoretical sense: the more specialised acute hospital care becomes, the more difficult it is to offer it in every hospital.
The issue of medical and nursing expertise also enters the equation. In order to maintain professional competence, highly trained professionals must deal with complex cases on a regular basis. Otherwise their expertise is quickly lost and their ability to perform life-saving procedures effectively, diminishes.
However, what seems fine in theory must be carefully implemented in practice. And the inevitable feelings of those living in areas where services are being lost must be recognised and carefully considered in whatever concrete plans are put in place to implement change.
This is where management skills enter the equation. A good manager plans ahead, recognises the pitfalls, takes careful steps to overcome any obstacles and most important of all, brings both his staff and his "customers" with him.
On the evidence to date, the North Eastern Health Board has not demonstrated an ability to manage change. It has long been said that health boards are largely made up of administrators and are notably lacking in managers; the truth of this has been confirmed in the sad events of the past week.
In transferring obstetric services to Cavan from Monaghan more than a year ago, the health board has apparently failed in the most basic manner. It did not extend the size of the Cavan maternity unit before the transfer occurred. Extra beds are crammed into the existing facility to cater for the Monaghan patients and there is anecdotal evidence that staff in Cavan have had to endure excessive pressure as a result.
But where health board officials appear to have fallen down most of all was in anticipating and filling the vacuum in obstetric services in the Monaghan area. By abruptly "closing up shop" - with the exception of a weekly ante-natal clinic at the hospital - the NEHB appears to have been more concerned with forcing through change than in managing the process. It does not require an MBA in health service management to realise that whatever instructions were given to ambulance crews, expectant mothers in need of emergency medical attention would continue to turn up at the hospital.
The decision not to continue to avail of the services of the consultant obstetrician at Monaghan and the cohort of midwives is a serious cause for concern. Experienced midwives have been reassigned to general nursing duties rather than being redeployed on a rota which would mean that one would be available for situations such as the Livingstone case. And although Dr Alphonsus Kennedy - who remains as consultant obstetrician at the hospital - clearly could not be available 24 hours a day, seven days a week, surely he could be used during normal working hours to help direct the management of obstetric emergencies.
The potential problems in the north-east are not confined to obstetric care. Next month, the hospital is due to lose its acute surgical service. According to medical sources this will mean that operating theatres will open only between 9 a.m. and 5 p.m., Monday to Friday and only pre-planned surgery will take place at the hospital, involving procedures such as hernia repair and removal of varicose veins.
However, if a person from the surrounding area comes into the hospital with an acute appendicitis - even when surgeons are operating there - she or he will apparently be transferred to Cavan for an urgent appendectomy.
It is this level of "absolutist" change that must be stopped. People are not machines who only require regular servicing. They get sick in many different ways and, as any experienced clinician will acknowledge, in ways that often defy the text books.
Holistic health care is about looking after the patient first and worrying about the system second.
What will sicken many people this weekend is that Denise Livingstone was initially denied access to a doctor at Monaghan hospital. This is a shocking indictment of our public health service and must be at the core of the investigation ordered by Health Minister Micheál Martin. The inequity endured by the people of Monaghan in the last year could, in the future, face those living in the catchment areas of Mallow, Roscommon, Nenagh and other small hospitals throughout the State. Therefore, we must ask if those charged with implementing healthcare change are up to the job. Regrettably, the answer appears to be No. Those who have called for the abolition of health boards and their replacement by a single national health authority have been vindicated by the events of the last week.
But the buck ultimately stops with the Minister for Health, Micheál Martin. It is not acceptable for him to shelter behind a delegated authority given to regional health boards. Minister for Transport Seamus Brennan moved to reduce road carnage by introducing penalty points in the face of opposition. Minister for Justice Michael McDowell has shown leadership in dealing with problems with the gardaí and the prison service.
Martin must demonstrate leadership by taking an admittedly difficult political decision: he must reform the health boards and re-focus the delivery of healthcare.
Action is needed now if the Monaghan tragedy is not to be repeated elsewhere in the State.