COMMITTEE FOR HEALTH, SOCIAL SERVICES AND PUBLIC SAFETY
Western Health and Social Care Trust on Tyrone County Hospital
29 January 2009
Members present for all or part of the proceedings:
Mrs Michelle O’Neill (Deputy Chairperson)
Mr Thomas Buchanan
Dr Kieran Deeny
Mr Alex Easton
Mr Tommy Gallagher
Mr Sam Gardiner
Mrs Carmel Hanna
Mr John McCallister
Ms Claire McGill
Witnesses:
Mr Alan Corry Finn )
Dr Anne Kilgallen ) Western Health and Social Care Trust
Mr Joe Lusby )
Mr Alan McKinney )
The Deputy Chairperson (Mrs O’Neill):
You are welcome to this afternoon’s Committee session. Mr Lusby will begin with a presentation, and Committee members’ questions will follow.
Mr Joe Lusby (Western Health and Social Care Trust):
I begin by introducing my colleagues: Dr Anne Kilgallen is the medical director for the Western Health and Social Care Trust; Mr Alan McKinney is a consultant in A& E and divisional clinical director for emergency care and medicine in the trust; and Mr Alan Corry Finn is the director of acute services. I am the chief executive of the Western Trust.
You have raised a number of questions to which we have responded. If you are content, I will address those and, following that, I will answer any other questions that the Committee may have.
First, you asked how many additional beds are to be provided in Altnagelvin Area Hospital or Erne Hospital to deal with extra acute patients.
As you would expect, we now have access to quite a body of information, which has been built over the past number of years, on numbers of attendances and admissions at Tyrone County Hospital. As a result, we have a good predictive model on which to plan services with regard to the impact on Altnagelvin Area Hospital and Erne Hospital. Mr McKinney will outline the detail.
Mr Alan McKinney (Western Health and Social Care Trust):
There are currently about 3,000 acute medical admissions to Tyrone County Hospital each year, and that figure has been relatively stable over the past couple of years. The change to the format of services will affect not only Omagh, but Erne Hospital and Altnagelvin Area Hospital. The concept is to try to get acute patients into acute hospitals and to get convalescent and rehabbing patients back closer to home early so that there is a transfer in both directions. Of the 3,000 patients, the net flow away from Omagh will be approximately 1,500, because patients will move in the opposite direction as well.
Five days is the average length of stay for a medical patient who does not require rehab, such as someone with a chest infection or a person from the normal acute medical take-in. That equates to a need for approximately 20 beds across the Altnagelvin and Erne hospitals to accommodate that number of admissions. We want to ensure that the number of beds is slightly more than adequate, and, therefore, we have suggested a working model —
The Deputy Chairperson:
I ask members to turn off mobile phones because they are interfering with the recording equipment.
Mr McKinney:
We want to ensure that we have sufficient capacity in both the Altnagelvin and Erne hospitals to cope with the changes, and we want everyone in Omagh to know that we have the capacity to look after them. We will try to overshoot our estimations slightly until we see how the situation settles down. We assume that approximately the same number of people will go to each hospital, which will constitute a fifty-fifty split. It is yet to be seen whether that will happen in practice, but it is fairly likely to be close to that figure because the majority of patients are brought to hospital by ambulance rather than by private transport. Therefore, the decision about arrival in hospital is based on clinical need, choice and other factors.
We intend to put approximately 12 beds into both hospitals, and we will reorganise services. For example, in the Erne Hospital, we are in the process of setting up a clinical decision unit, which we hope will replicate the success in Altnagelvin, where we have used existing beds more efficiently. The idea is that patients who do not require resuscitation, such as those who are relatively stable admissions, requested by GPs, can be assessed quickly. We will put in place a community package for some patients, who will be able to go home rather than remain in hospital as inpatients.
We have established a new team of rapid-response nurses who can administer intravenous injections of antibiotics, take blood samples and test for MRSA prior to moving a patient. Furthermore, they can ensure that patients can avail themselves of some treatments — without requiring a hospital bed — that might otherwise require hospital admissions. That system has operated successfully in Altnagelvin over the past 18 months, and we are in the process of rolling it out in Omagh and Enniskillen.
People who are taken from Omagh to one of the acute hospitals will not necessarily need to spend their entire inpatient episode in the distant hospital. If they have a chest infection, a heart-failure problem or something else that requires immediate treatment, it may be possible, after they have been stabilised, their treatment is well under way and there is no danger of relapse, to get them back to Omagh for a period of convalescence and rehabilitation before they return home. That way, we will continue to use and maintain the local services in Omagh.
We also want to try to move a range of other services to Omagh to provide additional acute capacity in Altnagelvin Area Hospital and Erne Hospital. Those services include gastroenterology, endoscopy sessions and rapid-access chest pain clinics. The briefing paper includes a list of new services that would move to Omagh to support the local population. That will free up some capacity in the other two hospitals and will allow them to look after acute patients.
Mr Lusby:
The second question that was raised was in relation to the evidence that indicates that it is no longer possible to maintain safe acute services at the Tyrone County Hospital. Committee members will be aware that the future of acute services for Northern Ireland — incorporating those that are provided at the Tyrone County Hospital — has been determined by the Department’s strategic document entitled ‘Developing Better Services’.
The Tyrone County Hospital is entirely consistent with that strategic approach for the future delivery of acute services. I will now hand over to Dr Kilgallen, who will take the Committee through some of the key milestones of the process and the evidence that led us to arrive at this position.
Dr Anne Kilgallen (Western Health and Social Care Trust):
It is more than 20 years since I first qualified as a doctor. In those 20 years, I have seen incredible changes in the practice of medicine. We have become much more sophisticated in our ability to test and to treat people. The impact of that has been that doctors — in order to stay on top of the growing body of knowledge — have had to become more specialised in their training and practice, with considerable demands and emphasis on them to maintain professional standards of practice. All of that has become much more explicit in those decades. To a large extent, that thinking underpinned the Developing Better Services strategy. It was obvious that those changes were coming, because there were changes in our population and in our workforce. That factor underpinned the strategy.
At a practical level for us as a trust — particularly in the Tyrone County Hospital — that has impacted in a number of ways. An example of one impact was when we considered the junior doctor workforce at our front door. We carried out an assessment of the range of skills that they had, because we are constantly aware of the need to update and maintain skills. Our experience was that the job that we expected those doctors to do was much too broad — there was a mismatch between the skills that they came with and the job that they were required to do.
That impacted in a number of ways. It made it difficult for them to maintain professional standards, and it also made the job increasingly unattractive; particularly in a world in which the medical workforce is currently shrinking. There is a mismatch between the workforce and the numbers that we require to deliver service. That is one very practical example that we were able to demonstrate in the trust. Over time, we found it increasingly difficult to recruit.
At the other end of the scale, we also considered our consultant workforce. The Committee is probably aware that some of the trust’s staff retired and another staff member suffered ill health. In that workforce, some of the consultants were very broadly trained and had a lifetime of experience and skills. The new consultant workforce does not have that breadth of skills and experience, and those consultants would be the first to admit that.
The doctor who retired had a range of expertise in treating heart diseases, lung diseases and in the broad range of general medicine. Replacing that doctor would require two, if not three, doctors. In the first instance, the royal colleges would not grant us permission to recruit to those posts. Secondly, we would find it enormously difficult to recruit that range of people to that service. That is the challenge of trying to replace people whose skills are no longer replaceable in the way that they were profiled.
The third issue is that we were unable to provide sophisticated level 3 critical care services at the Tyrone County Hospital. We made arrangements to safely transfer or redirect patients who were likely to need that level of service.
Due to the interdependence of services, that makes it extremely difficult for the doctor and, therefore, affects professional standards. It became increasingly difficult for us to provide the full range of services to acutely unwell patients who arrived at the door. In the last several months, we have ultimately had to rely on the huge commitment of the clinical workforce, both nurses and doctors, from right across the trust.
I am absolutely confident that I am representing the views of senior doctors from across our three sites. Individual doctors from Altnagelvin and Enniskillen have contributed to the out-of-hours cover in Omagh, so they have hands-on knowledge of the nature and demands of services in Omagh. Those doctors have told us that the services in Omagh could no longer be safely maintained and that alternative treatment and care need to be provided, particularly for acutely unwell patients.
The Deputy Chairperson:
Before we move on, I once again remind everyone in the Senate Chamber that it is not enough to have your mobile phone on silent mode; there has been interference with the recording equipment.
Mr Lusby:
When the Western Trust came into operation as an organisation on 1 April 2007, the outgoing chief executive of the former Sperrin Lakeland Trust highlighted serious concerns about the sustainability of services at Tyrone County Hospital and, indeed, that was one of the first things that the Department of Health, Social Services and Public Safety asked us to review.
Our review made it very clear that the services provided at Tyrone County Hospital at that time could not be sustained indefinitely. In May 2007, we informed Omagh District Council of our belief that we would be able to continue those services for a further 18 months at best. We are beyond that 18-month period now, and it is entirely consistent with the direction set by Developing Better Services.
As Dr Kilgallen said, we have only been able to maintain services due to the sterling commitment of the staff at Tyrone County Hospital, who have gone beyond what we could have reasonably expected of them. Senior clinicians and other staff have been saying for a considerable time that a decision needs to be taken because the situation is neither sustainable nor safe and is so fragile and precarious. Unfortunately, we have reached that point.
Members have requested further information on the urgent care and treatment centre at Tyrone County Hospital. The Minister was absolutely clear in saying that there will continue to be a 24/7 urgent-care and treatment service, which will be led by doctors and delivered by highly skilled and experienced nurses. Mr McKinney will now outline some of the background to this issue.
Mr McKinney:
For the last couple of years, the arrangement has been that the service is delivered by doctors. The service is required 24/7, and six doctors are needed for the rota. We have made repeated attempts to recruit doctors as people have left. However, we have had significant difficulties in finding doctors to do the job; the urgent-care and treatment centre philosophy means that it is a unique job.
Currently, we have one doctor on the rota and all of the other hours in the week are covered by casual locum staff, whom we attempt to recruit from locum agencies on a day-by-day basis. That is unsatisfactory from the point of view of consistency of care, and it means that there are occasions when, even up until the last moment, we are not even certain that a doctor will be on duty. It also adds huge pressure to the nursing team, who often find themselves having to direct doctors who may not have worked in the trust before and who, therefore, are unlikely to know the GPs in the area or be familiar with facilities, routines or the people to contact in emergencies. That has placed a burden on the nursing team, who, in effect, have acted as the safety net.
In the past couple of years, not just in Omagh but also in Enniskillen and Altnagelvin, we have been providing experienced nurses with additional degree-level training, as a result of which they have become emergency nurse specialists and are able to diagnose and treat in their own right. Consequently, they can order X-rays, examine patients and provide treatment, based on protocols and under the supervision of a broad team of doctors.
In Omagh, there are three emergency nurse practitioners, and we have been able to recruit two more from Altnagelvin. The new service will be based around those nurse practitioners, who are local nursing staff with vast accident and emergency experience, and who have been hand-picked and specifically trained. They will deliver care to patients, and they will have recourse to the senior teams in Altnagelvin and the Erne Hospital 24 hours a day.
In addition, we will appoint a senior doctor in Omagh to provide review, audit and safety-net services for certain periods during the day. For example, if a patient comes in with a broken wrist during the evening, and the nurse feels that it is a minor fracture, rather than a clear break, he or she will be able to put on a plaster and bring the patient back the following day for review by a senior doctor, when a more measured decision can be taken about whether additional treatment may be necessary. In that way, a safety net can be provided for the nurse, and the number of patients who must be transferred from Omagh to other places can be minimised. Obviously, we will have to limit the range of patients who attend the urgent care and treatment centre.
The protocols in place are based on UK national protocols, so, although nurses are trained to a standard, they cannot provide medicine across the entire range. Therefore, we must ensure that nurses work within defined limits, and processes are in place to appraise the nurses and train them as necessary. Moreover, we intend to rotate nurses through larger centres so that they gain experience and, in particular, are exposed to life-support training for both adults and children.
That, in a nutshell, is what the service will look like. Ambulances will not be arriving; the bulk of the work will involve minor injuries, which is the bulk of an accident and emergency department’s workload anyway. In the absence of ambulances arriving, we can manage that flow in the way that I have described and with those safeguards in place. Additional safeguards will be provided by the resident cardiac team.
Mr Lusby:
Members asked for further information about the new and additional services that are planned for the Tyrone County Hospital. In the past two years, the trust has been absolutely committed, and has been working really hard, to introduce a range of new and additional services to the Tyrone County Hospital, and that commitment will continue, because the hospital forms an important part of the network of services that are provided throughout the Western Health and Social Care Trust area. Alan Corry Finn will take members through some of the details.
Mr Alan Corry Finn (Western health and Social Care Trust):
As well as being the director of acute services, I am the executive director of nursing for the trust.
Before going into the details, I wish to reinforce what my colleagues said. For some time, I have been hearing the concerns of the nursing staff in the Tyrone County Hospital, particularly from those in the urgent care and treatment centre, where staff have often felt exposed and concerned about the fragility of the service and about the fact that they are dependent on locum staff, who can be of variable quality and, on occasions, fail to turn up.
That has left them very exposed, and created the potential of patients arriving in blue-light ambulances, in the back of a car or walking in to receive medical treatment from a nurse practitioner. Those nurse practitioners have advanced skills, but there are some procedures that they cannot carry out, which serves to reinforce what I have just said.
In relation to the new services, since its inception, the Western Trust has been committed to developing the network of services across its area in line with Developing Better Services, at the same time as recognising the fragility of the Tyrone County Hospital. We have received approval from the Royal College of Physicians for the establishment of some key consultant posts who will in-reach to the Tyrone County Hospital from both Altnagelvin and Erne hospitals.
We have recruited a consultant cardiologist, a consultant in respiratory medicine, and a consultant diabetologist, who is due to start, on a date to be confirmed, in April or May. It is also planned to appoint a consultant gastroenterologist.
We have also introduced new and additional services, and will continue to do so, in order to bring as wide a range of services as possible to the local population. We have ambulatory cardiology services, including rapid-access, chest-pain and heart-failure clinics. At present, there are 39 different types of outpatient clinics, and more are planned.
We have increased diagnostic and imaging services and additional rapid-response nursing resources to provide support to patients in the community, which will, in some cases, help to prevent hospital admission in the first place, and facilitate early discharge.
We also have specialist children’s nurses to provide hospital and community support in relation to asthma, epilepsy and continence care, and additional clinics for urodynamics. We recognise, and plan to develop, additional palliative care services in the area, particularly because there is no local hospice facility.
The introduction of outreach oncology services that bring chemotherapy to the home-hospital site is planned in order to prevent local patients having to travel for treatment. We also intend to increase day surgery at the Omagh Hospital site for the local population and, indeed, the whole population of the Western Trust area.
Mr Lusby:
The next area, Madam Chairman, is —
The Deputy Chairperson:
I apologise for interrupting, but time is running away with us. The Committee allocated only 30 minutes to this evidence session. I will open up the meeting to questions, and I am sure that the issues of job losses and ambulance services that you were about to address will be picked up.
Mr Easton:
Thank you for your presentation. I will try to be quick, because members from Tyrone will be keen to ask questions.
The bed closure announcement was a big shock and came as a bolt out of the blue, particularly for members of this Committee. I suggest that that announcement was badly handled. If the Committee had been informed about the problems that were faced in filling a senior position, it might have been able to put some pressure on the Minister to help you with that.
Are the closures of medical beds part, or separate from, your efficiency programme? I believe that you have four residential homes that face possible closure; how many residents will that affect? Around 134 nursing posts will disappear —
The Deputy Chairperson:
The Committee will deal with that in its next session, Alex. The hospital issue is being discussed at present. Will you hold back on the loss of nursing posts? We will move on to efficiency services next, and I will let you ask your question first.
Mr Easton:
The witnesses said that the senior doctor in post was competent in three really major areas, and that three doctors are needed to fill that role. He must have been a very special doctor.
Dr Kilgallen:
That reflects the way that medical training has changed. His training and experience allowed him to deliver a service across a broad range of areas. Doctors now specialise much earlier in their careers, and therefore they do not have that broad knowledge and experience; they tend to focus on areas of special interest.
That is a pragmatic reality of how doctors are now trained, and it has forced changes in the delivery of services. However, it has also resulted in much better experiences and outcomes for patients, because the level of sophistication around investigation and treatment is much greater than it would have been with the state of knowledge that existed 20 or 30 years ago. Therefore, the disadvantage is the loss of that broad range of experience; the advantage is more specialised teams and much more focused work.
Mr Easton:
Have those bed closures been factored into your efficiency savings, or are they separate?
Mr Corry Finn:
As regards changes that are planned to happen on 2 March 2009, it is a direct result of our inability to recruit senior doctors, as has already been explained.
Mr Easton:
Therefore, they are part of your efficiencies?
Mr Corry Finn:
No, it is a direct result of our inability to recruit staff. If we cannot recruit staff, we cannot sustain services.
Mr Lusby:
I want to pick up on an earlier point about the announcement. Of course, we all learn from such situations. We accept that, if the situation were to happen again, there is potential to conduct matters much better next time round.
However, as regards your point about it coming as a surprise, we have said consistently that, from the time that the trust was established in April 2007, the service was highly vulnerable. It is an isolated service that has no back-up to intensive-care services and all of the other services that are found in an acute hospital. We have made no secret of that at all. Indeed, the staff, who are part of the local community, have made no secret of the service’s fragility when they talk to local people.
Our difficulty with the announcement coming as it did was that we required clearance from the Department of Health, Social Services and Public Safety. We got its support, as we had anticipated. However, we got the letter from the permanent secretary on the Wednesday evening, and made the announcement on the Thursday morning. Our first priority as regards who we told was the staff of the Tyrone County Hospital — the very staff who, when you and I are in our beds at night, we rely on to deliver the service, despite its imperfections with regard to staff support. Therefore, we make no apology for the fact that our first priority was to tell staff. That is what we did.
Mr Easton:
Although it may not have been a secret in the Tyrone area, I certainly knew nothing about it and nor did the Committee. You did not inform the Committee, who may have been able to step in and try to help you. You did not bother to do that, which is a failing on your part.
The Deputy Chairperson:
The decision to make the announcement was not made on the Thursday morning. The Committee recognises that the manner in which the area’s MLAs, who include several Committee members, were informed was, frankly, not good enough. The Minister also acknowledged that in a meeting. There are lessons to be learned.
Dr Deeny:
I will try to be as brief as possible. I feel deeply about the matter. Let us get to the crux of it: County Tyrone is losing acute services in three hospitals. I am surprised that not one of the four of you has mentioned anywhere east of Omagh. I understand that your remit is the Western Health and Social Care Trust ’s area; however, you are aware that the Mid-Ulster Hospital in Magherafelt is earmarked for closure and that the South Tyrone Hospital in Dungannon has closed. That is why many people have fought tooth and nail to try to retain an acute-services facility in County Tyrone.
I have to repeat the point time and time again: it is not simply a matter of how Omagh is affected. I live 11 miles east of Omagh, in the triangle of the three big towns of Cookstown, Dungannon and Omagh. That is why I am involved in the matter — it is not about Omagh and Enniskillen; it is much wider.
I am not sure whether you are aware that Dr McCormick’s predecessor, Mr Gowdy, spoke to the previous Health Committee about the Tyrone County Hospital. Three members of that Committee are present at today’s meeting, one of whom is Tommy. He said that the Omagh hospital would be an enhanced hospital along the lines of the Downpatrick model, which is in my native town. I can get you proof if you wish. How can the Downshire Hospital and the South Eastern Health and Social Care Trust get staff, yet the trust in the west cannot? How can they maintain safety in order to facilitate acute medicine, inpatient coronary care, and accident and emergency services?
You mentioned that there are extra beds in Altnagelvin Area Hospital and the Erne Hospital. My 8,300 patients will not go to those hospitals; they will have to go to the Craigavon Area Hospital. Has the need for extra beds in that hospital been considered? It must be factored in.
Mr McKinney knows that we have had productive meetings in Altnagelvin Hospital on the protocols. Has that all gone by the wayside?
We were promised acute and mental-health services. I discussed the matter with staff, and I must disagree with you. I met with a number of staff last night, and I was shocked by what they told me. The staff — senior nurses — were asked recently to open the ear, nose and throat department, but they were not going to be provided with extra nurses, because there were no beds in either Altnagelvin Hospital or the Erne Hospital. On the grounds of safety, those nurses decided not to do that. However, a member of the management staff told them to so. Those same management staff are telling us to close the Tyrone County Hospital in Omagh on the grounds of safety. The senior nurses did not want to dilute their staff, because they would not be able to provide the care that patients deserve.
I have had to deal with a relative of someone who committed suicide recently. People who have taken overdoses must be stabilised in the Tyrone County Hospital and then transferred to the bigger hospitals. How will we be able to deal with acute mental-health issues now if that were to happen?
Let me make it clear, I live in the triangle between the three towns of Omagh, Dungannon and Cookstown. My family is over an hour away from each of those hospitals. It takes me an hour and a half to get to Altnagelvin Hospital — that is on a good day in the summer.
In a 13-month period that took in 1994, our practice had seven cases of children with meningitis. Four of those children had full-blown meningitis; I drove one child to hospital and my partner drove another child to the South Tyrone Hospital in Dungannon. We were able to get them stabilised and then move them to a paediatric hospital. If that were to happen now, those children would die.
Safety in a building is paramount. However, a whole area of Northern Ireland — County Tyrone — is now unsafe, as far as I am concerned. Mr McKinney talked about 20 years’ experience. I have been a GP for almost 29 years. I work in an area that is more unsafe now than it was 20 years ago.
Mr McKinney:
As a practising doctor, I appreciate the pressures in general practice and the concerns about emergencies, because that is my bread and butter: I manage emergencies daily. The majority of patients who suffer an emergency has not used the services before, and it is important for us to have consistent, clear and equitable services for those people so that they know exactly what they need to do and how they should access those services.
Dr Deeny referred to the heroic rescue of children with meningitis, and the capacity to do that remains. The staff who remain in the Tyrone County Hospital in Omagh will have advanced paediatric life-support training. We recently installed special age-related and colour-coded equipment for people who rarely deal with very sick children. I will not bore the Committee with specific details. Children require specific sizes of airway instrumentation, drips, and so on, and calculations of drugs based on their size and weight. It is difficult for doctors or nurses to carry that sort of information in the back of their mind about what should be used in any given circumstance — even if they see children regularly.
What we already have in place in the hospital in Omagh is a series of colour-coded shelves that are linked to a set of instructions. Basically, a very broad, large tape measure is attached to the side of the patient’s trolley when he or she arrives. Immediately, staff know from looking at the size of the child what box contains the correct equipment. If the child is a neonate, an orange line appears on the ruler; staff then look in the orange box and find the right size of airway and venous access devices, such as interosseous needles, and so on, and the correct combination of drugs for the variety of arrest situations that might have to be dealt with.
That sets us well ahead of what is happening in other parts of Northern Ireland. It is a unique way in which to deal with the issue. It means that our staff can deal with an unforeseen emergency that none of us wants to see. If anything, we are now better at handling that type of situation than we would have been a couple of years ago.
Dr Deeny mentioned work that we have done jointly in trying to ensure that the protocols for transfer from Omagh are balanced against the needs of people living in Omagh. It means that we have access to specialist services when needed, and we can look after people locally when they do not need the all-singing, all-dancing, bells-and-whistles approach to emergency services.
We have made a great deal of progress in fine-tuning and refining the protocols that were previously put in place at the time of the old Sperrin Lakeland Trust. Those protocols are part of the process that we need to go through in the next four weeks. We need to revise and review everything that is in place to ensure that the hospital is fit for purpose and provides maximum safety. The protocols that we have recently completed on paediatric care will not alter because of this, because we already have bypass protocols in place, and have had for several years. Today’s announcement has no impact on paediatric care.
We have also recently been looking at protocols on managing fractures, managing elderly people with hip fractures, and managing trauma. Those should also still be fit for purpose, but we will review them again in order to be absolutely certain.
Another point that Dr Deeny made was that there is now a triangle in the centre of Northern Ireland, including Omagh, Magherafelt and other hospitals. The reality is that Omagh is not alone in having difficulties in recruiting staff. Maid-Ulster Hospital has had the same difficulty. As older physicians retire, it is impossible to replace them on a like-for-like basis. We have decided to manage actively the transition rather than allow services to crash, as happened a couple of years ago when South Tyrone Hospital closed.
Over the past couple of years, we have persuaded the Royal College of Physicians about new models of working, which involve in-reach of specialties to the smaller hospital, based around hospitals working together as a network. For example, we have a very good arrangement in cardiology. We could not get permission to have a single cardiologist working in isolation in Omagh, so we persuaded the college to allow us to have an existing cardiologist, who works in Altnagelvin Hospital, but who is based in Omagh. He will perform several days’ work in Omagh each week, to be joined on the other days by a new appointment. The newly appointed person will, on the days when not working in Omagh, backfill for the existing cardiologist in Derry. There is also a recently appointed doctor at Erne Hospital, and among the three of them, they will provide in-reach to Omagh every day.
That allows the Omagh population, for the first time ever, to have access to a specialist cardiologist with an interest in invasive, diagnostic cardiology. One of the others has an interest in pacemaker implantation, and the third in non-invasive diagnostics, including treadmills and rapid-access chest-pain assessment. Cardiology is the first of those services that we have installed. The breadth and depth of cardiac diagnostics and access for Omagh people has improved as a consequence of that change.
The downside is that if someone had a heart attack, we would need to take them to the acute hospital, which is not Omagh, for the first period of recovery in order to ensure that he or she is initially monitored safely until it is appropriate for him or her to return to Omagh for a convalescing period.
The other limb of the cardiac service is that we have trained cardiac nurses to work closely with the Northern Ireland Ambulance Service. They will be based in Omagh and will go with the ambulance from Tyrone County Hospital to the patient’s bedside to make the diagnosis of a heart attack, if that is what has happened.
If appropriate at that point, they can deliver, on the spot, the clot-dissolving drugs that the patient requires. That is done in conjunction with consultant advice, which is available during the day from Omagh or, in the evenings, from Altnagelvin or Enniskillen. Having done the thrombolysis check, the patient can then be transferred directly to the acute hospital coronary-care unit. There, the patient has the backup, if necessary, of invasive diagnostics or, can be transferred to a tertiary centre for emergency cardiac surgery. As a result, the population in a rural area such as Omagh has exactly the same access to sophisticated, high-intensity cardiac centres that the urban population has. For the first time, we can deliver equitable cardiac services across the district; no matter where a person lives, be it Omagh, Enniskillen, Fintona, Castlederg or Derry, access to a cardiologist at the point of need will be exactly the same. The only difference is the travel time between the point at which the cardiac nurse picks up and begins to manage the patient, and the point at which the patient reaches a coronary care unit.
The same sort of thing is being done for gastroenterology. A gastroenterologist is being brought into Omagh so that patients who require the diagnostic services that only a gastroenterologist can provide, can have that done in Omagh without having to travel elsewhere. However, if a patient has a sudden haemorrhage from the gut, which would make the patient unstable, he or she would be admitted to that gastroenterologist’s specialist unit to be managed actively. When it is safe to do so, the patient will be brought back to the local centre. There is a respiratory physician in place who can provide services, such as a bronchoscopy, that have previously been unavailable to the population.
A diabetologist, who has just finished his specialist training, is due to start, and he will be able to provide services in conjunction with the remainder of the diabetology network. Diabetic services require input from ophthalmology, because of the eye complications associated with diabetes; from vascular surgeons, because of the vascular complications associated with diabetes; renal physicians; and a whole range of other specialists. Although the vast majority of diabetology work is outpatient and can be managed in a community setting, when it is necessary for a patient to have access to a specialist, that access will be provided instantly. Rather than describe that as a withdrawal of acute medicine, I think that it is an evolution and an improvement. I look forward to the day when the population of Omagh, and other rural centres, has the same access to services as other people — access to which they have a right. No matter where people live, they should be able to get to a cardiac surgeon, cardiologist or respiratory physician, or receive any other necessary treatment. Our services are designed around that model in order to make that happen.
Dr Deeny:
My question will, I am sure, be of interest to John McCallister, and to my family, two of whom are GPs in Downpatrick. Will the services in Downpatrick, which is half an hour’s journey from Belfast, remain safe? Is recruitment going to be a problem in that trust? Is it a case of one rule for one area of Northern Ireland, and a different rule for another?
Dr McKinney:
I cannot give you specific direction about what is happing in Downpatrick; that is outside my area of expertise. I do know that some staff there are having the same difficulties as we are in accessing specialist recruitment. The evolution of services in Downpatrick may be managed slightly differently as a result of geography, access, the configuration of roads, and so on. However, I would be very surprised if other small hospitals in Northern Ireland did not experience similar problems. The recipe is the same — there are difficulties with junior doctors, in accessing sufficient numbers of doctors, and in providing modernised education training for consultants. We are fishing from a very small pool — all of us are competing with one other for a small number of consultants.
Unless we can ensure that the services that we are managing and delivering are done so imaginatively, we will be unable to recruit new consultants. If the service is based on the old model, it will — sooner or later — collapse.
Mrs McGill:
You are all welcome to this afternoon’s Committee session. Kieran Deeny mentioned efficiency savings, and, in that regard, I say this: residential care; transition; and home helps.
I am a MLA for West Tyrone, and I am concerned that there will be a decrease in services at Tyrone County Hospital. We hear that there will be, but you have articulated that there will not. On Monday, the Minister and members of the Western Trust team came to the Assembly, and I thought that the content of Dr McNeill’s presentation, on cardiology in particular, was welcome. The presentation has, by no means, sorted everything, but — to be fair to the Minister, his team and the individuals from the Western Trust — it was, at least, a practical response. I welcome that.
Other MLAs in my area, hospital staff and potential patients are concerned about what has been happening for some time at Tyrone County Hospital.
Mr Lusby:
We realise that we have a responsibility to provide reassurance and to provide clarity to the local community. Last Thursday’s announcement has allowed us to move forward to establish a steering group and 10 work streams, one of which relates to communication, because there is a job to be done on that to ensure that the people of Omagh are clear and reassured about how to access services, and which services they will get from where, when the switch takes place. Dr McNeill, for instance, has not had the opportunity to be clear with people, and we hope that the comments that Mr McKinney made today will reassure people about the future delivery of services.
Mrs McGill:
I cannot say that people in my area will be reassured. Other MLAs and I hear what the people are saying. Over time, there has been a reduction in services at Tyrone County Hospital. I do not know the reasons for that; perhaps it is due to the state of the building or an inability to attract high-quality medical staff.
Mr Buchanan:
Some of the things that I have to say will cut to the core, but one must be realistic. In response to a question from Kieran Deeny, one of the witnesses went around the world in an attempt to provide an answer but failed to answer what was asked. Some of my questions will be fairly simple, and I ask you to stick to the point and answer what you are asked. I do not want you to go around the world in an attempt to answer a simple question. That is not what we want; we want to get to the truth of what is happening.
The meddling and tinkering with services that is taking place at Tyrone County Hospital is appalling. Rather than making services safer, it is rendering them more unsafe. You may ask from where I get that information. It is not from the people on the streets but from the professionals who work in the hospitals.
The trust’s representatives have said that staff told them that the service must close or be put to another use. However, Tyrone County Hospital staff and consultants from Altnagelvin who work at Tyrone County Hospital have told me something completely different. They say that the trust has a vendetta that will result in the closure of services at Tyrone County Hospital.
Therefore, conflicting messages are being sent out. I am more inclined to believe the people who provide front-line services than those from whom I have heard today. I am sorry to say that, but professionals — nurses and consultants who work at the coalface — have telephoned me to say that Tyrone County Hospital’s services are being run down.
As many as five patients a day will have to travel to the Erne Hospital in Enniskillen or to Altnagelvin for treatment. Mr McKinney said that he thought 20 beds might be needed in those hospitals but that 24 would be provided until the situation settled down. That could be interpreted as a signal of future cuts in beds at Altnagelvin and in Enniskillen. I want an immediate guarantee that 12 beds each will remain in Enniskillen and Altnagelvin. I do not like to have to read between the lines, but I have dealt with the Western Trust for long enough to know that every minute detail must be examined in order to establish the truth.
The provision of an assessment unit at the Erne Hospital has been discussed as a way of prioritising patient transfers. Is there a date for the opening of such a unit? A shortage of ambulances means that moving patients to or from the Erne, Altnagelvin and Tyrone County hospitals currently creates one crisis after another. A month does not pass without my office’s being informed of a crisis over the non-availability of ambulances for some reason or another. How will patients be transferred if there is a crisis over the Ambulance Service?
What use will be made of wards 5 and 6 at Tyrone County Hospital, which were recently refurbished, at a cost of £480,000? The Minister told me that those beds will remain until the new and enhanced hospital in Omagh opens. I received that information in answer to a written question. Will the trust clarify what use the beds will be put to in the event of the service’s being removed?
For up to 10 years, the trust has repeated that it has difficulty in recruiting staff. That is the excuse that it uses for removing services. I continue to ask whether it is because management is not fit for purpose. I do not know the answer to that question. However, how many members of staff in Tyrone County Hospital are on part-time contracts? If the number of part-time contracts is as big a problem as is suggested, that may, in part, be why it is so difficult to retain or recruit staff. I consider that a major difficulty.
A limited range of patients will attend the urgent-care and treatment centre, which, I see, will have no dedicated ambulances. Are the witnesses telling the Committee that ambulances will come to Tyrone County Hospital for no reason other than to transfer patients to somewhere else? Is the trust really telling the Committee that blue-light ambulances will be barred from Tyrone County Hospital?
Furthermore, as Kieran Deeny said, if the new and, supposedly, enhanced hospital has no acute medical backup, how will acute mental-health services be sustained?
Finally, when people read the Hansard of this evidence session, they will note Mr Corry Finn’s remarks about planning to do this and planning to do that. It is all right to talk about planning things, but when will those plans be delivered on? When existing services are removed, County Tyrone people will be left with a gap in services — talk of plans will be no good to those people. Services should not be removed until replacements are in place.
Mr Lusby:
I regret the fact that Mr Buchanan feels that we have taken him around the houses concerning these matters. It appears that, no matter what we do, we cannot win. On the one hand, the Committee is telling us that we are not informing people clearly enough about services that are, and will be, available on the ground and about how things will be better for patients, but, on the other hand, when we do attempt to inform people — as Mr McKinney and his colleague Dr Albert McNeill have been doing — we are closed down as well.
Mr Corry Finn will address some of the nursing issues.
Mr Corry Finn:
With regard to the opinions being expressed to Mr Buchanan by professionals, as I said in my introduction, I am the executive director of nursing for the trust, which means that I am a registered nurse and bound by the Nursing and Midwifery Council’s code of professional conduct. Consequently, I am as accountable as anyone else for my practice.
I joined the trust in March 2007, and, in my early days, the staff in the urgent-care and treatment centre expressed concerns to me about the vulnerability of the service, the variable quality of locums that we were able to attract, and the fact that we were having difficulty finding locums to fill slots in rotas.
Six to eight weeks ago, I assumed responsibility as the director of acute services, and in that time, there have been three occasions on which we have been living hand to mouth in our attempts to make the rotas work. On some afternoons, we did not know whether we had a doctor to cover the urgent-care and treatment centre that night or, indeed, the next morning. On several occasions, the locum, who had been booked in good faith, failed to turn up, so we were obliged to contact the Ambulance Service in order to have ambulances redirected to the Erne Hospital or to Altnagelvin. In addition, we had to contact local GPs to tell them that we did not have a doctor in the urgent-care and treatment centre and that nursing staff would be responding to the general public’s needs. Nursing staff feel vulnerable and exposed by such arrangements, and they worry that, if a blue-light ambulance were to be in transit, a doctor would not be available. Therefore, we must move quickly to address the problem.
I cannot comment about the opinions that have been expressed to Mr Buchannan; however, people have loudly and clearly said to me that something must be done to improve safety and to inform the public about the level of service that we are capable of providing.
Work on the assessment unit in the Erne Hospital is ongoing and due to be completed in April 2009. Members are quite right that wards 5 and 6 have been revamped within the past year. Ward 5 now houses the coronary-care unit, and ward 6 has been vacant since the works were completed. Owing to the changes that are planned for 2 March 2009, we will be determining with staff the accommodation that will be required for the remaining services in the hospital, and that process will dictate the future usage for wards 5 and 6.
Quite a lot of money has been used on it, and we want to use that money on patient accommodation
As far as part-time contracts are concerned; generally speaking, part-time contracts in the Health Service are usually due to a matter of choice. Dr Kilgallen may also want to respond on this issue.
In relation to the urgent care and treatment centre, we have had nine recruitment exercises in the past 15 months, and we still have only one permanent member of staff. There is another permanent member of staff, who is on long-term sick leave. The rest of the vacancies are filled with locums, of whom there should be six.
Mr Buchanan:
I know members of staff who left Tyrone County Hospital and went to work in other hospitals because they were continually being given part-time, rather than full-time, contracts.
Mr Corry Finn:
I cannot comment on the specifics of that.
Mr Buchanan:
I can get you the details.
Mr McKinney:
You are talking about nursing staff, but our problem is with medical staff. There are no medical doctors on part-time contracts; they are all on full-time contracts. We have tried to widen the field as much as possible and have offered part-time contracts to anyone who is interested in taking up part-time work; for example, if someone has been trained and is returning to medicine after having been on maternity leave.
Consultant physicians, who are the specific group of senior doctors responsible for providing services, are unanimous that this is the right thing to do. I do not know to whom Mr Buchanan has been speaking, but it is not the same group of people to whom I have been speaking.
Mr Buchanan:
With all due respect, it is they who have been speaking to me.
Mr McKinney:
Perhaps you have been speaking to some of our disillusioned part-time locum staff who are only there because they want to negotiate rates of between £50 and £98 per hour and then, at the last minute, withdraw their services.
Consultants in Enniskillen and Altnagelvin, and the consultant who is about to retire — and the one who is on sick leave — have said the same thing. There is no inconsistency in that line: blue-light ambulances will not be going to Omagh.
Mr Buchanan:
What ambulances will go to Omagh? Under the proposed model, no ambulances will come to the urgent care and treatment centre. Will no ambulances go to Omagh?
Mr McKinney:
That is correct. Ambulances could take a patient who is referred by a GP, and who requires admission for convalescence, or they could take someone with a chronic disease without acute complications. Therefore, if a patient were to require admission, that type of ambulance would be used. However, emergency patients will not be accommodated. They will be taken to acute hospitals where it is safe to look after them.
Our mental health service in Altnagelvin is provided by community psychiatric nurses (CPNs), who are specialist trained nurses. The same service will be available in Enniskillen and in Omagh. The CPNs act as the initial point of contact between acute services and psychiatry. For some time now, it has not been possible to have direct access to a psychiatric junior doctor to carry out assessments of psychiatric need. Therefore, the CPNs provide that service, and they have done so for some time. Patients are assessed, and they are either directed to the inpatient/outpatient service or to the community service. That is a consistent service plan, and Omagh will not change in that.
Mr Buchanan:
Again, with all due respect, anyone with an acute mental health problem in Enniskillen or Altnagelvin will have the back-up of acute medicine, but that is not going to help people in Omagh, because we are going to an acute mental health service in Omagh, but we are not going to have the back-up of acute medicine.
Mr McKinney:
Someone who presents with an acute crisis, where they have perhaps taken a drugs overdose or have attempted suicide, cannot safely be managed in the environment that we envisage in Omagh.
In such a situation, that patient will be taken to an acute hospital so that his or her acute medical needs can be met. Following the management of that acute care, the patient will receive a psychiatric assessment. Such assessments always come second to acute medical needs.
Mr Buchanan:
To that clarity the matter further; will the new local enhanced hospital in Omagh have an acute mental-health facility?
Mr McKinney:
Yes.
Mr Buchanan:
Is that without acute medical back-up?
Mr McKinney:
It will operate without acute medical admissions. Patients with psychiatric needs but who do not require acute medical services can be admitted directly to a psychiatric service. Patients requiring acute medical admission will have to go to an acute medical unit. No psychiatric hospital can look after patients who have taken drug overdoses. That does not happen anywhere in Northern Ireland.
Mr Gallagher:
I want to ask about the number of part-time doctors or consultants. We heard about the difficulty of recruiting for permanent posts; but using part-time staff sounds very expensive. Does the trust have information about the number of staff who have been employed on a part-time basis over the past three or four years and the cost per hour? The Committee would find that information useful.
I also want to ask about ambulance cover at Tyrone County Hospital, which has an unsatisfactory record. What communications have you had with the Ambulance Service about last week’s announcement about changes to acute services at that hospital? I presume that you had some communication with them prior to that announcement.
It is to be hoped that decisions will be made about the new hospitals and that building will begin soon. Some questions have been raised about one financial institution that was involved in the Enniskillen hospital project. Has a new financial institution come forward to replace the one that has dropped out?
Mr Lusby:
I will answer those questions as quickly as I can. As I said earlier, we have already established a steering group on the back of last Thursday’s announcement about changes to acute services at Tyrone County Hospital. That group will have 10 subgroups, one of which will serve as an interface between us and the Ambulance Service. I have spoken to the chief executive of the Ambulance Service on several occasions in the past couple of days. Furthermore, members will be aware that the Minister has already invested an additional £1·4 million to enhance ambulance services for Omagh and Enniskillen and provide new deployment points in Castlederg and Irvinestown. That represents a significant investment, and we are working closely, as members would expect, with the Ambulance Service, which is confident that it will be able to meet the additional requirements that will be placed on it by 2 March.
The new hospital in the south-west of Enniskillen is a private-finance initiative (PFI) project, which will cost around £240 million to build. However, it is important to remember that the Department of Health, Social Services and Public Safety has already committed to investing £100 million towards the construction cost of the new hospital. Therefore, it is not an entirely PFI-funded project, as the Department has already committed to £100 million of capital funding from the public purse for the project. That means that the PFI company must secure £140 million. As part of the process, the trust has already reserved the right to direct the PFI company to secure 50% of that £140 million from the European Investment Bank, because its rates are very competitive. We are confident that there will be financial closure on the deal and that the final business case will be approved by the end of March. We are applying all of our energies to achieving that closure.
Mrs Hanna:
I appreciate your presentation, during which you spoke about the new models of working and in-reach speciality services. However, we are talking about a reduction in acute services, and I understand the real concerns of local representatives. On the wider issue, you said that ambulances would no longer take people to Tyrone County Hospital. If there is an emergency, will it be decided at source whether the ambulance should go immediately to Erne Hospital, or to somewhere else? Will all ambulances be diverted from Tyrone County Hospital, or just some of them?
The second part of my question is about maternity services in the wider Western Trust area. Do you anticipate any gaps between level of need and service provision, particularly if there is going to be a delay in the provision of the new hospital at Erne?
Mr McKinney:
I will clarify that. Dr Deeny will know the answer to this already, because he has been working with us. There are occasions when ambulances are called for people who do not have acute major medical conditions. Those are called category 3 calls; if someone falls and sprains a wrist or breaks an ankle, for example. There is no reason why a person with that sort of injury could not be treated in Omagh. We want to maintain in Omagh those services that can safely be carried out there.
The protocols that we have been discussing include the potential for a paramedic who picks up a call such as that to make direct telephone contact with the senior nurse in the urgent care centre. He can then describe the patient’s condition, and they can jointly decide the best thing to do. If the nurse at the urgent care centre feels that the condition is within their range of expertise — and I would expect them to be able to look after simple fractures, sprains, soft tissue injuries, or wounds — then those patients can go to Omagh to be treated.
The patients who cannot go to Omagh to be treated are those with acute medical conditions, who may suddenly develop life-threatening complications. I am thinking about people with severe asthmatic attacks, those suffering from an acute stroke, those with heart failure, patients who are diabetic who perhaps develop complications, people with belly pain where the cause is unclear. Those patients should not be taken to Omagh, because if they were and then required transfer from Omagh to another hospital, that would lengthen the journey before they can be given definitive care.
Mrs Hanna:
I was also thinking of acute traumas. If a patient is not going directly to the Royal Victoria Hospital or somewhere else because of a head injury, for example, then even if they are close to Omagh, the decision will be made to send them elsewhere. We have talked a lot about the golden hour, and exactly what is done.
Mr McKinney:
Absolutely. There is currently no surgical service in Omagh; that is one of the difficulties faced by physicians in trying to maintain services. There are trauma-divert protocols currently in place, as well as a working group, including local representatives, members of the Ambulance Service and staff from the emergency care and surgical services. In cases of trauma that is undiagnosed, and where the extent of internal injury is unknown, it is very important that the patient is taken to an acute hospital that has immediate access to intensive care.
For lesser trauma, where there is no threat to life — for example, in the case of an elderly person who has fallen and has a broken or painful hip — patients can be safely managed locally if there are diagnostic facilities, including X-ray. If such patients need further assistance, they can be moved. However, for major trauma, such as is found with road accidents, the environment, the level of staffing and the backup facilities in Omagh are insufficient.
Mrs Hanna:
My last word is about the “golden hour”, and where patients should be brought to. It is of particular concern in rural areas, close to Omagh or Enniskillen. Whoever is driving the ambulance must make a tough decision, and he or she must be well trained. We should even consider the possibilities offered by air-ambulance. Life-and-death decisions must be made quickly in those circumstances.
Mr McKinney:
You are absolutely right. The Ambulance Service has been training paramedics for a long time. I have been involved in the medical advisory panel for the paramedic service since it was initiated nearly 20 years ago. The Ambulance Service has a lot of experience of managing trauma and major incidents. It also rallies and brings support to its staff through officers and senior backup. Recently, it has recruited and trained additional paramedics, specifically for the area around Omagh. At the end of March, seven new paramedics will come on-stream.
Paramedics have a difficult job to do and they do it incredibly well. I see them at work every day: I pay tribute to their excellence and skills. They manage difficult situations at the roadside and in people’s homes. They understand the “golden hour” concept: when someone has a life-threatening injury, he or she requires care within 60 minutes if their chances of survival are to be maximised.
Mrs Hanna:
I do not wish to delay the Committee further. As regards stabilisation, are you saying that patients will not be going to Omagh?
Mr McKinney:
That is correct. Kieran has suggested the case of a child who has stopped breathing. We will not be putting such a child in an ambulance and driving around for an hour. That is why we need nursing staff in Omagh who have additional skills in life-support.
Mr Hanna:
I suppose that is why we have been getting back to —
Mr McKinney:
The Ambulance Service can provide life-support: many of them are involved in giving life-support courses. To give an example, an advanced life-support course is ongoing in Northern Ireland today and tomorrow. Leaders of that course include the consultant in emergency medicine at the Enniskillen hospital and my colleague, the consultant in emergency medicine at Altnagelvin Area Hospital. We are heavily involved in that training and try to make it available to junior doctors, senior nursing staff and to the Ambulance Service. It is crucially important that people on the front line have those skills because lives depend on it.
Mr Gardiner:
I take a different slant on the issue. I appreciate that all MLAs feel aggrieved when something bad is happening in their constituency. I would feel the same if it happened in Upper Bann.
Naturally, I support the Minister. He made the right decision, and I say to Minister McGimpsey, “Hear, hear.” When he made the announcement, hands were raised in horror that it was happening. However, I commend Mr McKinney for his frankness and openness in expressing his fears. It is not his wish that any part of the hospitals should close. He puts patients first. His service is stretched, but he puts the inconvenience to himself in second place. I put on the record my appreciation of his frankness, openness and sincerity. I hope he does not have to cope with any of the disasters that he fears, until things are properly sorted out.
Mr Buchanan:
On the back of that, may I ask why, if there is so much openness and transparency on this issue, our briefing for this meeting is marked “strictly confidential”?
Mr McKinney:
The briefing is marked strictly confidential because it is for the Committee’s eyes only, it is not intended for the hospital staff. We need to talk to our own staff and explain the issues to them and answer their own specific questions.
Mr Buchanan:
Therefore, this is an example of the openness and transparency that is practised by the trust — that something is strictly confidential. I think that that answers my question.
Mr McKinney:
The answers were to the Committee’s specific questions and that is why we answered them in those terms. I am sorry if you do not like that concept but we felt that it was important that the answers went to the Committee and not to anybody else.
Mr Lusby:
I understand that this is the normal convention. However, we are happy to share that detail with anyone — we have no difficulty with doing that. Most of the information is in the public domain anyway.
Mr Gardiner:
The witnesses simply did not want the information to be released until the matter was discussed at the Committee — that is standard procedure.
The Deputy Chairperson:
We must leave the issue there. I am sure that members will keep it under review and can take up specific issues with the trust. The Committee will also keep the matter under review.
Mrs Hanna:
I would appreciate it if the witnesses would respond to my question about maternity services another time as I am interested in that.