In June 2003, The Report of The National Task Force on Medical Staffing was published. This, of course, is more commonly known as the Hanly Report. It was the third of a trinity of major reports on reform of the Health Service, following those of Brennan and Prospectus. A major part of the remit of Hanly was to devise a strategy for implementing the European Working Time Directive (EWTD) within the Health Service, which would mean a significant reduction in the working hours of NCHDs. Hanly’s initial approach was to focus on two pilot areas: the East Coast Area Health Board and the Mid-Western Health Board.
North Tipperary falls within the latter region and is served by Nenagh General Hospital, while other hospitals within the greater Mid-West area include Ennis, St John’s, Limerick and the large Limerick Regional Hospital. To say that the Hanly Report came as a bombshell to the people of North Tipperary and Clare would be an understatement. The logic of the report would mean a serious diminution in the services offered by Nenagh and Ennis (plus St John’s) because of a proposed area-wide concentration of acute services in the Limerick Regional. Nenagh would lose its acute beds because no doctor would be present in the hospital at night, and its 24-hour doctor-run A&E would be downgraded to a 9-5 nurse-led minor injuries unit.
For the remainder of this piece I will concentrate on Nenagh General, my local hospital, and outline how the residents of North Tipperary have reacted to Hanly, and the implications thereof, since its publication. Also, how in the intervening period, the rollout of the report has materially affected (or not) the services offered by the hospital. Those of you who live and work in our cities, particularly Dublin, might learn something of the concerns and the way of life of those who live in the greater part of this country.
The Government initially held back the report and it was October before the contents of Hanly became public knowledge. When they did emerge, the reaction locally was one of great unease and anxiety. This was followed by waves of anger and defiance. In time-honoured fashion a public meeting was called. This was held in a Nenagh hotel in October. Even though over three hundred attended, the impact of the meeting was somewhat diluted due to a boycott by certain local politicians after a squabble concerning the politics and agenda of the main organisers.
Nonetheless, the gathering had a galvanising effect on those present and the extent of community determination was very evident. It was known that the Hanly team, including David Hanly himself, were coming to town in a few weeks to address the populace, so a decision was made to pull out all the stops in organising an appropriate welcome. Furthermore, the skeleton of an Action Group was formed.
On November 10, a miserable Monday night, this second public meeting was held. The same hotel as before but a much larger hall. Even then, the venue was far too small. Long before the proceedings were due to commence the place was packed. Every seat was taken, the aisles were lined, people were five deep at the back and dozens spilled out the doors into the corridors. If there had been rafters, people would have been hanging from them. Over a thousand souls were in attendance. And every single one was deeply unhappy.
It was into this cauldron that David Hanly stepped, accompanied by a four-person backup team. The event was chaired by the local Mayor – an independent councillor. Among others present for the occasion were Máire Hoctor TD (FF), Michael Smith TD (FF), Michael Lowry TD (Ind) and Sen. Kathleen O’Meara (Lab).
The evening began in a calm atmosphere with the audience listening politely to the presentation of the Hanly team. Slides and graphs were produced, facts and figures were tossed around, while the soothing tones of reassurance comprised the soundtrack. But unfortunately for these hapless salesmen, the audience were having none of it. As soon as they’d made their pitch and the meeting was thrown open to the floor, the floodgates ruptured.
At the time, the term “shock and awe” was in vogue and it was quite something to witness a local version of this phenomenon. Certainly Mr Hanly and his colleagues couldn’t have anticipated the wrath that these otherwise mild-mannered people held in their hearts for the smooth-talking “experts” at the top table. One after another, a long succession of speakers proceeded to tear strips off the interlopers who dared to suggest the downgrading of Nenagh Hospital. And this wasn’t blind abuse. Far from it. Rather, most of the speakers proved to be highly informed on the issues, with several actually holding and quoting from copies of the Report itself. Many of the contributors were health professionals including local GPs.
As time passed one could see the Hanly quintet visibly wilting, discretely checking their watches and eyeing the exits. Finally, after just over an hour, they were allowed to depart the scene looking somewhat punch-drunk. Tails were tucked firmly between legs. But the evening’s drama was far from over.
After the retreat of Hanly & Co, it was time for the politicians to be heard. The opposition parties went first. One after another they stood up and roundly condemned the proposals. But the real fun came when it was the turn of the two local Fianna Fáil deputies to contribute. First up was Nenagh woman Máire Hoctor. To sporadic booing she somewhat hesitantly, but gamely, supported the Hanly vision, claiming that Nenagh Hospital would reap “serious benefits” from the implementation of the report. In the circumstances, this was a bad move.
She was immediately followed by party colleague and Minister for Defense Michael Smith, a Roscrea man. This fellow has been around the block a few times and knew which way the wind was blowing. Consequently, he approached the mic and declared that he “refused to endorse” the Hanly Report. Cheers all round. At this point I spotted a local journalist heading for the exit and overnight the story went national.
Back in the hall the meeting edged to a conclusion with a proposal to organise an anti-Hanly march in the town as soon as possible. This was agreed by acclamation.
We all know what happened next. The fallout from the Smith/Hoctor fiasco made the national newspapers for several days afterwards. Smith himself stuck to his guns till the end of the week, at one point telling RTE that his constituents should “not be sacrificed on the altar of the Hanly Report”. Finally Bertie decided to act and reportedly gave the Minister quite a dressing down over the phone. Apologise or resign or be fired. Late on the Friday night Mr Smith issued a statement expressing “regret” for his remarks. But his ministerial career was effectively over and he subsequently lost his portfolio at the next reshuffle.
Less well known is the U-turn performed by Deputy Hoctor. During the week following the meeting she issued a statement declaring that whereas she had originally supported the Hanly Report, “I do not do so now”. It is not known if she was reprimanded for this change of heart. Meanwhile back at local level, planning proceeded apace for the street demonstration and the Nenagh Hospital Action Group (NHAG) was put firmly in place.
The march took place on Nov 29, a Saturday. On the previous Sunday a notice of the event was read out at all masses in North Tipperary. During the week all school pupils had been informed and urged to attend, while volunteers scattered throughout the region putting up posters. On the day itself, all sporting events in the county were cancelled.
An impressive 10-15 thousand people showed up in Nenagh, contributing to a noisy, colourful and almost carnival-like atmosphere. Nothing like it had been seen in the town in living memory. Beginning at the hospital itself, the march wound its way through the streets to the assembly point at Banba Square, the largest open area in the town centre. There, in the shadow of the imposing Court House, a large stage had been erected.
Over the next hour or so a number of speakers addressed the crowd. There were local hospital consultants, GPs, nurses and ambulance personnel. There were senior members of the GAA, the IFA, the ICA. Local business people. All listened to by a mass of the "ordinary" people of North Tipperary. In short, a community united. Support was added by a speaker from Monaghan, one of the many visiting contingents. A lady beside me remarked that the occasion reflected true democracy in action. No one present would have disagreed.
In the months that followed, the report and all that flowed from it receded from the front pages. The people had spoken and now the ball was back with the politicians. Life went on. Along the way there was talk of Hanly 2 - the application of the report's philosophy across the entire country, which would reduce the number of acute hospitals to around 12. Attempts were made within each of the pilot Health Board areas to set up local implementation bodies. These were supposed to work out the nuts and bolts of actually putting Hanly into practice. People were nominated, meetings were held, but it all went nowhere. Initiatives fizzled and died. Then David Hanly was removed from his position by new Health Minister Mary Harney. The report was effectively shelved.
But it hadn't gone away, you know. And, in many ways, this was the worst of all possible worlds. Within the hospital system generally, the result was stagnation and no small amount of demoralisation as staff at all levels were left in Limbo-land, not knowing what was going to happen. This was certainly true in Nenagh, and spirits were not raised by signs of Hanly by stealth. In the period since the publication of the report, there has been a failure to fill two vacant consultant positions within the hospital, in surgery and anaesthetics. Also, since the retirement of the incumbent, the position of Hospital Manager has been left vacant for over a year. Currently, this position is being filled on a part-time basis. On a national level, the tragic debacle of Monaghan has served to confirm everyone’s worst fears.
Officially, the song remains the same. When, after a few false starts, Prof Brendan Drumm was appointed head of the new Health Service Executive, he asserted that no alternative to Hanly had been put forward. Michael Scanlan, Secretary General of the Department of Health, has declared that the Hanly Report is still the blueprint for the future of hospital services. So, as far as Nenagh and other hospitals are concerned, the Sword of Damocles remained unsheathed.
It was within this atmosphere of continuing uncertainty that, last Autumn, the Nenagh Hospital Action Group decided to take the initiative. “They won’t tell us where we’re going”, went the reasoning, “so let us tell them where we want to go”. It was felt that the powers-that–be had no concept of the role that Nenagh Hospital played in the community within which it existed, so it was up to those who knew to tell them. And to chart a way forward. The idea was to outline a future that would meet the needs of the people of North Tipperary, while being possible and safe for the hospital to deliver.
The project was quickly set in motion. An independent Project Manager, Ms Lorna Carney, was hired, and fortunately was in a position to begin work immediately. Though not based in the region, this lady virtually relocated to Nenagh for the duration. A Project Group was formed consisting of members of the Action Group, some local GPs, and health professionals from within the hospital itself. An intensive series of meetings and consultations got underway.
Ms Carney must have worn out several pairs of shoes and several sets of car tyres as she shuttled back and forth between all of those with an input. Health professionals, administrators, activists, representatives of the HSE – all were spoken to and spoken to again. And again. A series of meetings in towns and villages across the county elicited the views of the general public. Facts and figures and tables and charts were assembled. Meetings were regularly held at 7am. And gradually, a consensus and a vision for the future began to emerge.
It should be mentioned here that this process of consultation stands in stark contrast to that engaged in by the creators of the Hanly Report. Several times they tried on the line that their report was "the distilled wisdom of the medical profession" but this was, to be kind, somewhat economical with the truth. The views of most of the people they spoke to were ignored.
Meanwhile the Action Group was busy organising fund-raising events to pay for it all. These proved amazingly successful. There were table quizzes, race nights, card drives, you name it. All the towns and villages across the county participated and substantial amounts of money were raised in support of the project. One particular table quiz, held in Nenagh and involving GAA clubs from around North Tipp, generated a phenomenal €12,000. Here again was a united community rallying around.
At the time of writing, the report on Nenagh Hospital has just been published. What happens next is of vital importance. The Project Group will not be lacking in energy in ensuring that it finds its way into all the relevant hands and in insisting that they sit up and listen. The members of the group are determined that this has a national impact. As mentioned above, Prof Drumm has spoken of there being no alternative to Hanly. Well now there is one for Nenagh, and it is reasonable, well-considered, practical and, above all, in the best interests of patients. And it has the support of all the people in the region. But will 'they' listen?
There is a tendency for Dublin-based "experts" and Dublin-based media commentators to be totally dismissive of the concerns of rural communities throughout this country. Any agitation that develops beyond Newlands Cross is considered at best an irritant and at worst an irrelevancy, by this mindset. It is sneeringly declared that campaigners want to have "a hospital at every crossroads". This Dublin-centric mentality is only indicative of a profound ignorance of how citizens beyond the Pale actually live their lives and what worries they encounter day to day.
If I was run over by a bus on Dublin's Baggot St or Dorset St, I could be happy in the knowledge that there are several acute hospitals within a few miles. If Nenagh Hospital is downgraded, we are talking about journeys of fifty miles or more from parts of North Tipperary to Limerick. Imagine collapsing on O'Connell St and having to be ferried to Portlaoise for treatment. This is the reality.
For several years now, the glue that holds rural Ireland together has been dissolving. Towns and villages across the country have been losing post offices, banks, Garda stations and other services which city dwellers take for granted. I suppose it could be said that none of these are matters of life and death. No, but hospitals are. Let the rot stop here.