Nenagh Hospital is a 75-bed hospital serving a population of approximately 70,000 people, providing 24/7 emergency care to its patients.  In 2004, Nenagh Hospital treated 4,359 in-patients and 2,869 day cases.  There were 12,972 attendances at A&E and 11,067 at Out Patient Clinics.  Nenagh Hospital is part of a network of acute general hospitals with Limerick Regional hospital as its regional centre.  For the community, Nenagh Hospital represents a safety net, a first port of call in emergencies or when they become acutely ill.  It represents the opportunity to be treated or have a member of the family treated in the community, nursed by people you know and who know you.  It represents easily accessible and quality care. General Practitioners value the direct referral system which ensures that patients diagnosed as needing acute in-patient care are not waiting for hours on trolleys in an A&E department to be re-assessed by a junior doctor.

There are two blueprints that have been presented for the future of the Health Service – the National Health Strategy and the Hanly Report.  In the years since their publication, little clear progress has been made towards implementing the recommendations of these documents.  Neither gives clear direction for the future of this hospital that is in line with the current reality for patients and their families.  The future remains unclear, therefore any recommendations made must make sense under all futures.

The Hanly Report proposes changing Nenagh Hospital to a local hospital.  This would fundamentally alter the service offered making Nenagh Hospital, in essence, a location for elective day surgery and elective medicine, with a nurse-led minor injuries unit.  There would be no on-site medical presence overnight or at the weekends. Nenagh Hospital would not accept emergencies or be equipped or staffed to deal with them. But 90% of current in-patient admissions to Nenagh Hospital are emergencies.

Under the Hanly proposals, all Nenagh Hospital in-patients would go to Limerick Regional Hospital. Limerick Regional Hospital is one of Ireland’s busiest hospital’s with more 23,000 inpatient admissions and 50,000 attendances at A&E and a short length of stay.  Limerick Regional Hospital is currently short over 5,000 surgical bed days and 12,700 medical bed days to deal with its own workload. Nenagh Hospital patients use over 7,200 surgical and 18,000 medical bed days annually.  There are currently no plans to add bed capacity at Limerick Regional Hospital and the Hanly Report did not look at capital costs for this.

Hanly says “Patients in local hospitals would be treated under agreed protocols.” ¹  This is putting excessive faith in protocols.  There is a protocol already in place for major traumas, (eg serious car accidents), which states that these patients should bypass Nenagh Hospital and go directly to Limerick Regional Hospital.  However, major traumas still regularly arrive by ambulance to Nenagh Hospital for stabilisation before transfer.  Paediatric and obstetric emergencies also arrive at Nenagh Hospital in breach of long-standing regional protocols which state that they should go to Limerick.

There appears to be a significant gap between what is proposed for acute health services for North Tipperary and the need that is experienced on the ground.  Taking an attitude of “What we have, we hold” is not the answer.  However, if one looks at it from the perspective of “What we need, we hold and develop” we are closer to a solution.  There is an important question which must be asked: Would this report be necessary if Limerick Regional Hospital was a large, well-equipped major hospital with low bed occupancy and room in the Intensive Care Unit?  If there were beds and service guaranteed for the patients of North Tipperary?  If there was an ambulance service at every cross-roads adequately resourced and fully trained?  If inter-hospital transfer was a matter of one phone call?  If the roads were better?  The answer is probably not. However, these conditions do not yet exist.  Any change to services at Nenagh Hospital and within the region has to recognise this fact.

Maintaining the status quo is not enough.  Nenagh Hospital, like all hospitals, is changing constantly, because medicine is changing constantly.  More can be done, and should be done, for patients.  A hospital needs to develop and change, but that change has to improve patient care and patient safety in a real way.  If the Hanly Report were to be the blueprint for future hospital services, there would have to be a recognition that a significant period of overlap between the current situation and any future situation is required.  Services cannot be withdrawn or diminished when replacement services are not in place.  It is not reasonable and it is not safe. 

There are a number of foundation stones that will make change possible and which are valid under all futures:

• Links and cooperation between the local acute services at Nenagh Hospital and the regional acute services in Limerick Regional Hospital must be strengthened and developed at planning, management and operational levels.  This represents major organisational and cultural change and will not happen overnight.  Until the network is operating and cooperating smoothly and seamlessly, it is unrealistic to expect staff or patients to trust that changes to the system will improve patient care.
• Instead of North Tipperary patients joining the waiting list queue in Limerick Regional Hospital, there is the opportunity to reverse the flow and to use the facilities in Nenagh Hospital to allow many patients to be treated quicker and just as well.  This will be done by making theatre time available to surgeons from Limerick Regional Hospital.
• Increasing the number of specialist consultation clinics and access to Nenagh’s operating theatres for Limerick Regional Hospital surgeons, will permit the use of Nenagh Hospital’s potential for increased amounts of day case and 5-day surgery, not only for North Tipperary patients, but for patients across the region.
• One of the biggest problems for Nenagh Hospital is physical space.  There is insufficient space for current patient numbers.  The development of current and additional services is also curtailed by lack of space.  We propose the building of a Diagnostic and Treatment unit, housing A&E, Radiology including CT scanner, Laboratory and endoscopy and day surgery unit.  This will serve both GPs and other primary care professionals, as well as the hospital, giving quicker access to diagnostics for patients, improving the throughput on day surgery and endoscopy and, over time, reducing the number of in-patient bed days required and making the environment as good as the service.
• This will have the positive side effect of leaving space in the current building to decrease the size of wards, create more single rooms and improve the toilet and bathing facilities, thus improving patient dignity and privacy and the control of hospital acquired infection.
• Admissions processes at Nenagh Hospital are good.  Direct GP referral takes a wasteful loop out of the admissions process, prevents A&E pile-ups and has been shown to lead to appropriate admissions.  By creating an acute medical unit to process admissions, manage investigations and allow for admissions earlier in the day, there is potential for further increasing efficiency in use of in-patients beds and reducing out of hours costs.
• There are excellent relationships between Nenagh Hospital and primary care.  These links must be strengthened and developed further, giving direct access to General Practitioners to a wider range of services.  While these services are being developed, there are a number of facts which must be taken into account:
• 96.75% of the patients who present at Nenagh Hospital are treated safely and more cost effectively there than in Limerick Regional Hospital or elsewhere.
• Improving the inter-hospital transfer system is essential to protecting the other 3.25% of patients.  Until inter-hospital transfer is 100% reliable introducing new models of healthcare will be difficult.
• Because Limerick Regional Hospital is overwhelmed by its current workload, it has no room for North Tipperary patients. In the interests of the safety of the people of North Tipperary, Nenagh Hospital must continue to accept and treat acute medical and surgical patients on a 24/7 basis.
• Nenagh Hospital acts as an assessment centre for acute patients in North Tipperary, ensuring that only those patients who will benefit from the specialist teams offered in Limerick Regional Hospital are transferred, thus keeping the use of this more expensive resource for those who truly need it.
• Nenagh Hospital, Ennis Hospital and St. John’s Hospital together care for 53.8% of the all medical in-patients and 59% of general surgical in-patients in the in the Mid West. They must be properly resourced to do this.
• 90% of admissions to Nenagh Hospital are emergencies.  A 24/7 A&E service staffed by experienced doctors and under the responsibility of consultants is essential. A small hospital responds to major emergencies as a unit. Maintenance of current skill levels amongst doctors and nurses in Advanced Trauma Life Support, Advanced Cardiac Life Support and Basic Life Support techniques, is imperative.

Reasonable capital investment in Nenagh Hospital at this stage will ensure that a good service becomes even better.  It will prepare Nenagh Hospital for the future and provide increased support to the acute hospitals network in the region.  Realistic long-term plans must be made now.  Nationally, the contribution of hospitals like Nenagh and the range and volume of work they do has been underestimated.  As a result, so has the negative impact of reducing and/or moving the services they offer. Small hospitals treat large numbers of patients. In 2004, the largest 12 hospitals accounted for 246,902 in-patient admissions.  The other 329,571 in-patient admissions to acute hospitals were to smaller units.²

Smaller hospitals have found innovative solutions to some of the problems that are proving intractable in larger units, and already have the strong links with primary care that are so desired by larger urban hospitals.  Small hospitals work and represent value for money.  Average daily bed cost at Nenagh in 2004 was €711, compared with €956 for Limerick Regional Hospital and St Vincent’s Hospital at €1,158, yet the majority of in-patients in acute general hospitals are treated for the same conditions – heart attacks, strokes, infections, urgent operations and urgent treatment of cancer cases.

There is a critical range of services that a hospital must provide to ensure that it can safely accept acute patients.  Removing or compromising any one of these will lead to problems with the hospital’s ability to deal properly and safely with acutely ill patients.  The National Health Strategy, 2001, promised every citizen a health system based on the principles of Equity,  People- Centredness, Quality and Accountability.

It promises a system that:

“Supports and empowers you, your family and community to achieve your full health potential, that is there when you need it, that is fair and that you can trust.”

This report concludes that Nenagh Hospital is an essential element in delivering on this promise for the people of North Tipperary.

¹ Report of the National Taskforce on Medical Staffing, 2003, p68.

² Integrated Management Returns, Dept of Health & Children, 2004