Development of orthopaedic services: a discussion document

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Authors Comhairle na n'Ospideal

Publisher Comhairle na n'Ospideal

Download date 30/09/2021 07:48:48

Link to Item http://hdl.handle.net/10147/248533

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Comhairle na n-Ospideal

Development of Orthopaedic discussion docu CONTENTS

Section 1: Introduction Page 3/ 4

Section 2: Factual Information Page 4/5

Section 3: Generai Observations on the Existing Situation Page 6/7

Section 4: General Considerations Relating to the Future Organisation of Orthopaedic Services Page 7 / 10

Section 5: Bed Requirements in Orthopaedics Page 10/11

Section 6: Recommendations on the Development of Orthopaedic Services in each Health Board Area Page 11 (i) Eastern Health Board Area Page 11/13 (ii) North- Eastern Health Board Area Page 13/14 (iii) Midland Health Board Area Page 14 (iv) South-Eastern Health Board Area Page14/ 15 (v) Southern Health Board Area Page 15 / 16 (vi) Mid-Western Health Board Area Page 16 (vii) Western Health Board Area Page 17 (viii) North-Western Health Board Area Page 17

Section 7: Consultant Manpower Requirements in Orthopaedic Surgery Page 18 / 19

Section 8: Postgraduate Training Programmes at Senior Registrar Level Page 20 CONTENTS continued

Section 9: Miscellaneous Page 21 9.1 Peripheral Outpatient Clinics Page 21 9.2 Geriatric Services Page 21 9.3 Orthopaedic Nursing Page 21 9.4 Convalescent Orthopaedic Accommodation Page 21 9.5 Rehabilitation Services Page 22

Appendix A Elective Orthopaedics -In-patient Statistics 1975 Page 23/24

Appendix B Orthopaedic Out-patient Statistics 1975 Page 25/27

Appendix C Hospitals Providing Significant Accident & Emergency Services Page 2

Appendix D Extract from "Discussion Document on Hospital Bed Population Ratios - A Basis for Acute Hospital Planning" , (Department of Health, January, 1976). Page 29/30

Appendix E Submission by the Irish Institute of Orthopaedic Surgeons Page 31/36

2 Section 1 - Introduction

1.1 Arising from its consideration of a Comhairle is greatly indebted to number of applications, submitted Mr. MacAuley for his whole­ by various hospital authorities, hearted participation in the work for the appointment of additional of the sub-committee and for the consultant orthopaedic surgeons invaluable assistance which he and because of the feeling on the rendered to the exercise. part of the members that there was a need to examine the 1.3 The first meeting of the sub­ organisation of orthopaedic ser­ committee was held on 31 st vices in the country generally, the March, 1976. In pursuance of its Comhairle decided, early in 1976, task, the sub-committee, in to establish a sub-committee on addition to holding meetings of orthopaedic services under its own members, also visited the Section 41 (7) of the Health Act, following hospitals and held dis­ 1970. The task of the sub-com­ cussions on general problems in mittee was one of fact-finding to the field of orthopaedics with the ensure that the Comhairle would administrators and consultants have available to it all the associated with these hospitals :- necessary information to enable Merlin Park Regional Hospital, policy to be deterlJ1ined in the Galway, field of orthopaedics. In addition, Sligo General Hospital, the sub-committee was requested Ardkeen Hospital, Waterford, to consult with the various Kilcreene Orthopaedic Hospital interests concerned for the pur­ Kilkenny, pose of identifying the main Croom Orthopaedic Hospital, problems to be faced and possible Limerick, solutions to these. Finally, the St. Mary's Orthopaedic sub-committee was asked to Hospital,Gurranabraher,Cork, make recommendations to the Orthopaedic Unit, Navan Comhairle on the issues which Hospital, they identified. Cappagh Orthopaedic Hospital, Dublin (including Temple The following members of the Street and the Mater Comhairle were appointed to Hospitals) serve on the sub-committee:- Dr. Steevens' Hospital, Mr. J. S. R. Lavelle (Chairman) Discussions were also arranged Professor Eoin O'Malley with (i) the consultants from St. Mr. G. A. McLean Lee Laurence's Hospital, Jervis Street Mr. P. G. McQuillan Hospital and Our Lady's Hospital Mr. G. P. Martin (Chief Officer) for Sick Children, Crumlin, (ii) officials and consultant general In addition, Mr. Patrick MacAuley, surgeons from the Midland Health Consultant Orthopaedic Surgeon, Board, (iii) representatives of the who is not a member of the Senior Registrars in Orthopaedics, Comhairle, was invited, with the (iv) representatives of St. approval of the M inister for Vincent's Hospital, Dublin, and Health, to participate in the work (v) representatives of the Irish of the sub-committee and he I nstitute of Orthopaedic accepted the invitation. The Surgeons. 3 1.4 The sub-committee, which com­ vices incorporates the findings pleted its task in February, 1977, and the recommendations of the was greatly assisted by the advice sub-committee. It has been and information supplied by the adopted by the main body of the various groups with whom Comhairle and has been discussions were held. The forwarded to the Minister for Com hairle wishes to record its Health and to the health boards sincere appreciation to the many in pursuance of the advisory individuals who participated. function of the Comhairle on the organisation and operation of 1.5 This discussion document on the hospital services (Section 41 (1) development of orthopaedic ser- (b) (iii) of the Health Act, 1970).

Section 2 Factual Information

2.1 Basic figures on in-patient The Children's Hospital, services are set out in Appendix Temple Street, Dublin A and on out-patient services in Appendix B. North-Eastern Health Board The existing situation is sum­ Area: marised in the following para­ Orthopaedic Unit, Navan graphs. Hospital, Co. Meath (82 beds·) 2.2 Orthopaedic Units - In-patient services for elective or "cold" South-Eastern Health Board orthopaedics are provided at the Area: fifteen hospitals listed below. Kilcreene Orthopaedic Hospital, (An asterisk denotes beds used Kilkenny (90 beds*) exclusively or mainly for elective Ardkeen Hospital, Waterford surgery) . (38 beds) Eastern Health Board Area: Cappagh Orthopaedic Hospital, Southern Health Board Are . Dublin (200 beds*) St. Mary's Orthopae Jervis Street Hospital, Dublin Hospital, Gurranabrah I , (20 beds approximately) Cork (187 beds*) St. Laurence's Hospital, Dublin (8 beds approximately) Mid-Western Health Board James Connolly Memorial Area: Hospital, Blanchardstown, Croom Orthopaedic Hospital, Dublin (20 beds*) Limerick (120 beds*) Adelaide Hospital, Dublin (28 beds) Western Health Board Area: Merlin Park Regional Hospital, Dr. Steevens' Hospital, Dublin (32 beds) Galway (176 beds*) Meath Hospital, Dublin B~tween them, these hospitals Our Lady's Hospital for Sick provide a total of about 1,061 Children, Crumlin, Dublin beds (0.36 per 1,000 population) (60 beds) of which 875 (those with asterisk)

4 are exclusively or mainly used for 2.4 Out-patient Clinics: According elective surgery, the remaining to the information available to the 186 beds being available for both sub-committee, out-patient elective and traumatic ortho­ clinics are conducted by ortho­ paedics. It will be noted that only paedic surgeons at 41 centres four of the fifteen units have more (mainly general hospitals) than 100 beds. Five of the ortho­ throughout the country, involving paedic units are physically approximately 250 clinics per separated from a general hospital month (see detailed breakdown (Cappagh, Kilcreene, Gurrana­ at Appendix B). Some of these braher, Croom and Merlin Park) centres are situated a consider­ and these include the largest of able distance away from the the units comprising, between orthopaedic unit at which the them, 73% of the beds available consultants are based, notably in for elective work. In several the case of the Merlin Park unit instances, the lack of a second and the Navan unit. Figures of operating theatre was cited as a first attendances and total attend­ major deficiency as was also the ances which are available only absence of adequate clean-air in respect of the West North­ systems in theatres for the control West South and part of the East of infection. and Mid-West indicate a ratio of 1 : 3. During the course of 2.3 Accident Hospitals: There is a several discussions with local total of 40 hospitals in the consultants, comments were country which receive a signifi­ made about the lack of bas ic cant number of accident and facilities (e.g. radiology) at some emergency cases. These are listed centres where clinics are held and at Appendix C. There are no also about the large number of figures available to indicate the relatively minor complaints which number of beds used for trauma are referred to specialist cl inics cases. Of these 40 hospitals, only particularly from the school 13 have a significant presence medical service. (i.e. attendance on a regular and frequent basis by orthopaedic 2.5 Convalescent Accommoda­ surg30ns), 10 have no ortho­ tion: Separate convalescent paedic surgeon associated with accommodation, to which long­ them and the remaining 17 have stay patients can be transferred, limited access to the services of is available in only a small number an orthopaedic surgeon, mainly of areas - the Incorporated on the basis of out-patient clinics Orthopaedic Hospital, Clontarf, held on either a weekly, fort­ (131 beds - mainly adult). nightly or monthly basis during Leopardstown Hospital, Dublin, the course of which consultant and St. Joseph's Hospital, Coo le, advice is usually made available Co. Westmeath . for in-patients as well. Of course, it must be noted that, in many of the hospitals with either limited or no access to an orthopaedic surgeon, there are general surgeons who are experienced and competent in the treatment of musculo-skeletal injuries. 5 Section 3 -General Observations on the Existing Situation

3.1 The general view within the 3.2 At present, there are no ortho­ medical profession is that an paedic units within the country elective orthopaedic unit should which meet the ideal requirements ideally be an integral part of a described in the preceding para- general hospital and be located graph. Only three units on the same site. Again, ideally, Cappagh, Gurranabraher the unit should cater for a Merlin Park - are of the s le sufficient volume of patients to suggested as optimum (and then enable expertise to be developed only Cappagh in relation to the in the different surgical techniques number of consultants on the and to facilitate some degree of staff) but these suffer from being specialisation and research - an physically separated from the optimum size might be a con­ general hospitals. In the case of sultant staff of about 6 ortho­ the western region, there are paedic surgeons with supporting plans for the integration of Merlin facilities and approaching 200 Park and Galway Regional Hos­ beds. The elective orthopaedic pitals. Although, in the case of unit should be in a separate unit, Cappagh and Gurranabraher in but it should preferably be located particular, excellent arrangements on the general hospital campus, have been introduced for close particularly in view of the role of liaison with a general hospital the orthopaedic surgeon in trauma or hospitals, nevertheless, they which is best treated within the fall short of the ideal. The units general hospital itself. Because which are located within many accident victims with general hospitals tend to be multiple InJunes suffer from on a small scale and in many fractures, ready access to the instances they do not have services of an orthopaedic an identifiable number surgeon is important, perhaps beds devoted to elec vital in some cases, for the proper orthopaedics. I n addition, management of patients. Paedi ­ operating theatre arrange­ atric orthopaedic surgery should ments are either inadequate preferably be performed in a or insufficient and many are situation where all the necessary without the "clean-air" nursing and other expertise for systems appropriate to a the care of children can be made modern orthopaedic service. available and the general environ­ ment is suitable to the needs of 3.3 The lack of a significant the child. However, the paediatric presence of orthopaedic sur­ unit should be closely associated geons at 27 of the 40 hospitals with an adult unit and the in the country which receive paediatric orthopaedic surgeon accident cases (see par. 2.3 should be a member of the staff above), is a deficiency of of the adult unit. serious concern in the

6 present services. In the certain rural areas, is the long Comhairle's view it justifies distances that surgeons have to an increase in the number of travel to conduct many out­ orthopaedic surgeons. patient clinics at peripheral centres. 3.4 With regard to out-patient ser­ vices (see par. 2.4 above), the 3.5 The waiting list situation, particu­ Comhairle considers that the need larly for in-patients, is unsatis­ for the number of clinics held at factory in many instances: the some of these centres must be waiting period, mainly for hip open to question. It is recom­ replacements, can be as long as mended that each orthopaedic two years. While a detailed unit should review its arrange­ analysis of those on the waiting ments for out-patient services, lists would be necessary before at regu lar intervals, with the aim comment in depth could be made, of achieving greater centralisa­ it is clear that the main problem tion. Clinics should not be con­ lies in the field of hip replacement, tinued at centres where the basic for which the demand has grown facilities, particularly x-ray enormously over the last few facilities, are inadequate. The years. The reasons for such long limited information available waiting periods are many, in­ about the ratio of first attendances cluding the backlog of demand, to total attendances suggests that the lack of theatre facilities, a there are a sizeable number of less than maximum use of avail­ unnecessary referrals to clinics - able consultant manpower and the ratio of one new patient for and also a shortage of consultants. every three return visits points to It must be borne in mind that hip the fact that many of the new replacement operations take patients have relatively trivial about 1 ~ hours and tax the problems. A further feature which physical energy of the consult­ applies, particularly in the case of ant.

ection 4 - General Considerations relating to the Future Organisation of Orthopaedic Services

4.1 The Comhairle considers that, in in the context of the Government the future planning of services, decisions on the future develop­ the policy should be to locate all ment of the general hospital orthopaedic units on the site of a system. The plans announced by general hospital. Because ortho­ the M inister for the general paedic services are an integral part hospitals in the ma in centres of of the general hospital system, it population (i. e. Dublin and Cork) is necessary to approach the are based on population catch­ question of future organisation ments of about 250,000 and also 7 involve the co-ordination of ser­ the general hospitals. In recom­ vices between hospitals each of mending this organisational which will, in itself. be of the approach, the Comhairle wishes order of 600 beds. Catchments of to stress that health board this size do not present viability boundaries should not inhibit problems for the orthopaedic patients going to the hospital that services, so that it is possible to is most convenient for them. aim for optimum size units as proposed in paragraph 3.1. 4.4 It appears to the Comhairle that if present trends continue, a 4.2 However, outside Dublin and professional problem of serious Cork, serious viability problems proportions is inevitable. It arises arise. In most cases, the popula­ thus: in the past, general surgeons tion catchments on which the received a wider training th general hospital system will be they do now. This includ " developed, are often less than experience in the field of skeletal 100,000. Even a population of trauma, which was. appropriate 100,000 is insufficient to support to the small hospital situations in a minimum scale-unit of two which they provided a wide range orthopaedic surgeons, for two of general services. However, surgeons, each with a reasonable the advancement of surgical tech­ workload, could service a popula­ niques on both the general and the tion of about 140,000. The orthopaedic sides has resulted in Comhairle considers that single­ the emergence of trained ortho­ surgeon units should not be paedic surgeons who specialise developed, although it is and general surgeons who will acknowledged that, in some cir­ not undertake major elective cumstances, units which would orthopaedic surgery. Despite this have two or more consultant staff trend, there is as yet a sizeable may have to be built up over a number of general surgeons in period. It is clear, however, that provincial hospitals who are inter­ the provision of an orthopaedic ested and competent in treating unit at every general hospital musculo-skeletal injuries. How­ designated by the Government ever, to an increasing extent, for future development would not general surgeons, and especially be a viable proposition. the younger, are tending t regard this type of surgery 4.3 The Comhairle recommends outside the scope of the I that the future organisation expertise and are seeking to have of the orthopaedic services orthopaedic services made avail­ should be based on health able to them. Perhaps the most board areas with the aim of significant fact to confirm the developing an elective ortho­ present trend is the emergence paedic centre in each area of formal postgraduate training while making provision for programmes in general surgery consultants to be available which do not incorporate, at to some extent at each higher specialist level. specific general hospital within the training in the treatment of injuries health board area_ The pattern of the musculo-skeletal system. of alignment between health board For formal training purposes, areas for the purposes of teaching fractures are regarded as falling and the referral of special cases within the realm of orthopaedic should be that which applies to surgery. Coupled with this is the 8 firm medical view that primary between the orthopaedic surgeon trauma should be treated in a and the general surgeons. Under general hospital by a consultant such management arrangements, team which includes orthopaedic the orthopaedic centre should be surgeons. Since units for elective obliged to admit acute major orthopaedics cannot be justified fracture cases if requested by the at every general hospital, the general hospital. The orthopaedic problem arises of how to cope surgeon involved could be either with fractures at those general (i) based at the regional centre hospitals where orthopaedic sur­ and travel on certain days to the geons will not be based. There is general hospital or (ii) live in the also the important point that the vicinity of the general hospital treatment of trauma must precede and attend on certain days at the the treatment of fractures and regional unit to perform elective there will be a continuing need surgery. The arrangement to be for general surgeons to be proper­ adopted could be decided locally ly trained to deal with trauma in each case. problems. Because of the volume (b) General surgeons, before of patients involved and indeed, being appointed to a general the expectation on the part of hospital with no orthopaedic unit, the general public that such a should have, or be obliged to basic service should be available acquire before taking up duty, in their local general hospital (as adequate training and experience it has always been in the past) it of about one year's duration in is not feasible to consider the the management of fractures. organisation of a trauma and Back-up consultant orthopaedic fracture service solely on a region ­ services would still be required al basis. from a regional unit.

4.5 The Comhairle suggests that the Neither of these suggestions is following would be appropriate ideal, but they offer some solution methods of coping with this to the basic problem, namely, how increasing problem :- to supply some sort of service to (a) Every regional elective ortho­ the large number of relatively paedic centre should be associ­ small general hospitals in the ated with a particular general country. hospital and also be responsible for providing orthopaedic services 4.6 The Comhairle considers that the to the other general hospitals in its suggestion at (a) represents the catchment area . Each orthopaedic better solution for the majority of surgeon from the regional centre general hospitals w ith no ortho­ should have a formal appoint­ paedic unit, provided adeq uate ment to a particular general hos­ arrangements are made to pro­ pital in the catchment area vide continuous consultant cover involving a commitment to visit at the regional centres. I n certa in that general hospital on a regular areas, where the distances in ­ basis (minimum of one visit per volved may be such as to make it week) to conduct out-patient impracticable for the orthopaedic clinics and to provide an in ­ surgeon to travel on a frequent patient consultation service. The basis, the solution at (b) would be management of fracture cases appropriate. Th e Comhairle would be by arrangement strongly recommends that the 9 continuing need for general sur- 4.8 The Comhairle has given con­ geons to have experience in sideration to the question of how trauma in order to meet the needs a scoliosis service might be in a number of areas in this organised. At the present time, country should be impressed by Cappagh Hospital is the main the appropriate training body on centre which specialises to an senior registrars in general surgery appreciable extent in the treat­ so that the individuals concerned ment of this cond ition, but other might select their optional training units have expressed a desire to areas with this in mind. develop a service. Is such a development desirable? The following points are relevant. The equipment involved is not unduly 4.7 At the present time, a degree of expensive. Because of the size sub-specialisation is evolving the population of this country, within the field of orthopaedic small caseload can be expected, surgery. It is expected that this but up to four months hospitalisa­ trend will continue and the tion may be involved for each Comhairle considers that special child. This presents a problem of interests should be encouraged. schooling. There is also a problem However, in itially, these should of patient management, in be confined to the larger centres monitoring the growth of the at Dublin, Cork and Galway. The child (from 6-18 years) and in areas of special interest which developing the level of surgical seem to be emerging at present expertise required. A national are in the fields of specialised centre would, the Comhairle joint replacement (excluding hip thinks, result in a child being seen replacement), rheumatoid arth ­ earlier and thus less corrective ritis, particular aspects of ortho­ action would be needed later. paedics in childhood and Essentially this issue is a matter scoliosis. Consideration might for the profession, but there also be given to the inclusion of appears to be a strong case for a hand surgery in this category. national centre for scoliosis.

Section 5 -Bed Requirements in Orthopaedics

5.1 Attached as Appendix D is an specialty because of the close extract on bed requirements in association with general surgery orthopaedics from the "Dis­ and because of the difficulty of cussion Document on Hospital separating the bed needs for Bed Population Ratios - a basis elective orthopaedics from for acute hospital planning", trauma. It recommends a bed issued by the Department of population ratio of 0.4 per 1,000 Health in January, 1976. This population, but points out that extract refers to the difficulties in this must be considered in con­ identifying bed needs for this junction with the ratio of 0.6 beds 10 per 1,000 population recom­ able to assume that there is, in mended for general surgery. The general, no serious underpro­ document states that, in practice, vision of elective orthopaedic the 0.4 for orthopaedics would be beds on a national level. How­ found partly in regional ortho­ ever, the distribution ofthese beds, paedic units, partly in smaller both from a geographical and traumatic/orthopaedic units in a medical organisational view­ acute hospitals and partly in point, is less than ideal as this general surgical units. It is clear report has attempted to show. from this document that there are no specific guidelines available 5.2 The Department's document re­ on bed needs for elective ortho­ fers to the upsurge in demand for paedics. The Comhairle, from the joint replacement operations and information which it has gathered, to a projected study to measure estimates that the present bed this demand. A survey to be complement available exclusively undertaken by the Department or mainly for elective ortho­ in the near future will, it is hoped, paedics is approximately 0.36 reveal more detailed information per 1,000 population - a figure on the volume of orthopaedic that excludes convalescent-type services being provided, both in accommodation but includes a orthopaedic and general hospitals, limited number of trauma beds and on the unmet demand as (see par. 2.2 above) . It is reason- reflected in waiting lists. Section 6 - Recommendations on the Development of Orthopaedic Services in each Health Board Area

(i) Eastern Health Board Area 6.2 In this area there are three groups, The Comhairle thinks that long­ each associated with a medical term objectives should be school. In general, orthopaedic identified now in order to ensure services in Dublin tend to revolve that whatever short to medium around the three medical schools term plans are adopted should be rather than being grouped geo­ in harmony with the ultimate graphically. development of the services on the lines suggested above. Since, (a) Cappagh Orthopaedic Hos­ in many instances, site develop­ pital is the largest elective ortho­ ment plans are now being evolved paedic centre in Dublin. It has for many hospitals, it is of great good close associations including importance that such plan:, should joint staffing arrangements with take account of long-term pro­ the Mater, Temple Street and St. posals, despite the fact that, in the Vincent's Hospitals. The ortho­ phasing of building projects, paedic surgeons concerned per­ orthopaedic units might not form their trauma work and out­ warrant early priority. patient clinics at the general 11 hospitals and all elective cases including trauma. As already men­ are dealt with at Cappagh. While tioned, there are no figures avail­ elective paediatric orthopaedics able to indicate the bed needs is performed at Cappagh, the in elective orthopaedics alone. intention is to transfer this activity The Comhairle thinks that about to Temple Street Hospital. 350-400 beds would be ade­ Because of the highly specialised quate. Thus, there is need for nature of scoliosis and C.D.H . one or at most, two elective (congenital dislocation of the orthopaedic centres. hip) treatment, out-patient clinics are conducted at Cappagh Hosp­ 6.4 The Comhairle considers that, pital. despite several advantages from the medical viewpoint, one el tive orthopaedic centre in Du . (in the 1990's) catering for 1! million people with a complement of at least 300 beds and up to (b) Within the Federated Dublin 20 consultants would be too Voluntary Hospitals Group, elect­ large and would involve difficult ive orthopaedic units, which are transport problems for many pat­ on a small scale, exist at Dr. ients, staff and visitors as well Steevens' Hospital and the as too high a degree of centralisa­ Adelaide Hospital. There are plans tion of services in one specialty. to centralise elective orthopaedics Therefore, it recommends that, in one centre, namely Dr. in the long-term, there should be Steevens' Hospital. two elective orthopaedic centres in Dublin - one on either side (c) The third group comprises St. of the City - and that both be Laurence's Hospital, Jervis Street situated within a general hospital Hospital, James Connolly Mem­ campus. On the north side, orial Hospital, Blanchardstown, Cappagh Hospital is already there (which is associated with the St. and is of the size required. Ideally, Laurence's unit for orthopaedic it should be on a general hospital purposes) and Our Lady's Hos­ campus and this should be kept pital for Sick Children, Crumlin. in mind in the acquisition of site 6.3 The Comhairle notes· that it is space for the north side gene intended to develop the general hospitals. In practice, because hospital services in the future on the large capital expenditure in­ a North Dublin and South Dublin volved, the re-location of basis. The projected population Cappagh Hospital would not by 1990 indicated in the Comh­ warrant a high priority and it airle report on future develop­ would be unrealistic not to accept ment of general hospital services that it will remain where it is for for North Dublin is 535,000 and a considerable number of years. for South Dublin 749,000 - a The second elective orthopaedic total of 1,284,000 (with the centre on the south side should, inclusion of Wicklow and Kildare, in the long-term, be located on the total population catchment either the St. Vincent's Hospital will be in the region of 1 ,450,000). site or the St. James's Hospital On the basis of 0.4 beds per site. The decision should only 1,000 population, this would be made after a full assessment require 580 orthopaedic beds of the potential of the two sites

12 in question to accommodate a ports the proposed rationalisation unit of about 150-200 beds. of services within the Federation / The factors to such an assess­ St. James's Group as a short­ mentshould include geographical, t erm solution only. It is im­ architectural and medical con­ portant that this development siderations. should not inhibit the full in­ volvement of St. Vincent's Hos­ 6.5 Pending the implementation of pital in the planning for the the long - term objective, the implementation of the long-term Comhairle recommends:- objective for South Dublin set (a) North Dublin : Cappagh out at par. 6.4. Hospital should be designated as the elective orthopaedic centre 6.6 With regard to paediatric ortho­ for North Dublin. This recom­ paedics, it is recommended that mendation will involve changes the unit at Our Lady's Hospital in the existing associations of for Sick Children, Crumlin should some of the general hospitals in be continued, but that links North Dublin (i.e. St. Laurence's, should be developed w ith ~he Jervis Street and James Connolly proposed Dr. Steevens' un it as Memorial Hospitals) to bring recommended in the case of about a situation where all the Cappagh and Temple Street in general hospitals would be linked North Dublin. to Cappagh Hospital. It would necessitate joint staffing arrange­ 6.7 There will be a need to co­ ments. The existing linkages be­ ordinate highly specialised work tween Cappagh Hospital and the as between the two elective Children's Hospital,TempleStreet, orthopaedic centres in Dublin and should be continued. Elective it is suggested that the Comhairle paediatric orthopaedics should be and the Department of Health concentrated at Temple Street acting jointly could have an Hospital. important role to play in this (b) South Dublin : At the present respect. time, St. Vincent's Hospital is associated with Cappagh Hospital (ii) North - Eastern Health where all the elective ortho­ Board Area paedic work is undertaken. This 6.8 At the present time, the reg ional arrangement should continue orthopaedic unit at Navan is pending the implementation of situated at Navan General Hos­ the long-term recommendation pital. Under the national hospital for South Dublin. The Federation/ plan announced by the Govern­ St. James's Hospital Group are ment. it is intended that the general planning to concentrate ortho­ hospital services at Navan will paedics at Dr. Steevens' Hospital. be transferred to James Connolly Initially this will include both Memorial Hospital, Blanchards­ trauma and elective orthopaedics town. It has also been decided but consequent on the develop­ to retain and develop the ortho­ ment of the new St. James's paedic unit at Navan to serve the Hospital (within the next eight north-east region. However, for years or so) , the intention is to the reasons set out in the earl ier devote the whole of Dr. Steevens' part of this report, the Comhairl e Hospital to elective orthopaedics. considers that, in the long-term, The Comhairle notes and sup- it would be medically inadvisabl e

13 to retain the Navan Orthopaedic proposals for the North- Eastern Unit as a separate isolated unit. Health Board area. Pending the In the short-term, the Comhairle implementation of this recom­ recommends that formal arrange­ mendation, the Comhairle con­ ments (including the joint ap­ siders that the Navan unit should pointment of an orthopaedic sur­ continue to provide a service for geon) should be made between Westmeath / Longford. It is the North-Eastern Health Board recommended that Laois/ Offaly and the International Missionary should obtain consultant services Training Hospital, Drogheda, from Cappagh Hospital subject to under which consultant ortho­ the arrangement under which paed ic services for the latter Wexford is serviced by Cappagh hospital would be provided by Hospital being discontinued (s ' the regional orthopaedic unit next paragraph) . The Midi at Navan. In view of the size of Health Board area is fortunate In the International Missionary having available a number of Training Hospital - 333 beds - general surgeons who are in­ and the fact that the highest terested and competent to deal concentration of population in the with trauma and fracture patients. north-east is along the coastal However, difficult problems can strip, the Comhairle considers be expected to arise when vacan­ that the Navan Orthopaedic Unit cies occur for general surgeons in shou Id be re-located on the this area unless the existing cam'pus of that hospital in the consultants are replaced by others long-term. Possible methods of of equal competence in the field providing orthopaedic services of trauma. This factor should be at the other general hospitals in borne in mind when deciding the the area (i .e. Cavan and Dundalk priority to be accorded to the Hospitals and, in the short-term, provision of an orthopaedic unit Monaghan Hospital) are sug­ in the Midlands. gested at pars. 4.4 and 4.5 of this report. (iv) South - Eastern Health (iii) Midland Health Board Board Area 6.9 There are no consultant ortho­ 6.10 Apart from Wexford, which is paedic surgeons based in the serviced by Cappagh Hospital, Midland Health Board Area nor the elective orthopaedic cen does the possibility of a short­ for the south-east is located term solution to the orthopaedic Kilcreene Hospital, Kilkenny. This problems exist. At the present is a separate isolated unit which time, orthopaedic services for has some links with Kilkenny Westmeath / Longford are pro­ County Hospital, but there is vided by the Navan Orthopaedic much room for improvement. Unit. Laois/ Offaly obtain their Some elective orthopaedic work services from Kilcreene Hospital, is undertaken at Ardkeen Hospital Kilkenny. The Comhairle recom­ but, from the information available mends that, in the long-term, a to the Comhairle, it appears that consultant staffed elective ortho­ many Waterford patients go to paedic unit should be provided Dublin for treatment rather than at Mullingar Hospital to service to Kilcreene Hospital. The Comh­ all of the midlands. Mullingar is airle recommends that, in the regarded as preferable to Port­ long - term, a regional elective laoise, in view of the long-term orthopaedic unit for all of the

14 south-east should be developed services in the voluntary hospita ls at Ardkeen Hospital, Waterford must be viewed as a serious which already accommodates deficiency. several regional specialties (e.g. paediatrics, E.N.T. ophthal­ 6.12 The population of Cork City and mology) . Until then, all elective County is expected to grow to orthopaedics should be under­ about 466,000 by 1990. This taken at Kilcreene Hospital, in­ population is sufficient to sup­ cluding patients from Wexford. port one elective orthopaedic Much closer liaison should be centre of optimum size. Ideally, developed between Kilcreene such a unit should be within a Hospital and Kilkenny County general hospital and the Comh ­ Hospital including joint staffing airle recommends this as a arrangements for all new con­ long-term objective for Cork. This sultant appointments. The pro­ recommendation is of particular vision of orthopaedic services to relevance in the context of the the general hospitals at which long-term proposal to develop a orthopaedic units cannot be de­ new gene'r fll hospital in Cork to veloped i.e., Wexford, Cashell replace the existing voluntary Clonmel, Ardkeen (in the short­ hospitals. Pending the achieve­ term) and Kilkenny (in the long­ ment of the ultimate objective, term) should be made along the the Gu rranabraher unit should lines suggested in pars. 4.4 and continue to be developed as the 4.5 above. elective orthopaedic unit for all Cork. The present good liaison (v) Southern Health Board with St. Finbarr's Hospital should Area be continued. 6.11 The elective orthopaedic centre for the south is at St. Mary's 6.13 The situation with regard to the Hospital, Gurranabraher, Cork development of the Cork volun ­ which is owned by the Southern tary hospitals is unclear at present. Health Board. It has very close The decision announced by the links with St. Finbarr's Hospital Minister to establish a Cork and these will continue with the Voluntary Hospitals Board w ill transfer of services from St. greatly facilitate the development Finbarr's to the new Regional of a co-ordinated service between Hospital at Wilton (to be com­ the voluntary hospitals. However. pleted in 1978). It is not pro­ consequent on the rejection of posed to incorporate the Gurrana­ the proposal of the Comhairle bra her services into the new for a transfer of services to the Regional Hospital. There are no vacated St. Finbarr's site in 1978. orthopaedic surgeons at the Cork it is not clear whether a physical voluntary general hospitals integration of services is possible (Mercy, North I nfirmary, South in the near future. Nevertheless, Infirmary, Victoria and Bon the Comhairle considers that the Secours Hospitals) nor have any provision of a second major links been developed between accident centre in Cork City is an these hospitals and the ortho­ urgent priority. Problems will paedic services. St. Finbarr's is undoubtedly arise on the opening the main accident centre in Cork, of the new Regional Hospital if but some accident cases are also it is the only major intake point admitted to the voluntary hos­ for accidents. The in creasing pitals. The lack of orthopaedic number of trauma cases w ill 15 put a great strain on the bed near future by the appointment resources of the new hospital. of a consultant orthopaedic sur-' It is clearly urgent that ortho­ geon. paedic services should be located 6.15 The two remaining general hos­ in the voluntary hospital group. pitals in the south are at Bantry The Comhairle strongly recom­ and Mallow, both of which are to mends that urgent attention be be retained under the Govern­ given by all the authorities con­ ment's hospital plan. Because of cerned to the making of appro­ its isolated position, it is essential priate arrangements to provide an in the Comhairle's view, that the accident centre within the volun­ general surgeon at Bantry Hos­ tary hospitals group which would pital should possess the com­ be linked (i.e. joint staffing ar­ petence to deal with trauma case rangements at consultant level) Apart from this aspect, the c with the Gurranabraher elective siderations at pars 4.4 and .~ orthopaedic centre. of this report appJy to both Bantry and Mallow Hospitals. 6.14 Because of the distance from (vi) Mid-Western Health Tralee to Cork or Limerick, and Board Area the large hinterland which it 6.1 6 The elective orthopaedic centre serves, the situation at Tralee for the mid-west is situated at Hospital, where planning for the Croom which is 13 miles from replacement of the existing gen­ Limerick city. There are close eral hospital is well advanced, associations with the Limerick needs reassessing. In May, 1975, Regional Hospital at Dooradoyle. the Comhairle responded to a There are no orthopaedic sur­ query from the Southern Health geons in the two Limerick volun­ Board by advising that a solution tary hospitals St. John's on the lines of that set out at par. Hospital and Barrington's Hos­ 4.5 (b) of this report would be pital - despite the fact that the appropriate in the case of Tralee latter hospital has a busy accident Hospital. However, following its unit. Future hospital development recent comprehensive in-depth within Limerick city has yet to be study of the orthopaedic services determined. The Comhairle (including local consultations), recommends that, in the long­ the Comhairle now feels that term, the Croom unit should neither of the solutions set out relocated on the campus of t . at par. 4.5 of this report would Limerick Regional Hospital and be adequate to meet the needs should continue to be developed of the Tralee situation. The pop­ as the elective orthopaedic centre ulation of Kerry is 112,000 and for the mid-western area. In the it is projected to grow to 143,000 short-term, it is strongly recom­ by 1990. The Comhairle recom­ mended that closer arrangements mends that a minimum-scale be made with the voluntary hos­ orthopaedic unit (two con­ pitals. Outside Limerick city, the sultants) should be incorporated general hospitals at Ennis and into the planning of the new Nenagh are to be retained under Tralee Hospital. If the facilities of the national hospital plan anno­ the existing hospital will allow unced by the Government. Ortho­ it, the Comhairle thinks that the paedic services at these hospitals development of an orthopaedic should be provided as suggested service should be started in the in pars. 4.4 and 4.5. of this report.

16 (vii) Western Health Board and discussions with representa­ Area tives of the North-Western Health 6.17 The orthopaedic unit in the Board took place on the possi­ western area is at Merlin Park bility of establishing a separate Regional Hospital. It provides service for the north-west. The services for both the Western and Health Board, on the advice of North-Western Health Board the Comhairle and with the areas. It has recently been decided approval of the Department of to develop a separate orthopaedic Health, has decided to proceed service in the north -west. The quickly with the building of a Comhairle recommends that the new 50-bed orthopaedic unit at orthopaedic unit at Merlin Park Sligo General Hospital. It is should continue to be developed hoped that the actual building as the elective orthopaedic centre work will commence in Sept­ for the western area alone. The ember, 1977 and be completed closest possible integration with early in 1979. In the meantime, the Galway Regional Hospital arrangements are being made by should be evolved and the ortho­ the Health Board to have a paedic surgeons should under­ temporary service at Manor­ take trauma work there as well as hamilton Hospital. The Comhairle conducting their out-patient has approved the appointment of clinics. In the short-term, the two consultant orthopaedic sur­ Comhairle considers that a re­ geons for the new unit. organisation of beds at Merlin Park is an urgent priority. It should be possible to reduce the number of orthopaedic beds as a consequence of the setting up of a separate service in the north­ west. Outside Galway city, under the Government plan, the general hospital at Castlebar is to be continued and developed. A federation of the services of Roscommon Hospital and Port­ iuncula Hospital, Ballinasloe is at present under consideration. Again orthopaedic services for trauma and fracture cases should be provided as set out in pars. 4.4 and 4.5 of this report.

(viii) North-Western Health Board Area 5.18 Because of the urgency of the situation arising from the Western Health Board's inability to main­ tain services in the north-western area, the Comhairle considered the development of services in this part of the country before it finalised this report. Examination 17 Section 7 - Consultant Manpower Requirements in Orthopaedic Surgery

7.1 The Comhairle was grateful to Comhairle has decided to adopt receive from the I rish I nstitute of this target ratio as a general guid - Orthopaedic Surgeons, a docu­ line for the future. I n doing so, i ment setting out its views. The recognised that there may be 'a document is attached as Appendix need to review this target at some E. The Comhairle wishes to time in the next few years. It is record its appreciation to the considered that the increase in the Institute for greatly assisting it in establishment of orthopaedic its task of examining the ortho­ surgeons which will result from paedic services in the country. the adoption of this ratio should The Institute's advice on organisa­ be on a phased basis related to tion and future development much the capacity of the existing influenced the Comhairle in facilities in each area to cope with making its recommendations on the increased activity generated these matters in the foregoing by additional consultants. Full sections. I n respect of ma n­ account will have to be taken of power needs, the Institute's views local circumstances and, indeed, are of special importance. priorities, in reaching decisions on specific applications for 7.2 One of the most important recom­ additional appointments. mendations of the I nstitute is that Ireland should adopt a target 7.3 At present, as the following table manpower figure of 1 ortho­ shows, there are 26 orthopaedic paedic surgeon per 70,000 popu­ surgeons holding appointments lation. It is understood from in public hospitals througho enquiries made of the British the country. This represents Orthopaedic Association that this consultant/population ratio of ratio, which the Association 1/120,000 ;- recommended some years ago, is being reviewed. While a revised consultant/ population ratio has not yet been determined, there is talk of its being increased to one consultant per 50,000 population. The specific manpower needs set out by the Institute, which involve a doubling, on a phased basis, of the present consultant establish­ ment, result from the application of the norm of 1/70,000 to available population statistics. The

18 H. B. AREA PRESENT ESTABLISHMENT CONSULTANT/ POPULATION RATIO

Mater/Cappagh/Temple St. 3 St. Vincent's/Cappagh 2 Eastern St. Laurence's 1 1/97,000 (includes Jervis St./Crumlin 2 Wexford) F.O.V.H. 4 - TOTAL 12

North - Eastern * Navan 3 1/114,000 (includes Longford/Westmeath)

Midland Nil Nil Nil

Kilcreene 1 1/177,000 (includes South - Eastern * Kilcreene/ Ardkeen 1 Laois/Offaly and - excludes Wexford) TOTAL 2

Southern Gurranabraher/St. Finbarrs 3 1/162,000

Mid-Western Croom/Limerick Regional 2 1/140,000

Western Merlin Park/Galway Reg. 4** 1/125,000 (includes North-West)

North-Western Nil*** Nil Nil

Whole Country 26 1/120,000

*The services of a temporary part-time consultant are also available to Kilcreene Hospital and to the International Missionary Training Hospital, Orogheda. **One new post has recently been created and is not yet filled. ···See paragraph 6.17 of this report.

7.4 Having regard to the availability these additional consultant of manpower and the capacity of appointments, there is the possi­ existing facilities to cope with bility of 4 retirals (at 65 years of increased activity, it is considered age) over the next five years. that over the next five years, the (However, two of these arise in establishment should be increased the volu ntary hospitals where to about 35 posts, with priority there is no compulsory retirement being given to those areas where and it cannot be assumed that the consultant/ population ratio they will actually occur) . is the least satisfactory. As well as

19 Section 8 Postgraduate Training Programmes at Senior Registrar Level

8.1 To date, eight training pro­ 8.3 The decision on the recognition grammes in orthopaedic surgery of training centres is a matter fo~ at senior registrar level have been the Joint Committee on Higher recognised by the Joint Com­ Surgical Training and its appropri­ mittee on Higher Surgical Train­ ate specialist advisory committee. ing for accreditation purposes. No units outside Dublin are The programmes are of four years recognised for postgraduate train­ duration. Thus there will be an ing at senior registrar. level and annual output of two accredited this has created problems for surgeons. All the programmes are these units in attracting good based in Dublin and involve a quality support medical staff. The rotation period through Cappagh Comhairle considers that these Hospital. The Comhairle con­ problems could be eased some­ siders that the manpower require­ what if consideration was given ments in orthopaedic surgery by the Joint Committee, in associ· would warrant the filling of these ation with the Irish Institute of eight recognised programmes. Orthopaedic Surgeons, to the creation of suitable approved posts at registrar level at peripheral orthopaedic units. A further suggestion which should be con­ 8.2 The Institute recommends that sidered is the creation of new posts of orthopaedic surgeon "holding" posts of limited dura­ should be introduced gradually to tion, say one year, in non­ ensure that consultant appoint­ training units which could be hel ments match the senior registrar by accredited surgeons awaiting output. Although the Comhairle the opportunity to apply for has some sympathy with this consultant vacancies. It is recommendation, nevertheless, it essential that the holders should is considered that the prime factor not be permitted to remain in post in the creation of posts must be for longer than the fixed tenure the service needs of the popula­ of appointment. tion. While the possibility exists of filling a post with a suitably 8.4 The Comhairle agrees with the qualified person from abroad or recommendation of the Institute from outside the formal post­ that all training programmes at graduate training programmes, its Senior Registrar level should be creation should not be delayed organised on a national basis solely for the purposes of facilita­ under the aegis of the Institute ting senior registrars in this which is the recognised body for country. training in this country. 20 Section 9 - Miscellaneous

9.1 Peripheral Out - Patient such patients to occupy acute Clinics: Some general remarks beds has a serious effect on the on out-patient clinics have already operation of an acute orthopaedic been made at par. 2.4 and par. 3.4. unit and could add significantly The Comhairle concurs with the to the waiting list for treatment. views of the I rish I nstitute of In some instances where a con­ Orthopaedic Surgeons (see Ap­ stant and sizeable number of pendix E) that peripheral out­ geriatric patients may have to be patient clinics should be held only retained in what are designated as in general hospitals. The referral orthopaedic beds, it might be of a sizeable number of relatively preferable to re-classify some minor complaints to out-patient wards as geriatric and concen ­ specialist clinics has been raised trate such patients in these beds. as a problem at every local dis­ cussion in which the Comhairle sub-committee participated. This 9.3 Orthopaedic Nursing: The is a matter for the consultants and Comhalrle wishes to endorse the the referring doctors particularly comments of the Institute (see those involved in the Child Wel- Appendix E) on the need for fare and School Health Examina- properly tra ined orthopaed ic tion schemes. Clearly, better com ­ nurses. It is recommended that th e munications between them are Department of Health shou ld JivE needed. It is recommended that consideration to an expansion of each orthopaedic unit should, the post-registration co urse in from time to time, organise orthopaedic nursing at Cappagh meetings with the referring Hospital with a view to increasing doctors in their catchment area the availability of trained ortho­ to improve communications and paedic nurses. to exchange views on mutual problems. 9.4 Convalescent Orthopaedic 9.2 Geriatric Services: Because of Accommodation: Information the number of elderly patients on the location of convalescent who come in contact with the accommodation is given at pa r. orthopaedic services, it is essential 2.5 of this report. The importance that good liaison should exist at of the availability of such beds local level with the geriatric from an economic, organisational services. In particular, it is import­ and medical viewpoint cannot be ant that patients who have passed over-stressed . The Comhairle the acute stage of orthopaedic recommends that, in the develop­ treatment should not continue to ment of orthopaedic services, occupy acute beds if, for social each orthopaedic centre and its or other reasons, they cannot be associated general hospitals discharged to their homes. For should have a reasonable numbe r 21 of convalescent beds associated with it. This will involve a con­ siderable expansion of existing facilities, but these would result in considerable savings by obvi­ ating the necessity for more expensive acute care beds.

9.5 Rehabilitation Services: The Comhairle is conscious of the fact that it has not looked at rehabilitation services and facilit­ ies which are vital to the ortho­ paedic services. However, re­ habilitation is not a service for orthopaedic patients alone: it is of equal significance in relation to other conditions. The Comhairle hopes, at some stage in the future, to undertake a separate study of rehabilitation services in this country.

COMHAIRLE NA N-OSPIDEAL MAY, 1977 22 Appendix A

ELECTIVE ORTHOPAEDICS - IN-PATIENT STATISTICS 1975

Area / Hospital Bed Percentage Average No. of Admissions Waiting Complement Occupancy Duration Operations List of Stay

'iil:;n Health B rd St. Mary's 200 76 . 0 17 . 1 3,283 2,093 72 cases Orthopaedic (1,476 - 9 Hospital, Cappagh paediatric) months

Jervis Street 20' N.A. , NA NA NA 7 months Hospital for hips

St. Laurence's 8' NA NA 377 (76 NA 6 months Hospital cold)

James Connolly 20 NA NA N.A, N.A. NA Memorial Hospital

Adelaide Hospital 28 NA NA 654 (72 637 12 months hips)

Dr. Steevens' 32 NA N.A. 762 (77 935 N.A. Hospital hips)

Meath Hospital NA NA NA 134 409 NA

Our Lady's Hospital 60 NA NA NA. NA 5 months for Sick Children, lin

The Children's NA NA NA 285 NA N.A. Hospital, Temple Street

NA= Not Available ' = Estimate

23 Appendix A continued

ELECTIVE ORTHOPAEDICS - IN-PATIENT STATISTICS 1975

Area / Hospital Bed Percentage Average No. of Waiting Complement Occupancy Duration Operations Admissions List of Stay

N orth-Eastern Health Board Our Lady's 82 80.6 23.12 1,915 1,044 240 Hospital, Navan ... South-Eastern ~ Health Board Kilcreene Hospital 90 81.8 29 . 8 1.073 900 130

Ardkeen Hospital 38 87 .5 18 . 7 561 648 42

Southern Health Board St. Mary's 187 82 . 4 23.1 1,236 (150 2,436 339 Orthopaedic hips) Hospital, Gurranabraher

Mid-Western Health Board St. Nessan's 120 92.5 16 . 8 1,480 - 2,400 N.A. Orthopaedic (35 hip Hospital, Croom replace- ments) Western Health Board Merlin Park 176 83 . 1 27.1 1,889 1,973 410 (at 30/9/76)

24 Appendix B

ORTHOPAEDIC OUT-PATIENT STATISTICS 1975

Location Number of Total First Waiting Clinics Attendances Attendances List/ Time -- Eastern Health Board (10) St. Vincent's Hospital 4 (orth) per 2,084 (orth) NA NA mth. 8 (fracture) 3,431 (fract) per mth. is Street Hospital 8 per month 5,318 NA 2 months

Our Lady's Hospital for Sick 16 per month NA NA NA Children, Crumlin

St. Laurence's Hospital 4 per month NA N.A. NA

Mater Misericordiae Hospital 20 per mth. 5,869 2,055 (orth) 16 per mth. 7,294 2,569 352 (fract.)

The Children's Hospital, Temple 8 per month 4,886 1,910 6 weeks Street

Dr. Steevens' Hospital 12 per month 6,441 1,233 2 months (approx.)

A delaide Hospital 16 per month 7,255 1,514 1 month

N ational Children's Hospital 4 per month 1,027 367 NA

M eath Hospital 4 per month 1,990 322 NA N orth-Eastern Health Board(5) ady of Lourdes Hospital, 2 per month heda

County Hospital, Dundalk 2 per month

C ounty Hospital, Monaghan 8 per month

C ounty Hospital, Cavan 5 per month NA NA 609 cases o ur Lady's, Navan 18 per month

M idland Health Board (4) County Hospital, Mullingar 6 per month o istrict Hospital, Athlone 6 per month

NA= Not Available

25 APPENDIX B continued

ORTHOPAEDIC OUT-PATIENT STATISTICS 1975

Location Number of Total First Waiting Clinics Attendances Attendances List - M idlands continued - County Hospital, Portlaoise 2 per month 769

County Hospital, Tullamore 1 per month 1,044

N.A. 460 ca S outh-Eastern Health Board (5) o rthopaedic Hospital, Kilcreene 4 per month 2,803

D istrict Hospital, Carlow 1 per month 240

C ounty Hospital, Cashel 2.75 per mth. 408 \ - A rdkeen Hospital. Waterford 4 per month 4,075 103 cases

C ounty Hospital. Wexford 2 per month 2,419 821 79 (first appointments)

S outhern Health Board (6) S t. Finbarr's Hospital 12 per month 6,795 1,505

S t. Mary's Orthopaedic Hospital. 4 per month 795 172 G urranabraher

County Hospital, Mallow 4 per month 346 136 none in most cases Bantry Hospital 4 per month 193 45

County Hospital, Tralee 4 per month 2,328 791

District Hospital, Killarney 1 per month 621 209 Mid-Western Health Board (3) - Limerick Regional 4 (fracture) 2,167 772 per month 4 (orth) per month N.A.

County Hospital, Ennis 2 per month 1,124 N.A.

County Hospital, Nenagh 2 per month 1,275 600 1-

N.A. = not available

26 APPENDIX B continued

ORTHOPAEDIC OUT-PATIENT STATISTICS 1975 continued

Location Number of Total First Waiting Clinics Attendances Attendances List

Western Health Board (3) 1- (1974 statistics) Merlin Park/ Galway Regional 12 per month 4,285 2,300

County Hospital, Castlebar 4 per month 1,442 914 runty Hospital, Roscommon 2 per month 822 451 1,111 at rth-Western Health Board (5) 30.9.75 (1974 statistics) County Hospital, Sligo 2 per month 819 451

County Hospital, Manorhamilton 1 per month 241 103

St. Patrick's Hospital, 1 bi-monthly 184 67 Carrick-on-Shannon

St. Conal's Hospital, Letterkenny 2 per month 894 438

District Hospital, Donegal 1 per month 469 165 1-

27 Appendix C

HOSPITALS PROVIDING SIGNIFICANT ACCIDENT AND EMERGENCY SERVICES

Dublin (11) Southern (7) Mater Misericordiae Hospitalt St. Finbarr's Hospitalt Jervis Street Hospitalt Mercy Hospital" St. Laurence's Hospitalt North Infirmary' The Children's Hospital, Temple South Infirmary' Streett County Hospital, Mallow" Dr. Steevens' Hospitalt Bantry Hospital" Meath Hospitalt County Hospital, Tralee Our Lady's Hospital for Sick Children, Crumlint Mid-Western (4) St. Vincent's Hospitalt Limerick Regional t St. Michael's Hospital, Dun Laoghaire" Barrington's Hospital' St. Columcille's Hospital, County Hospital, Nenagh Loughlinstown" County Hospital, Ennis County Hospital, Naas' Western (4) South-Eastern (4) Galway Regional Hospitalt County Hospital, Wexford County Hospital, Roscommon County Hospital, Kilkenny Portiuncula Hospital: Ardkeen Hospital, Waterfordt County Hospital, Castlebar County Hospital, Cashel North-Western (2) North-Eastern (5) Sligo General Hospital County Hospital, Cavan County Hospital, Letterkenny County Hospital, Monaghan County Hospital, Dundalk Summary Our Lady of Lourdes Hospital, 40 accident hospitals Drogheda t 13 - good orthopaedic presence Our Lady's Hospital, Navant "10 - no orthopaedic presence 17 - limited orthopaedic presence Midland (3) (monthly clinics) County Hospital, Tullamore County Hospital, Portlaoise County Hospital, Mullingar

28 Appendix D

Extract from "Discussion Document on Hospital Bed Population Ratios - A basis for acute hospital planning" (Department of Health 1976)

ORTHOPAEDICS This speciality has been well developed at a number of regional centres - Galway, Limerick, Cork, Waterford/ Kilkenny and Navan. These regional centres were provided at a time when orthopaedics was mainly a long-stay specialty and lengthy waiting periods were acceptable. More recently the tendency has been towards the in­ clusion of acute traumatic work with a considerable reduction in length of stay. The question is arising whether orthopaedic units should be provided on a more widespread basis. If this should happen, a reduction in the volume of general surgery can be expected because of a transfer of some work to the orthopaedic unit. The following is a summary of the target ratios. Because of the close association between the two, the ratios for general surgery are also shown, together with the combined ratio :-

29 BED/POPULATION TARGET RATIOS FOR ORTHOPAED ICS

Beds per 1,000 Population

Orthopaedic and General Orthopaedics General Surgery Surgery Combined

Liverpool 0.315 0.76 1.075

Birmingham 0.4 (plus 0.09 for 0.55 0.95 specialised trauma/ orthopaedics/ burns)

Sheffield 0.44 (including 0.58 1.02 0.06 for children)

East Anglia 0.28 (including 0.52 0.80 0.03 for children)

North East 0.35 (including 0.54 0.89 Thames 0.07 for children)

Motherwell 0.53 0.57 1.10

FitzGerald 0.33 0.80 1.13

Judging from these figures, the Fitzgerald ratio may understate the need somewhat.

A revised ratio of 0.4 is suggested. This must, however, be considered in conjunction with the suggested ratio of 0.6 for general surgery i.e. that the combined ratio of 1.0 is designed to meet the total needs of general surgery/ trauma / orthopaedics. In practice, the 0.4 for orthopaedics would be found partly in regional orthopaedic units with a large element of long-stay patients, partly in smaller traumatic/orthopaedic units in acute hospitals and partly in general surgical units.

The recent upsurge in demand for joint replacement operations is making particular demands on orthopaedic facilities. A study to measure this demand is at present being planned.

30 Appendix E -Irish Institute of Orthopaedic Surgeons

The I nstitute welcomes this opportunity IV. The Post Fellowship Training to prepare a development plan for Programmes in Orthopaedic Surgery orthopaedic services in Ireland. and General Surgery are such that only the former are qualified to give the level ~ . . report deals specifically with man- of care necessary in fracture manage­ er requirements. It is not felt ment. necessary in this report to go into the V. The Institute agrees that single capital and services required to imple­ surgeon units should not be developed; ment such a programme. but this would not prevent the appoint­ ment of a single orthopaedic surgeon The general considerations underlying in a general hospital if satisfactory this report are : cover and backup is available at all times, and providing such a surgeon I. The Regional Hospitals should be has a regular commitment to the main equipped for general and specialised orthopaedic unit. orthopaedic surgery. Every' surgeon should have access to the Regional VI. The Post Fellowship Training Hospital. Programme has just produced its first accredited surgeons. Under our pro­ Sub-specialisation will evolve in the posals we will continue to produce future and should be encouraged, as it two per annum. We regard it as seems probable that the orthopaedic essential that the new posts be intro­ surgeons will tend to develop special duced gradually to ensure that con­ interests in areas such as Joint sultant appointments match the Senior Replacement, Rheumatoid Arthritis, Registrar output. Paediatric Orthopaedics, and Fractures "and Associated Injuries. VII. It is recommended that the Senior Registrar Programme be devel­ The Regional Orthopaedic Service oped at national level, and the present should be retained but the orthopaedic provisional number of Senior Registrars surgeons should have a more active be increased from six to eight. presence in the general hospitals, on a joint clinical arrangement with their 1. The consultant orthopaedic re ­ general surgical colleagues. It is agreed quirements have been estimated on that such an arrangement would be the basis of the following figures : of mutual benefit. (a) The English manpower figure of Ill. Orthopaedic Surgeons should 1 orthopaedic surgeon per 70,000 treat all acute and cold orthopaedics, population. including fractures and associated (b) The 1971 population census. injuries. The latter is not a practical (c) 1986 population estimates in proposition at the moment, but the each health board area (as in The overall hospital plan must be developed General Hospital Plan published by on this concept. the Department of Health, 21 / 10/75). 31 TABLE 1

One onhopaedic surgeon per 70,000 and estimating on retiral at 65 years.

Mid . E.H.B. M.H.B. West N.E. N.w. West S.E. South Po pulation 1971 1,034,216 178,908 269,804 245,504 86,979 312,267 328,604 465,655

No . Requ ired 15(14.77) 2(2.5) 4(3.8) 4(3.5) 3(2.67) 4(4.46) 5(4.69) 7(6.65)

Actual 12 - 2 3 - 3 1 3

Ret irals to 1986 3 - 1 - - 1 1 Add. to 1986 + 6 + 2 + 3 + 1 + 3 + 2 + 5 -t~ Retirals 1986 - 96 5 - - 1 - - - 1 Population ex 1986 1,250,000 215.000 339,000 304,000 188,000 345,000 399.000 555,000

Ad ditionals ex 1986 + 3(17.8} + 1 + 1(4.8 ) + 2(0.7} 0 + 1(0.5} + 1 + 1

Total 18 3 5 5 3 5 6 8

Table 1 is a detailed study of the re ­ quirements as shown in summary:

(a) Present number of ortho- paedic surgeons 24 (b) Present number required 44 (c) Expected retirals next 10 y~ffi 7 (d) Additional surgeons in next 10 years 29 (e) Retirals in 10 years 1986- 1996 7 (f) Additional surgeons on basis of estimated population in 1986 and retirals in period 1986-96 10 It is recommended therefore, that 29 orthopaedic surgeons should be appointed in the period 1976 to 1986.

32 it must be noted particularly (3) Galway and Associated Areas: (1) that the figures for population are Western Health Board five years old North Western Health Board (2) the population to orthopaedic sur­ Mid-Western Health Board geon ratio is also five years old (3) this ratio does not take into account Orthopaedic Development in the joint replacement "explosion", Dublin and Associated Regions: or the significant increase in operative (1) The present association between treatment of fractures. Cappagh, the Mater, Temple Street and (4) these figures do not include con­ St. Vincent's Hospital be continued. sideration of the acute registrar sh rtage in peripheral areas, and the (2) The orthopaedic units in the able need for more consultants Dublin North City Hospitals should be o ause of this situation. actively associated with Cappagh. The I nstitute is most anxious that Whilst the present orthopaedic sur­ these appointments be made on a geons in the Dublin North City· may gradual basis so as to fit in with the not wish to be actively committed to Post Fellowship Training Scheme. Cappagh, it is recommended that future appointments in these areas be In the present scheme there are 6 joint appointments with Cappagh. Senior Registrar trainees. The number of trainees should be increased to (3) Federated Group of Hospitals eight, which would give a consultant (F. G. H.) There are two methods of output of 2 orthopaedic surgeons per integrating orthopaedic practice in annum. this group with the overall Dublin plan : It must be noted that the J .A.C. have (i) Include this group for cold ortho­ approved 8 posts in the Dublin area. paedics in Cappagh. This would On the basis of the estimates in Table 1, involve considerable capital out­ a further Senior Registrar Training lay and the creation of a new joint Programme is required. management structure in Cappagh. (ii) A more practical proposal is the 11. Orthopaedic Regions: expansion of the F.G.H. orthopaedic (a) There should be three main ortho­ services to serve its existing area, paedic regions associated with Region­ including the present associ ation a' ospitals: with County Kildare. ublin Cappagh It would be important under such Cork Gurranabraher an arrangement that the unit be Galway Merlin Park closely associated with Cappagh.

(b) The peripheral Health Board areas (4) North East Health Board should be grouped as follows with the At present the Orthopaedic Unit is in regions: Navan and serves in addition Counties Westmeath and Longford. If the (1) Dublin and Associated Areas: General Hospital Development Plan to Eastern Health Board close the County Hospital in Navan North Eastern Health Board comes about then the Navan Ortho­ Midland Health Board paedic Unit should be sited in Cavan.

(2) Cork and Associated Areas: ·Other than the Mater Orthopaedic Southern Health Board Surgeons. South Eastern Health Board 33 (5) South Eastern Health Board LOCATION OF NEW Whilst the original main regional CONSULTANT APPOINTMENTS structure suggests that the S.E.H.B. services be associated with Dublin - (1) Dublin Area this could lead to over centralisation. (a) Orthopaedic Surgeon with special These services might be more satis­ interest in paediatric orthopaedics factorily aligned with Cork. Such an based in Temple Street and Cappagh arrangement would be helpful in with minor commitment to the. Mater promoting a Senior Registrar Training for accident/emergency service. Programme in the Cork area. (b) Orthopaedic Surgeon St. Vincent's Hospital and Cappagh, to be associated (6) Midland Health Board Area with St. Michael's Hospital. Dun At present this area has no orthopaedic Laoghaire and Loughlinstown. In the service - the southern half of the area development period under rev.' '. a is serviced in Kilcreene and the northern further surgeon would be re .led half is serviced in Navan. It is here. recorr:mended that the present arrange­ (c) Federated Group - one further ment for the northern half of the area surgeon on the basis of an expected be retained, and the orthopaedic retiral and one further at a later stage. services for the southern half be linked (d) North City Hospitals (other than to Dublin. Certainly alternative arrange­ the Mater) - one further surgeon ments will have to be made for this during the second half of the develop­ area when Kilcreene and Waterford ment programme. take on the Wexford patient load, presently catered for in Cappagh. (2) Cork Area (a) Two orthopaedic surgeons will be required to service a unit in Tralee - the appointments to be staggered. (b) South Eastern Health Board area - on population figures,four are required (7) Cork and Associated Area - two attached to Kilcreene and two in (a) As suggested the South Eastern Waterford. At present there is one area should be associated with it. permanent orthopaedic surgeon. (b) Limerick Unit be associated with It is recommended that the temporary the Western Region. post in Kilcreene be filled now and the (8) Galway and Associated remaining posts introduced grad lIy. Areas (3) At present this region services the Galway Area North West Health Board Area . (a) Western Health Board Area: In (a) It is recommended that a new view of the geographical size of this orthopaedic unit be set up in the latter area and travelling involved, two area, but it should retain some associ­ further surgeons will be required. ation with the main hospital in Merlin Park. (b) North Western Area (b) The present informal association Establish a new orthopaedic unit as an between Merlin Park and the Ortho­ extension to Sligo General Hospital. paedic Unit in Croom be expanded. As a short term project it is recom­ mended that either the Sheil or Ballyshannon Hospitals be converted for orthopaedic surgery.

34 Both on population figures and the works very satisfactorily in Dublin distance between Sligo and Letter­ where each of the accident/ emergency kenny, three surgeons will be receiving hospitals have visiting ortho­ eventually required. paedic surgeons responsible for the primary care of all fractures and (c) Mid Western Area associated injuries. One surgeon required in the medium term with a major commitment to The arrangement of comparable or Ennis Hospital. A further appointment nearly comparable services for the rest will be required later associated with of the country would be achieved by Nenagh Hospital. linking a number of general hospitals to each of the orthopaedic regional T e existing surgeons recommend that hospitals and units, and to achieve as Orthopaedic Unit in Croom should far as is practical that each general eventually transferred to the hospital has a visiting orthopaedic Regional Hospital Limerick. surgeon who works there or visits on a regular basis to do joint ward rounds Association of Orthopaedic and regular review fracture clinics. Surgeons and Acute General Hospitals: Peripheral Clinics: Whilst the regional orthopaedic (1) All clinics must be held in the structure should be retained, the general hospitals associated with each I nstitute are satisfied that the ortho­ region or unit area. The present paedic surgeons should be more clinics are far too large, and it is actively involved in the primary recommended that as many patients management of fractures and associ­ as possible have their first consultation ated injuries in the county and at the main orthopaedic centre for regional general hospitals. It is recog­ the area . Apart from helping to reduce nised that total care of all these cases the number of cases seen at each is not a practical proposition at peripheral clinic, it would facilitate present, nor in the immediate future. medical records and reduce the number In fact the General Hospital Develop­ of x-ray procedures per patient. It ment Plan (October 1975) has decided would reduce the amount of time on too many general hospitals to orthopaedic surgeons would spend allow such an arrangement. away from their main centres of work.

I nstitute recommends that the (2) Consultations should be held with eneral Hospital Development Plan the doctors concerned with the Child be such that all patients with fractures Welfare and School Examination and associated injuries have immediate Clinics. or very early access to orthopaedic care. Geriatric Service The increasing elderly population and If such an arrangement is to develop ensuing orthopaedic workload is such then all orthopaedic surgeons should that the immediate post orthopaedic not be rigidly appointed to work in care of the elderly be undertaken by regional orthopaedic hospitals or the geriatric service. Patients in this units. A number of surgeons must be category will have to be treated as appointed with a major commitment emergencies in the geriatric units or to the general hospitals and a minor the acute care and cold orthopaedic commitment to the centres for cold beds will be blocked. This will have a orthopaedic surgery. This arrangement serious affect on waiting lists etc.

35 Orthopaedic Nursing There is an almost total absence of properly trained orthopaedic nurses in the general hospitals. It is recom­ mended that this situation be remedied. It is noted that the post registration course in orthopaedic nursing in Cappagh is not fully availed of, although it is approved by An Bord Altranais. In the first instance this will mean the separation of ortho­ paedic and general surgical wards. This is very important having regard to the increasing use of operative tech­ niques in fracture management.

Convalescent Orthopaedic Beds Quite apart from the convalescent care of geriatric patients, it is felt that convalescent (or second level) beds are particularly suitable for the manage­ ment of post fracture and aoute orthopaedic cases initially treated in acute general hospitals. Our experi­ ence in the use of Clontarf Ortho­ paedic and Leopardstown hospitals confirms this view.

It is recommended that these facilities be expanded in Dublin in relation to the accident/emergency hospitals. It is further recommended that the general hospital plan should include provision for similar facilities outside Dublin, as it represents a considerable saving in the use of first level acute care beds.

36