We need plain speaking from medical leaders about centres of critical mass

Earlier this month I was delighted to meet up with one of the legendary figures of Irish medicine at a reception in Áras in Uachtaráin to celebrate 50 years of the Irish Heart Foundation. A co-founder of the foundation, Prof Barry O'Donnell was also celebrating his 90th birthday on the day.

Among his many achievements was to be the first (and only) doctor to be simultaneously president of the Irish, British and Canadian medical associations. Without taking away from his many other accomplishments, what has always impressed me about Prof O’Donnell was an act of bravery and professionalism half a century ago which illustrates the difficulty of trying to do the right thing in a small country.

The medical profession has long known that trauma care requires a critical mass of services in terms of expertise, personnel, facilities and patient experience, and cannot be distributed among 37 hospitals in a small country.

However, loyalty to one’s hospital – wearing the jersey, so to speak – has been a feature of Irish medicine, as is the likelihood of constantly bumping into colleagues at professional meetings and other forums. These have acted as a brake on speaking plainly about reorganisation of services into centres of critical mass.

This is not just an issue of an urban/rural divide – these distorting features have also come into play between larger hospitals when discussions arose over the provision of services such as cancer, interventional cardiology and more recently thrombectomy (the removal of clots from neck arteries) for stroke.

Prof O’Donnell caused a furore by stating that, should he be in a car accident outside certain county hospitals, he would advise the ambulance driver to drive on to a major urban hospital. It is ironic that a similar proposal 50 years later to remove trauma (but not other) services from nine smaller emergency departments caused a similar ruckus.

What characterises these and other episodes has been a reticence from the leadership of professional bodies and the medical directors of major advocacy organisations to speak plainly and consistently to the public to strongly support the concept that certain forms of complex care need to be carried out in centres of critical mass of staffing, facilities and patient throughput.

In the absence of clear and distinct messaging from the leaders of the medical and nursing professions, it is not surprising that the politicians in multiseat constituencies will rush in to promote the local hospital/service, even if the service defended does not have sufficient critical mass to ensure standards of care that would be expected in the 21st century.

What these dramas reveal is the challenge of ensuring that advocacy in health care recognises potential self-interest, not only financial but also in the potential to maintain hierarchies of power, esteem, influence and convenience.

In addition, we have a responsibility in terms of distributive justice to ensure that we direct attention to those most in need, aware that a retreat to the high C’s of advocacy – cancer, cardiac and children – may deflect attention from other areas badly needing support, such as disability and mental health.

Sources outside of medicine provide the most helpful literature on professional vested interest and public advocacy. A paper from the wildlife sector provides this insightful quote: “Knowledge and expertise are not the neutral scientific elements emphasised by traditional theory but political resources in the battle for power and status.”

An equally helpful reflection from the social sciences points out how advocacy directed by professionals can become divorced from the palette of needs of the vulnerable and marginalised.

The generic concept of philosopher and social critic Ivan Illich that the original altruistic goals of any institution become diverted to varying degrees to the needs of those running the system should be a constant presence in our efforts at public advocacy, even if his expression of his ideas in the medical context ran to occasional unhappy hyperbole in his book, Medical Nemesis.

As a profession however, we need to do better in terms of more formal reflection, discussion, and research into how we undertake public advocacy. This should include more debate as to who is benefitting and whether our advocacy is unwittingly skewing provision of healthcare and reinforcing deficits in neglected health services with less purchase on the heart-strings of the public.

Des O’Neill is a geriatrician and co-chairman of the Medical and Health Humanities Initiative.