The changes required by the Hanly report are in line with internationalexperience and essential to maintaining high-quality care, argues Gerard Loftus, a member of the task force which drew up the report
The Hanly report has given rise to considerable comment since its publication. Most recently, Dr Christine O'Malley (Irish Times, December 13th) makes a number of claims about its effects on patient care and the organisation of services that deserve a response.
It is worth reiterating a number of crucial points. First, the Hanly report - the report of the National Task Force on Medical Staffing - represents the first, and so far the only, clear, well-thought-out response to the problems that we face as the working hours of junior doctors reduce. Its proposals were formulated by a large group of healthcare professionals - not just doctors - with the aim of achieving the best possible acute hospital services for patients, wherever they live. Second, the report emphasises that the substantial changes it proposes should only happen when the services are ready for them.
Third, the report does not recommend the closure of beds in local hospitals. It states that the additional 3,000 beds promised in the Health Strategy would be required, together with implementation of the Primary Care Strategy, if we are to achieve the substantial improvements in services for patients that are proposed. And fourth, there is no suggestion that A&E departments should close in smaller hospitals. They would continue to cater for a high proportion - up to 85 per cent - of the patients they currently see.
Much of the frontline medical care and round-the-clock emergency services in our hospitals are delivered by junior doctors, most of whom work excessively long hours. This situation is no longer sustainable. How then do we provide safe, high-quality acute hospital services, 24 hours a day, seven days a week and do so as the working hours of our junior doctors are reduced in line with EU law?
Hanly sets out a series of measures to achieve the first deadline of August 1st, 2004 (58-hour week), before detailing the significant changes needed to meet the ultimate European Working Time Directive deadline of August 2009 (48-hour week). The report stresses the need to establish a consultant-provided service, harness the contribution of all our hospitals and provide a wider range of services in local hospitals, including elective medical and surgical services not currently available there.
In her article, Dr O'Malley notes that hospital care can be delivered in a centralised or decentralised way. Hanly agrees, but it is important to be clear about what we should decentralise. At the core of the Hanly report is the decentralisation of a large proportion of the elective care and other services currently delivered in large acute hospitals to smaller hospitals such as Nenagh.
Currently, hospitals such as Limerick Regional or St Vincent's deliver a volume of inpatient, day-case and outpatient workload almost five times as large as that delivered in hospitals such as Ennis, Nenagh and Loughlinstown. Properly resourced, local hospitals such as these could do much more and eliminate the need for people to travel outside of their own region for most procedures.
Dr O'Malley quotes figures from the Department of Health which, she claims, show that "county hospitals are more efficient". However, the costs per day cited (€390 in a county hospital versus €560 in a teaching hospital) take no account of differences in the complexity of cases treated. It should be no surprise that average daily costs per patient would be higher in large teaching hospitals, which treat more complex cases overall. This is no indication of relative efficiency.
The Hanly report recognises that while choice and convenience are powerful reasons to build up local services, what patients need, above all, is high-quality care.
This, coupled with the required reduction in junior doctors' working hours, ultimately requires some concentration of hospital-based emergency care. The Hanly report does not suggest that we experiment in this key area. Instead, it recognises that the challenges we in Ireland face regarding the provision of high-quality acute hospital care are identical to those in other EU states and in Australia, New Zealand and Canada.
In New Zealand, which Dr O'Malley cites as an example of a decentralised hospital service, a 1998 Ministry of Health report on the provision of acute hospital services over the 24-hour period noted that because of "current trends toward centralisation of highly technical services and questions arising over the clinical viability of surgical services in some of the smaller hospitals, the need for optimal operation of acute management services is becoming more important". Their strategy of increasing numbers of junior doctors to reduce hours is now seen as a major error.
More recently, the British Ministry of Health has concluded in Keeping the NHS Local - A New Direction of Travel (2003) that there is a need for change in delivery of A&E and acute services in smaller hospitals. It proposes the introduction of minor injury units and a greater role for local hospitals in delivery of day procedures, specialist outpatient care and diagnostics.
A report by the Northern Ireland Department of Health (Developing Better Services - Modernising Hospitals, 2002) states: "the specialist teams and technology necessary to treat acutely ill patients, and those with complex conditions, can only be maintained in large hospitals serving substantial numbers of patients", while "larger facilities are considered better able to use sophisticated diagnostic and other support services efficiently and economically, and support the number of clinicians necessary to provide 24-hour medical cover". The same message comes through internationally.
In the future envisaged by the Hanly report, an appendicitis case, as described by Dr O'Malley, would be seen and assessed by a fully trained specialist with access to the diagnostic aids (around the clock) that would reduce the need for unnecessary surgery. If a young person needed an operation, an anaesthetist skilled and practising regularly in paediatric anaesthesia would be available (as recommended by the relevant expert groups).
The current style of care can only be sustained in the context of the Working Time Directive by recommending a staffing structure that we know will fail. The Hanly recommendations mirror reform of acute hospital systems across Europe and the developed world. They are the best means of ensuring that safe, high-quality acute hospital care is provided to everyone
Prof Gerard Loftus is a Consultant Paediatrician at the University College Hospital, Galway. He was a member of the National Task Force on Medical Staffing.