Madam, - We note the response of the Minister for Health and Children (March 16th) to a news item in your edition of March 12th about recent Canadian research on the relationship between hospital volume and patient outcome for five complex surgical procedures.
It should now be clear that the Minister, the Hanly Group and the critics of the Hanly proposals (the latter supported by the major research results) all agree totally that very complex procedures, especially surgical ones, have better outcomes when performed in larger-volume hospitals.
Indeed, most of the procedures listed in the Canadian research are identical to those listed by the critics of Hanly as the very few procedures where large volume does lead to better outcomes. Unfortunately, the Hanly Group goes much further than the evidence available and argues that not only a few complex procedures, but all in-patient procedures, are better treated in large rather than smaller hospitals.
As Hanly puts it (page 63): "Hospitals without sufficient volumes of patients and activity cannot sustain large numbers of consultants. Without sufficient consultants, hospitals will not be able to provide quality care." There is no good published evidence to show that this is true for the majority of patients who need in-patient care.
According to the Minister, "The message in the Hanly Report is clear: decentralise a large proportion of care to our smaller hospitals, as long as it can be done safely." We sympathise with the Minister in his attempts to clarify what Hanly means in its reorganisation proposals which are set out in such an impressionistic and unquantified way. What Hanly actually says (page 68) is that, in time, "in local hospitals. . .there should not be a requirement for on-site medical presence overnight or at weekends".
This means that the majority of smaller hospitals around the country will not be able to provide any in-patient care or effective A&E services since these both require 24-hour medical care.
Hanly does not explain what is to happen to the roughly 8,000 in-patients treated annually in local hospitals in the Dublin East-Coast Pilot Region; nor what will happen to the more than 13,000 inpatients currently treated in local hospitals in the Mid-Western Pilot Region. It merely implies that local hospitals will exchange their current high volumes of in-patient care in some painless way for much increased levels of day care:
"An increasing proportion of elective work, primarily in the area of surgical and medical day procedures, should be carried out in local hospitals" (page 77). Yet the Minister's own thorough, properly researched and quantified Report on acute hospital bed capacity shows that, even by 2011, only 460 in-patient beds for the whole country could be saved by increased day care in hospitals, and that, over the same period, there will be a considerable increase in the need for in-patient beds.
The Hanly proposals are based on a deeply flawed analysis of the evidence relating to high hospital volume and patient outcome - and on very little analysis at all of the current volumes of all services provided by the smaller hospitals. It is this lack of adequate analysis which leads Hanly to make the proposal that in-patient beds in smaller hospitals should be closed down in the next l0 years. This is a bizarre proposal given the present major shortage of in-patient beds in the country; and one which the Minister should repudiate.
The Minister for Health and Children has a very complex job and we would not wish to increase his difficulties. But his problems in this area are due to the inadequacies of the Hanly Task Force Report and not to those of us who are critics of the Hanly proposals. - Yours. etc.,
Dr JOHN BARTON, Portiuncula Hospital, Ballinasloe, Co Galway
CATHERINE McNAMARA, Dalkey, Co Dublin.