Madam, – Recently, Dr Chris Luke correctly highlighted the crisis in staffing our AE departments but also took the opportunity to agree with his RTÉ interviewer that the closure of smaller hospital AE services may be no bad thing and would bring about economies of scale and improved quality of care. He indicated that more resources would need to be invested in the larger hospitals before the transfer of services from smaller units.
While I agree that the concentration of services in larger hospitals provides improved patient outcomes for certain conditions such as breast or oesophageal cancer, heart surgery or severely injured patients in road accidents, the research on many common medical conditions does not necessarily support centralisation to larger hospitals and economies of scale in hospital size is reached at a relatively small hospital size. There is unfortunately, a limited knowledge among influential members of the medical profession, politicians and HSE officials regarding these issues, and as a result, the population has been subjected to a successful campaign suggesting the only place to get quality care is in a larger hospital.
The health economist, Professor John Posnett, director of the York Health Economics Consortium, has written extensively about economies of scale and concentration of hospital services and reveals: 1. No evidence of a beneficial effect of the general concentration of services in larger hospitals, 2. Economies of scale are reached at a hospital size of between 200 and 400 beds beyond which, economies of scale reduce and costs increase, 3. Hospital services should be local and easily accessible, 4. Mergers of hospitals are a way of eliminating excess capacity and reducing costs, and finally, 5. The evidence showing hospitals with higher patient throughput having better patient outcomes are too crude to be useful in planning hospital services.
Professor David Urbach at the Centre for Clinical Evaluative Sciences in Toronto, Canada has indicated that a more efficient use of resources may be gained by improving the quality of care at smaller hospitals through investment in development of care processes at those institutions, rather than concentrating resources in larger ones as is occurring at present.
Access to a local hospital service may be lifesaving, and improving the quality of care at smaller rural hospitals should be a health policy priority.
While I do not deny the need for change in provision of hospital services, it is a pity that in the planning and reorganisation of our hospital services, the level of mediocrity commonplace in Irish public life is once again all too evident and may result in a poorer hospital service than that which it seeks to replace. Many patients, including the frail elderly, continue to spend days on trolleys in our public hospital AE departments, a disgraceful indignity, the legacy among other factors, of our failed political system. – Yours, etc,