Head 2 Head: Yes - John Hillerysays that patients are best served by hospitals large enough to have a critical mass of expertise. No - Marie O'Connorsays the closure of smaller hospitals is about medical empire building, not patient safety.
Yes - John Hillery
Any of us would be concerned if, when travelling, we were told that the pilots and the ground support of our aircraft were not used to working on the type of craft we were on, had had no refresher training on the new aircraft, had no one with them to advise them on the workings of it, and had no time for holidays.
We should be more concerned if the doctor or team looking after us in hospital were not used to dealing with our condition, or had had little time for refresher training, or for holidays. We will continue to encounter analogous situations in our healthcare system until our health service is reformed. The result of this reform must be a national structure with full development of primary care, delivery of routine assessment and treatment in local hospitals or clinics and the centralisation of acute hospital services with the necessary emergency transport infrastructure to ensure rapid transfer of patients in emergency situations.
Acute healthcare has become and will continue to be increasingly specialised. This specialisation does not just apply to the doctors but also to nurses, paramedical specialists and to the environments in which they work. International evidence shows that the best outcomes for patients who are acutely ill or who have complex chronic conditions are achieved by specialist teams in specialist settings. Such teams and settings can only be realistically provided in a system where acute hospital services are centralised.
One reason for centralisation of acute hospital services is to maximise scarce resources but, more importantly, it is about the maximisation of staff competence for patient safety. Competence is gained initially through training. Competence is maintained in staff by ongoing education, training and peer review.
It is difficult for a doctor (or other clinician) to stay competent in dealing with a certain condition if they only deal with a few such cases a year. Such is bound to be the case in a health system made up of dispersed small hospitals that are trying to be all things to all people with small numbers of staff who have exposure to small amounts of a broad and diverse range of medical conditions. This requirement for safe practice applies to issues as seemingly straightforward as childbirth and those as complicated as cardiac surgery. In a system with centralised hospital care and specialist teams, there is sufficient throughput of cases to ensure that doctors, nurses and other clinicians get sufficient exposure to relevant conditions to maintain their competence.
Modern medicine can achieve much but it is complex and open to error. A critical mass of expertise is necessary to allow for the peer review and consultation necessary to minimise error and maximise outcomes for patients. Peer review takes many forms. It includes formal processes such as audit and case conferences. It also includes the informal quality control that occurs through clinicians observing each other at work and asking questions of each other. In a system made up of small dispersed hospitals there can only be small amounts of staff (sometimes none) with knowledge of proper practice in a certain specialist area. Due to lack of a critical mass of expertise, the formal processes become more difficult and weaker. The informal processes available are also weakened, as there may be no one with the expertise to be consulted on a particular case. Another problem is that it is very difficult to question the practice of a colleague when they are the only expert readily available and where one may run the risk of alienating the only ally on other work issues on a day-to-day basis.
Continuing education is necessary for clinicians to maintain their competence. For this to happen in a meaningful way, there must be time to attend educational events and time to reflect on one's own practice. In situations where a small group of staff are trying to provide a broad set of services, such time is difficult to find. The absence of one member of a specialist team puts increased pressure on the other members and may even lead to the temporary discontinuation of services. This is a problem as regards holiday and sick leave also. The provision of locums is difficult. It is rare now to find a person of equal skill to the permanent professional to act as a locum. Centralised acute care means that there are enough permanent staff available at all times to prevent the absence of any one team member compromising patient safety.
Modern medicine must be about the most effective treatments delivered as quickly as possible in the safest environments by the most skilled people. Centralisation of acute hospital services is a key component of the delivery of safe, successful health care.
It is urgent that doctors, other clinicians and policy makers allay current public anxieties by explaining this and working together towards the delivery of a modern, accessible and effective health service in Ireland.
• Dr John Hillery is a consultant psychiatrist and chairman of the International Association of Medical Regulatory Authorities.
No - Marie O'Connor
No other industrialised country has eliminated its general hospitals. Medical ambition is being served at the expense of patient safety, research findings show.
Implementing the Hanly report, which is Government policy, will close two-thirds of our hospital casualty units. The planned new "hyper-hospitals" will "cover" catchment areas of more than 2,400 square miles, leaving whole swathes of the country without a hospital and hundreds of thousands without a service. Several hundred people will die needlessly every year in non-urban communities. Getting to a hospital A&E within the "golden hour" matters: your chances of dying rise by 1 per cent for every 10 kilometres travelled. This bed-cutting programme will shut one-third of our maternity units. Roadside births and deaths will rise. Hanly endangers all road users: one in three trauma victims dies unnecessarily during that first hour, in the absence of an adjacent hospital casualty unit.
We are told that "paramedic" ambulances taking up to two hours to reach their new, remote destinations will (safely) replace hospitals. As if. Four out of five people drive themselves to an A&E. Being looked after by an emergency technician in a speeding ambulance cannot compare with being cared for by hospital doctors and nurses. Ambulance services are lethally under-resourced: incoming EU regulations and additional drive-time will require a quadrupling of resources. At least.
Hanly will cram all acute patients into New York-style 1,000-bed hospitals. What is good for the construction industry is bad for patient health. Technocratic factories, however sophisticated, fragment, isolate and alienate patients. Birth may become dehumanised on the assembly lines of human production; there may be no more dignity in death.
Closing smaller public hospitals in the name of "safety" while showering small (unregulated) private hospitals with public subsidies and contracts is a cynical strategy. No evidence has been produced here to support the theology that large patient volumes result in better quality care. Scotland publishes surgical death rates by procedure, by surgeon, by hospital. Not Ireland. The evidence linking higher patient volumes to lower death rates points to just four elective surgical procedures and the treatment of Aids, all irrelevant here. Teaching hospitals have been shown to have a higher rate of adverse events.
Behind the rhetoric of "best practice" and "centres of excellence" lies a professional agenda - empire-building - powered by an urban, academic, medical elite. Under Comhairle na n-Ospidéal, medical specialties proliferated, with public posts tailored to suit the royal colleges' increasingly arcane subspecialties. Society's health needs took second or third place. Large city university hospitals got the lion's share of specialties while others starved. Surgery was, and is, the driver. Until recently, A&Es were run satisfactorily by general surgeons and physicians. Today, the Royal College of Surgeons in Ireland requires these services to be run by graduates in its new specialty, emergency medicine. Up to 23 casualty units not so run are slated to close.
Centralisation is a way-paver for privatisation: corporate interests fuel the bed-cutting agenda. Teamwork, the British firm retained to implement Hanly, specialises in public hospital cuts and private corporate bids. Teamwork's 2006 report on the northeast (a "national blueprint") divides hospital services into "clinical networks" long identified by companies as profit- or loss-making. Radiology and chronic diseases, such as cancer, are among the money-makers, as is pathology. (Teamwork's recent report on laboratories will, if implemented, decimate smaller hospitals and privatise public services. Just like the national cancer strategy, which will additionally boost bio-tech profits.) Closing more than 3,000 public hospital beds will create a vacuum that American corporations and others plan to fill. Some of these chains (including several under contract to the State) have a history of fraud in the US. Promoting this murky culture in Ireland risks corrupting the medical profession.
These draconian cuts directly assault people's right to access basic hospital services. Non-urban communities will wither. Children, the elderly and the poor will suffer disproportionately. And delivering all acute services in hyper-hospitals is economically unsustainable: patients cost twice as much to treat in bigger centres.
It is argued that smaller hospitals "waste resources" that would otherwise enable consultants to develop micro-specialties. Our population is too small to support such costly, esoteric empires. Few patients require them: many need ready access to a hospital in a hurry. General hospitals treat the everyday conditions - asthma, appendicitis, heart attacks, hernias - that drive the vast majority of patients to seek hospital care urgently. Medical hubris and corporate greed cannot be allowed to crush our smaller public hospitals, now menaced by a careerist, corporatist, US-style model of health.
• Marie O'Connor, secretary of the Health Services Action Group, is a health policy analyst and author ofEmergency: Irish Hospitals in Chaos.
Last week, Mark Fielding and Paul Sweeney debated the question 'Would breaking up the ESB bring down electricity prices?' Here is an edited selection of your comments:
Over the past 5 years ESB has embraced competition in the Irish market. The complete retail market opening of February 2005 was delivered by ESB in the most transparent manner possible. The wholesale market opening on November 1st was again championed by ESB. In a European market, Ireland needs the strength of truly asset-based utility.
Anthony Byrne, Ireland
Privatisation and the break-up of the ESB will not lower prices. Private companies maximise their profit, not lower it. Since the Nice Treaty was passed, the agenda is to privatise all our services, but not for our benefit. Look at Railtrack in the UK. Privatising the ESB will just make a few people rich, and have the rest of us stuck ringing call centres when we get incorrect bills.
Tim, Ireland
I was incredulous at Paul Sweeney's views, which support the State ownership of an integrated near-monopoly and its protection - this is practically communist and definitely more suited to the UK of the 1970s or France in the 1980s than the 21st century.
Market forces work! Competition forces each of us to improve and to provide a better service to our customers. Deliberately protecting any commercial entity means we all subsidise that entity. This is bad for the consumer and bad for the ESB . . . The ESB's future can be assured by being competitive in a global context. They can sell assets in Ireland and purchase assets overseas, thereby creating a truly competitive company with a global presence. Let the ESB put its business model to the competitive test. Then privatise it. Set the company free from both Government and Ictu interference.
Conor McWade, Dublin
Mark Fielding neglects to mention that until a few years ago, Ireland had one of the lowest domestic rates in the EU - the increases brought in to compensate for this were brought about by EU pressure (not by increasing global fossil fuel prices) if I recall correctly. Anyone else remember this? On another note, the current investment of taxpayers' money to upgrade ESB's infrastructure is an echo of the Eircom theft - taxpayers' money is injected into a national asset, and the asset is then handed at a bargain price to private companies who proceed to fleece the same taxpayers who paid to build the asset in the first place. If we had a national oil company, our government would be preparing to privatise that too, now that it's becoming profitable to extract oil/gas off our shores.
Glen, Ireland
Breaking up the ESB could likely result in higher prices. Ireland is a small market in the overall industry picture. Two or more small providers operating in such an environment will not be able to generate the internal savings needed to reduce prices. In the New York area the largest provider is Consolidated Edison. In 1998 a deregulation programme removed control of power generation from Consolidated Edison in the belief this would lead to lower prices. Nothing of the sort happened. Prices are higher and no other major firm has tried to operate in the area. The ESB should seek partners to operate a regional power supply system designed to reward customers rather than management.
Dan, Ireland
After the Eircom debacle, it should be clear that privatisation is not necessarily the way to go, and that if the ESB is privatised, the national network of power lines should be kept as a State asset.
Daren, Ireland
The number one priority to private companies is profit, not the consumer. At least now if we are unhappy we can (try to) get our politicians to make it better. If the ESB is privatised, we will be helpless.
Then there is the problem of burning fossil fuels. The State would lose a method of giving people an incentive to use less electricity (price increases). No self-respecting multinational firm would voluntarily invest the colossal funds needed to make Ireland a country run solely on renewable energy.
Robert, N Ireland
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