OPINION:IN AN Irish Times HEALTHplus article (July 19th), Dr Jacky Jones, a former regional manager of health promotion with the Health Service Executive, referred to the handling of the Roscommon emergency department closure by politicians and the HSE as "a dog's dinner" and a metaphor of what's wrong with the health service.
She argued that the Health Information and Quality Authority reports on Ennis and Mallow are crystal clear in commenting on international evidence that patients are better off being treated by doctors that treat larger numbers of patients, the “volume-outcome” hypothesis.
Yet how many people have read the reference papers provided by the authority in their reports? I accept there is a relationship between numbers of patients treated and outcome, in particular for complex conditions like surgery for aneurysms, some cancers, heart disease, Aids and those critically injured in road and other accidents. The authority uses such information to advise government that it is appropriate to close smaller institutions as unsafe.
But in the research papers in the Ennis report on volumes and outcomes – used to support the authority’s case that Ennis hospital was unsafe and that care should be transferred to Limerick Regional Hospital – the authors and experts took a different interpretation to that of the authority.
So, for instance, Prof Gordon Rubenfeld of the University of Washington states in the discussion section of his New England Journal of Medicine study that hospitals treating larger numbers of patients requiring life support breathing machines resulted in lower mortality. And in his subsequent letter in the Journal that the act of transferring such patients to regional centres may cause harm. Moreover, that the regional centre may not be able to maintain high-quality care if it has to deal with greater numbers of patients.
We have recently seen the stress on regional centres in Limerick, in part consequent on closure of services at Ennis and Nenagh. And since the Roscommon emergency closure even on non-regional hospitals such as Portiuncula in Ballinasloe. The overcrowding of emergency departments, best exemplified most recently by the problems in University Hospital Galway, has been well shown in international research literature to be unsafe.
One of the correspondents commenting on Rubenfeld’s research, Prof Arah, now of the University of California, indicates that a 10 per cent reduction in mortality for patients requiring life support at all hospitals would result in a greater reduction in mortality than a strategy of regionalisation, a view shared by Prof Rubenfeld.
A further paper in the Ennis report deals with clots to the lung and is flagrantly misrepresented by the authority to support its volume-outcome argument. This is clear from a commentary on the paper by Prof Marc Carrier and Prof Philip Wells from the Civic Hospital in Ottawa, in which they point out that the paper actually showed that hospitals treating 10 to 19 cases of lung clots per year had lower mortality than those treating 20 to 41 cases per year.
It is disappointing and worrying that the authority is not balanced in reference to this issue. As the Government’s regulator on quality in healthcare, it should provide balanced opinion. If the authority is unwilling to do so, then observers with alternative views must provide that balance.
And so, for instance, in addition to the opinions mentioned, a report in Health Care Quarterly, a journal of the Institute for Clinical Evaluative Sciences in Toronto, Prof David Urbach, makes the point that the closure of a hospital results in disadvantaging the majority of the public requiring medical attention who attend that hospital, many with a broad range of conditions for which there is no, or minimal, relationship to volumes treated, such as pneumonia, tonsillitis, urinary infection, chest pains, asthma attacks, appendicitis and so on, while a minority of those with more complex disorders benefit by being transferred to the regional hospital.
Finally, how many people are aware of the potential health impact on patients of distance travelled in an ambulance or what advanced paramedics can and cannot provide in delivery of pre-hospital care?
The public should be very concerned when doctors representing the HSE, including professors, use the media to comment on healthcare policy outside their area of expertise, to reassure the public that all will be well for them despite closure of their local hospital emergency department.
As an example, they reassure doubters that care by paramedics will be most acceptable, by inference as good as at your local emergency department. And that you are better off to travel the longer distance to the “most appropriate” hospital.
What the authority and medical personnel have not told you or the Government is the findings of research in 2007 by Prof Jon Nicholl from the University of Sheffield on distance travelled in an ambulance. For every 10km, patients with acute respiratory, cardiac or drug overdose experience a rise in mortality of 1 per cent. Nor have they informed you about the Ontario PreHospital Advanced Life Support Study, one of the largest studies carried out on the value of adding advanced paramedics to a programme of rapid defibrillation for heart attack victims, which revealed no extra benefit to such patients.
The authors suggest that provision of such skilled and more costly health professionals needs to be considered in the context of efficient health spending. Other European nations such as Belgium, the Netherlands, Germany, France and Greece, appreciate the limitations of paramedics and have greater concern for patients who must travel further distances to hospital and instead transport doctors and nurses out in mobile medical units to treat the most seriously ill alongside the paramedics. It is essential to have a body such as the Health Information and Quality Authority providing guidance and regulation on quality in healthcare and also to have doctors involved in reform of the delivery of our health services. But the Government should more rigorously question its advice on the closure of hospital services and pause to reflect on the unintended consequences.
Dr John Barton is a consultant cardiologist at Portiuncula Hospital, Ballinasloe.