Why is it so difficult to downgrade local hospitals?

The response to the Compton Report has thus far been remarkably low key. In part this may be because the Report is so comprehensive and so well argued, backed up by studies and statistics at every turn. Furthermore it says very little that anyone with any significant interest in health policy has not known for years. Possibly (and depressingly) one of the other reasons is that the Report carefully avoided stating which acute hospitals should be downgraded.

It seems pretty inevitable that Lagan Valley will go as an acute hospital and although there may be a bit of a fight it seems that Lisburn will accept the inevitability of this. The fact that for years major trauma and heart attacks (to pick two of the most immediately life threatening conditions) have already gone via ambulance to Belfast makes the transition much less painful. The campaign over the Downe will no doubt continue but so small is the current Downe (having no inpatient surgery, ICU, paediatrics or a host of other acute specialities) that survival in its current form is practically impossible.

The Erne may be safe (as a sixth hospital if we have 5 to 7 acute hospitals) and it seems as though Fermanagh and West Tyrone is collectively keeping its head down over the issue in the expectation of keeping the new hospital’s acute status.

The main battles in contrast seem to be beginning over Daisy Hill in Newry and Causeway in Coleraine. The usual calls have been made: one of the SDLP councillors in Newry has issued “a clarion call” to save the hospital whilst David McClarty and John Dallat in Coleraine have come closest thus far to winning the prize for being the first politician to say “People will die” if the local hospital is downgraded.

The Comtpon Report is one of the first documents in the public domain to state what has been known amongst healthcare professionals for years, something they have been much too poor at sharing with the wider public. That is that moving patients over large distances to specialist care is associated with better outcomes (translation into normal people speak: less death, less disability and less lengthy hospitalisations). Hence, centralising acute emergency care and driving patients from rural areas past the local small hospital to the larger hospital is associated with better survival for those rural patients. Edwin Poots has been the first politician anyone can remember actually to state the fact (known in health circles for years) that outcomes are four times poorer if seriously unwell patients are admitted to their local hospital rather than taken to a major fully equipped centre (the initial statement was made by one of the Compton team). The irony is that those who are loudest in protesting against the closure of the small hospital (the people in that rural locality) are the very ones whom the evidence shows would benefit from transport past the local hospital.

It is important to look at why this is the case before looking at why people still demand a local hospital (“or people will die” – cue demonstrations complete with pretend coffins and the like). Taking the two emergencies mentioned above: major trauma (ie accidents) and heart attacks. To treat major trauma one needs a large team of people – the following list is not exhaustive. Several A+E staff – doctors and nurses to treat the patient initially; a trauma surgeon (usually an orthopaedic surgeon), often a general surgeon as well and the whole team with such people. Then there is the theatre staff, the anaesthetists, the intensive care unit staff etc. All those people are necessary in the first short period of time following major trauma. In smaller hospitals there may well not be all those people: the A+E will have fewer staff, there will be no orthopaedic surgeon, sometimes no ICU etc. The obvious answer from the local hospital campaigners would be to have all those people in the local hospital. However, there would need to be several of each as people cannot be on call 24/7. That would then cost a fortune but much more importantly even if cost was not an issue each individual of those people would see a major trauma so rarely that s/he would deskill and no matter how good they were, they would become less effective and, hence, less safe putting the patients at greater risk.

The next suggestion raised by local hospital campaigners is to suggest stabilisation at the local hospital before transfer. Again this is flawed. The studies quoted by Compton and many others have shown that direct transfer to definitive treatment is the best option To use the jargon: “Stay and Play” versus “Scoop and Run”. In this context the “golden hour” is often misunderstood. It is not an absolute: clearly people are not much less likely to survive if they arrive at hospital 1 hour and 2 minutes after trauma than if they arrive at 59 minutes after it. Also the “golden hour” is not the hour to initial treatment: it is the hour to definitive treatment; treatment which cannot be offered outside a major centre.

The issue of heart attacks is actually even easier to understand. Heart attacks can be treated with “clot busting” drugs but the most effective treatment is “Primary Percutaneous Coronary Intervention” (there are some scrabble words for the holidays). This is when a wire and balloon are used to open the blocked artery. This procedure is exactly what the Duke of Edinburgh had done yesterday. There is a trendy guide to this on the BBC’s website so if you want to take it up as a hobby you can learn it over the holidays. It is worth noting that Prince Philip was taken 61 miles directly to a specialist hospital (in a helicopter – though actually road ambulances are usually better for a variety of different reasons). This procedure requires a heart doctor (cardiologist – another good scrabble word) and a team of nurses, cardiac physiologists and radiographers). If one had such teams of people doing these procedures in small hospitals they would (yet again) see so few patients that they would deskill.

If the evidence is so clear that major life threatening conditions are best treated in large centres the question has to be asked why people so vociferously defend the small local hospitals?

People not involved in health care are not fully equipped to understand the complexities of 21st century medicine. All people like the idea of the comfort blanket of their local hospital. No one would want to think that the local hospital could not treat a given illness as well as another larger hospital and as such may simply disbelieve or impute devious motives to those telling them the local hospital must be downgraded. Local hospitals are always seen as friendly places where staff have time for patients and relatives. In actual fact larger hospitals are just the same – doctors and nurses tend to be nice to their patients- but with their large concourses with coffee bars and people from all over milling about at all hours; larger hospitals seem less personal and less “the property” of the local community. Furthermore the constant business and bustle of a big hospital combined with the fact that rapid discharge of patients (especially elderly ones) improves survival can make people feel that their relative is being “pushed out the door.” In reality they are being pushed out as quickly as possible and it is for the patient’s benefit they are being.

The professionals in the small hospitals are also often anxious about downgrading the hospital. Cynics might suggest that this is fear of loosing one's job but it is not unreasonable to fear that. In reality all the proposals seem to envisage few or no job losses but even a change in what people do and where they do it is disruptive. The senior staff in the local hospitals may fear a loss of status and no longer being a big fish in a little pool where they tended to get their own way. More important, however, may be the fact that few want to admit that maybe what they have been offering is not quite as good a service as elsewhere. Even if that is not the case, admitting that to advance, their unit must merge with another larger one and loose its identity, could be very galling for hospital staff. It could make one feel that a professional lifetime given in the service of others might have no legacy.

Other non medical concerns can become entangled with the downgrading of a local hospital. The fear of a loss of employment in the area with people gradually moving to be nearer to their new place of employment is a real one. Sometimes people fear that there could be a loss of future inward investment if there is no local hospital (though again Northern Ireland is so small that by US standards the Royal Victoria is local to Derrylin).

Without being insulting our parochiality in Northern Ireland is part of the problem. Omagh is not far from Enniskillen in anything other than a Northern Ireland context and in actual fact the road (far from perfect as it is) is better than many roads in rural England, Wales and Scotland where much greater distances are involved in getting to hospitals. Equally only in Northern Ireland is the 23 miles between Daisy Hill and Craigavon Area Hospital a distance which is unacceptable or even the 38 miles between Antrim and Causeway (though the hospital would probably have been better in Ballymena). Even the hinterland of the rural hospitals is never as far from a proposed major acute hospital as many places in mainland UK and the road links are no worse (often better) than in many rural parts of GB. Clearly the distances are laughably short compared to those in rural North America or Australia.

Leaving aside the issues of life and death treatments many of the concerns surrounding the downgrading of local hospitals regard A+E. As mentioned above the case for seriously unwell or injured people being transferred to major hospitals is fairly overwhelming. Although life and death issues are usually the emotive concerns raised when downgrading small hospitals is mentioned the issue of practically is also important. The problem of excessive A+E attendances in Northern Ireland has been raised repeatedly. The concern is that if the smaller hospitals loose A+E the waiting times in the larger hospitals will rise. This is likely to be a valid concern. However, one of the problems with offering a highly efficient (in terms of treatment time for minor aliments) A+E is that people are more likely to use it inappropriately. This is something of a vicious circle for the NHS. Closure of a small A+E may well result in longer waits for minor or trivial problems at the main A+E. This will cause a public outcry and undermine confidence in the changes. The calls from politicians and senior health bureaucrats for people not to attend A+E over trivia may help but in actual fact lengthening queues may be one of the most effective strategies to reduce excessive A+E usage yet at the same time they will create an outcry. One solution might be maximising the use of minor injuries units. Providing a minor injuries unit in each of the hospitals to be downgraded may help assuage the complaints.

Further acceptance may be gained by keeping rehabilitation and out patients units in the smaller hospitals. These would ensure that the local hospital survives and flourishes doing the things they do best and avoiding doing the things which can be better done elsewhere.

All the above may make sense in a health care setting. However, it is very difficult to get around the idea that one is safer with a hospital on one's doorstep. The only way to explain this is to suggest that under certain circumstances the nearby hospital is less safe than the drive to another hospital. Edwin Poots has come as close to saying this as he can (further than most would have expected him to). Whether the public are listening is another question. It is interesting that some months ago even that arch controversialist Stephen Nolan got very concerned when on his show Newton Emerson suggested that one hospital might be less safe than another. That is of course precisely what Edwin Poots has been saying albeit in much more diplomatic language. The fact that the likes of Nolan baulked at that suggestion a few months ago shows the enormity of the mountain which needs to be climbed in terms of public understanding of the needed changes in Northern Ireland.

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  • Barry the Blender

    What do you know about Cardiology Turgon?

  • Barry,

    If you aren’t simply dissing Turgon, use Wiki. Good stuff there. I’ve had stents inserted on two separate occasions.

  • Barnshee

    “To treat major trauma one needs a large team of people –”

    Equally if not more important is prompt attention

    At leat 2 people injured in Portstewart in ther last couple of years would have died if the ambulance had had to come from Derry or Ballymena and transport the patient back there.

    I have no problems withe Comptons etc of this world promoting and implementing policies. I just want some means of making them accountable when they fuck it up.

  • Barnshee,

    We simply cannot afford to have a major trauma centre in everyone’s backyard.

  • Some excellent points Turgon.
    For reasons I wont go into, my family has more than one interest and indeed more than one kind of interest.

    There are all kinds of reasons……budgets merely being one of them …..why there will have to be changes. Reasons of Demography or just the fact that some procedures are so expensive that they cannot be reasonably available in every single (former) “cottage hospital”.

    But why the re-action. There is a cerain parochial response but to a large extent this seems to be reasonable. At this moment in time, I live about 10 minutes from a very large hospital. It is not under threat…but my attitude would be less academic if I suddenly found that my journey was the best part of an hour.
    “People will die”? That is probably true.
    It is probably already true in some places. If any of us is unfortunate enough to have a massive heart attac on top of the Sperrins, we probably have a lesser chance of survival than if we collapse on the Lisburn Road in Belfast.
    I know that among women, the issue of maternity services is very important………talk to any woman long enough and you will be told how MEN make health policy. But as I understand it no babies are born in Dungannon for example. Those babies are born in Craigavon.
    There is frankly a little hypocrisy going on. Go to just about any provincial town and talk to people and they will tell you “if I broke my leg in a football match, Id tel the ambulance driver NOT to take me to the local hospital”.
    Ive heard that said in a lot of towns……but threaten the local hospital with closure and these people are the first to sign the petition.

    Politicians are also vulnerable.
    Even in five party coalitions.
    DUP and Sinn Féin are more vulnerable because they are more in government.
    Thus a SDLP politican CAN issue that “clarion call” about Daisy Hill.
    And David McClarty CAN issue another one in East Derry.
    Basil McCrea is less vulnerable in Lagan Valley than a DUP MLA.

    High Policy and Opportunism. Politicians would be foolish NOT to see an opportunity and take it. With UUP and SDLP on just one Executive seat they are effectively detached from Decisions. Clearly this is often a disadvantage so might as well use it when it becomes an advantage. There are Electoral considerations. Can we be totally certain that both at local and Westminster level, there will be no “events” to trigger an election?

    Clearly decisions made by Technocrats have limited electoral effect. And passing the ball to Compton and then accepting his decisions might work. But there is room for mischief, including the unstated working up of perceived disadvantages to any community……for example employment opportunity as well as Health.

    Effectively beefing up these “health centres” and GP surgeries seems a return to “cottage hospitals”. But new procedures and day surgery seem to mean that we can have better turn around.
    I declare an interest. Earlier this month my son went into hospital at 7.30am, had his gall bladder removed at 10am and was back home at 7.30pm. And is making a good recovery.

  • Barry the Blender

    There is frankly a little hypocrisy going on. Go to just about any provincial town and talk to people and they will tell you “if I broke my leg in a football match, Id tel the ambulance driver NOT to take me to the local hospital”.

    I think you’re onto something there fitjameshorse. I worked for a while in Coleraine, and locals had some very unkind things to say about Causeway (and it’s one of the more major hospitals these days)

  • Turgon

    Barnshee,
    There are some misunderstandings in your position. Take a hypothetical patient in Portstewart. The ambulance would not come from Ballymena or Londonderry: it would come from the same place as it does now. There is no proposal to close ambulance stations and indeed the suggestions are to upgrade the ambulance services. As such the patient would be collected just as quickly.

    They would indeed take longer to get to Altnagelvin or Antrim than to Causeway. However, the whole point of the Scottish Trauma Outcomes Study (referenced in Compton) was that patients did not do less well being transported long distances to hospital. Furthermore as I noted above there is evidence that people do less well being taken to less well equipped hospitals rather than being taken past them to larger hospitals.

    The public perception and prejudice is indeed that “people will die” but the evidence from real world clinical outcomes is that fewer people die with the sorts of changes being proposed by Comtpon.

    One can no doubt construct a hypothetical scenario in which a person would survive by being taken to Causeway but would die being taken on to Altnagelvin or Antrim. However, the evidence of the studies is the reverse; that more people survive by being taken on to the larger hospitals. This may sound counter-intuitive but remember a small hospital for the reasons I outlined in the main post simply cannot have all the necessary specialists on call and stabilisation in a unit without full facilities does not work. As such the actual evidence shows that the best idea is to drive on to the fully equipped hospital.

  • DC

    Straight outta Compton!

  • Cynic2

    ” if the ambulance had had to come from Derry or Ballymena and transport the patient back there.”

    Doh! This is a 1950s approach. Ambulances now stay out on the road almost all the time. The best Ambulance services use dynamic management where they are controlled by computer. The system knows the likely pattern of demand and tasks empty ambulances to park up in areas closest to where they may be needed. It uses GPS to track them and deploy the nearest vehicle to each job. This has been used for years in the UK.

    As for minor injuries, I believe that something like 20% of punters presenting at A&E could be self treated at home or dealt with by their GP. In the end, if they have a minor injury and have to wait, frankly, its much more important to have the expert assistance in big centres to save those whose life / long term health is threatened. Many of those who now call an ambulance are checked and treated in the ambulance and not brought to A&E because they don’t need to go there

  • I find it curious that you think that the Erne would be the sixth hospital – my money would be on Daisy Hill being the sixth.

    The key problem with the Compton review is that with the exception of Craigavon and the Royal, the most likely hospitals are all in precisely the wrong place.

    Altnagelvin would be far better in Dungiven; Erne should be at Ballygawley; and Daisy Hill should be no further south than Downpatrick or Ballynahinch. All three are far too close to the periphery of the areas they serve. Similarly, Antrim is ridiculously close to Belfast, and for this model should be in Ballymena.

    I reckon it’ll go to six hospitals: Royal, Craigavon, Erne, Altnagelvin, Antrim, and possibly Daisy Hill for the sake of South Down.

    Lagan Valley and the Ulster are too close to Belfast (please, nobody throw up the irrelevance that neither is in Belfast – someone did that with reference to the Ulster on the Belfast Telegraph website, but in reality it serves most of east Belfast!); Causeway is much further from south Antrim than Antrim is from north Antrim; the City A&E will never re-open and the Mater A&E is the wrong side of a peace wall. There are potential issues with the Royal’s capacity to cope, but actually its siting is excellent.

    I reckon there’ll be an increased number of walk-in injury units (rather than Minor Injury Units, if you see what I mean – greater capability), but blue light ambulances won’t go there.

  • Turgon

    AndyB,
    Some good points but equally you also completely miss the point. The distances involved are so small that nowhere is that far from a major hospital by UK let alone European, US or Australian standards. If the Erne did not exist getting people to Craigavon would not be out with safe drive times. Even more so for Daisy Hill and the Downe being downgraded and people going to Craigavon / the Ulster respectively.

    Getting rid of the Ulster is no problem in terms of geography but in terms of capacity would mean that you would have to expand the Royal / City / Mater a fair bit. That in a time of economic hardship would be problematic. Equally, however, I do still believe even in the current climate there would be merit to abandoning Antrim and Causeway and building in Ballymena.

    The overall point is we need many fewer hospitals so each can be a centre of excellence with almost all the specialities that locality needs. This would be best achieved with 5 hospitals (or possibly even less) and the drive times are such that the clear evidence (not the shroud waving prejudice) is that such a move would improve patient outcomes for the very patients in the rural areas who are likely to be mobilised the most to complain about the changes.

  • I was talking about that on Facebook shortly after Compton came out. The reckoning is that, surprisingly to me, A&E in the City doesn’t have room to expand on the ground floor. I would have thought that a major refurb could have moved some of the services currently on the ground floor of the Tower to other areas, but there you go. The medical staff who commented reckoned that the Royal could be expanded rightly, and besides the Royal already has the acute specialities on site where they are needed. They reckoned the City will move towards solely elective and other non-emergency work.

    Where this could all fall down is the capital investment required to do the job properly. It wouldn’t be the first time that someone decided to do a government job on the cheap, and if infrastructure and facilities were not to be upgraded properly, the money saved in running fewer emergency departments could be wasted in time lost, transporting patients to where the best care is available unnecessarily, and cheaper intervention in acute cases ruled out because of time elapsed.

    So the question is whether the Assembly (and the Treasury) will be prepared to put the money in now to save money later. I always fear the scenario where they go for the “cheapest” option, and then have to spend much more to undo the cheap work and do it all over again properly (qv Westlink, Newry Bypass MkI-III!)

  • Turgon

    Andy B,
    As I said you simply miss the point.

    ” the money saved in running fewer emergency departments could be wasted
    in time lost, transporting patients to where the best care is available
    unnecessarily, and cheaper intervention in acute cases ruled out because
    of time elapsed.”

    You fail to understand. Moving the patient is not about cheaper interventions or saving money. Moving patients to centres of excellence is not to save money; it is to save lives, reduce disability and shorten their illness. Why should people in rural areas be deprived of going directly to a centre of excellence for that is exactly what having the small acute hospital achieves.

    The fewer hospitals we have the better: not merely in terms of cost but more importantly in terms of outcomes. In England where they have per head of population fewer hospitals and longer drive times on no better roads they are talking about reducing hospital numbers further. This is driven centrally not by cost but by the need to improve outcomes and the evidence that outcomes are better if all the hospitals which admit acute patients have almost all the necessary specialities.

    As such if we reduce to say 7 hospitals we will still be behind England / Wales and Scotland: the patients in the smaller hospitals will still not get access to all the specialist treatments they need in a timely fashion and we will be back again in another 10-20 years, again years behind the rest of the UK and again needing another reorganisation.

    The nettle should be grasped now and the minimum number of acute hospitals kept with the others doing the useful jobs they can do but not the acute admissions. Comtpon’s minimum of five should be stuck to rigidly. I fear, however, it will go up to 6 and maybe more. That will be proclaimed as a great victory by the local people who kept their small hospital and they will refuse to believe the evidence that they will have done themselves and their sick relatives a considerable disservice.

  • No, you missed my point:

    “Where this could all fall down is the capital investment required to do the job properly… So the question is whether the Assembly (and the Treasury) will be prepared to put the money in now to save money later”

    If they do the job properly and invest in infrastructure and facilities, the outcomes in benefit to patients which you foresee ought to be achieved.

    The price will be less accessibility for visitors, but the quality of care is far more important than whether your family can visit you as much as you or they would like. Of course I would like to be near my family if I were sick in hospital, everyone would, but if being further away is the price I have to pay to get the ideal treatment, so be it. That of course bears in mind that some very serious cases are already transferred to Belfast hospitals because they are currently best equipped to deliver them – this model might see the extension of some of those services to the other remaining acute sites.

    It is however true that reducing the number of acute hospitals will save millions in running costs as beds are transferred to fewer sites. Like it or not, there is no way that DHSSPS would be even considering this if there weren’t cash savings to be made.

    If they don’t do the job properly, we will be worse off than we are now – and they will have to revisit rather sooner than in 10-20 years, wasting billions of taxpayers’ money for the sake of a few million now. To use your appropriate metaphor, if they don’t grasp the nettle properly, they (and we) will get stung.

  • I’d never expect Turgon-the -Wise to go for one of those Daily Mail type questions: Why is it so difficult to downgrade local hospitals?

    In a word, localism, dear boy. Localism.

  • Turgon

    Andy B,
    You simply do not understand. We do not need to invest now to save later. It is much more simple than that. We need to move patients to larger centres now to save lives. We can sort out the extra we need to spend later. The system is currently, right now, dangerously and disastrously broken. Currently outcomes are poorer in smaller acute hospitals. That is what the studies Compton cites show: furthermore the studies also show that moving patients large distances is associated with better outcomes.

    The point is that we need to do this now. Northern Ireland has many more beds and more health infrastructure than the rest of the UK: we simply use it very badly.

    The infrastructure changes needed are surprisingly modest. The real problem is the inefficiency of our system and that inefficiency is greatest in the smaller hospitals.

    These changes could be driven through remarkably quickly. However, the idea that we need to invest to save is in danger of becoming another stalling tactic by the supporters of the small hospitals. They will wail that inadequate extra has been spent in the large hospital and as such the small hospital cannot be downgraded: they will argue this almost no matter what. Hence, the solution is simply to announce a date and stick to it.

    All else is dangerous procrastination.

  • Turgon: All of which is blindingly obvious, except for the narrow sub-nationalist view: Northern Ireland has many more beds and more health infrastructure than the rest of the UK: we simply use it very badly.

    Add in the (other side of the Border) counties. Start programming and implementing health as a cross-border issue. Suddenly major health centres of excellence at Newry and Enniskillen make real sense. Apart from a self-regarding petting-parlour of medical-insurance fatted cats, who suffers?

    Below those regional (not “NI”) facilities, there has to be a lesser tier, providing care and attention for knocks and bruises. On top of that, somewhere we have to accommodate the needs of an elderly (and terminal) population.

    The NHS, across the whole of the UK&NI, is among the most cost-effective in the world — and, I suspect, could teach lessons to others on the island. Quite how one measures “inefficiency” (money? survival rates and life-expectancy? perinatal mortality? customer satisfaction?) is in the eye of the beholder. I must admit I find the arrival over the horizon at this moment of economic stress curiously coincidental and partisan-politically convenient.

  • Turgon

    Malcolm,
    I am afraid you are wrong there. Cross border health creates multiple problems:

    There is inadequate accountability: how can an MP for Louth complain about Daisy Hill in the Dail; it would not be the RoI health minister’s problem.

    If the RoI does not offer some things on the NHS which NI does that creates inequities in say Erne or Daisy Hill. If, on the other hand, all get the same in the border hospital then some RoI citizens (those served by NI hospitals) get different care to others in the RoI.

    Then there is the fact that health care costs are largely about staffing costs. That money does not vanish. The staff pay taxes, buy food, clothes, cars and houses etc. and in the process pay tax, keep other businesses going etc. If the hospitals are in NI then most staff will be in NI and as such the RoI is essentially throwing money at NI for much less return than if it did the stuff itself.

    These issues can be overcome for some specialist things which can be easily worked out in terms of expense: say ENT operations and the like (as is currently done). However, for general care it is much more difficult.

    You also ignore the simple fact that people in the RoI are most unlikely to welcome their own hospitals being downgraded to help NI’s hospitals.

    Finally in terms of centres of excellence even with the RoI hinterland Daisy Hill would (and the Erne may well) have too small a catchment area in terms of population to be large enough to have the specialities and be a centre of excellence.

    What people are continuously ignoring here is that you need very large populations to have centres of excellence with the necessary specialist teams and for those teams to keep their skills up. Then people are ignoring the very small geographical distances involved: as an example 23 miles from Newry to Craigavon.

    In terms of the convenience of saving money again you are largely wrong. People have been proposing for years reducing the number of hospitals (six for NI was suggested in 1966). In England (and Wales and Scotland) Labour had a massive hospital building programme but what is often less noted is that they closed a lot of the smaller hospitals which is one of the reasons health care is so much better in England than it is here – in terms of waiting lists etc. it is colossally better.

  • Turgon @ 1:48 pm:

    By no coincidence, those very valid objections are remarkably similar to those argued against Andrew Lansley’s master plan.

  • Turgon

    Malcolm,
    Lansley’s plan has problems in terms of fear of private involvement and other issues: rightly or wrongly, I make no comment in it.

    There is no significant opposition to centralisation from those who understand about centralisation of services and the needs for it. I mentioned heart attacks above. Most of mainland UK now has Primary Percutaneous Coronary Intervention as standard treatment with patients moved past local hospitals to centres of excellence for the aforementioned procedure. The reason for this is that it improves patient outcome in terms of survival, length of stay and on going ill health for the patient: that it also saves money is an added bonus but not the primary objective.

    Much of the debate here starts from a flawed premise: how do we keep Daisy Hill, the Erne or wherever open?

    Much better is to say how do we offer best health care to NI’s population? That is actually what Comtpon has done but now various vested interests are trying to make the square peg of small acute hospitals fit the round hole of top quality health care.

    If they are permitted to do this we need to be very clear. What they are saying is that they do not mind excessive deaths and poorer health in rural communities. They are saying that they want that and the extra expense it involves in order to keep their local hospital open for reasons best known to themselves. It is really a population scale version of ignoring medical advice to stop smoking, not be grossly obese etc and saying “What do doctors know about that.”

  • I gulp when I read:

    Lansley’s plan has problems in terms of fear of private involvement and other issues: rightly or wrongly, I make no comment in it.

    There is no significant opposition to centralisation from those who understand about centralisation of services and the needs for it.

    Were it that simple, it wouldn’t need (in its current form) 305 clauses and twenty-four attached schedules.

    Meanwhile the issue of national policy-making versus localism is much, much more than Erne or Daisy Hill. Across the UK, wherever Tory politicians campaigned in 2010, they littered the neighbourhoods with promised retention of the local hospital. Many of those “promises” have been downgraded via “pledges” to becoming wishful thinking and then consigned to the waste-paper basket. And it’ll all cost £1.5 billion on administrative costs alone.

    Wherever one goes, hospital closures are on the agenda. Here, in London, Tomlinson recommended closing four back in … gosh! 1992! Then, as now, “centralisation” was a consideration. In passing, under present circs, anyone like to take a pop at Papworth?

    In itself, closure is not the essential issue: why most definitely is. Take the iconic St Mary’s in Paddington (y’know — Alexander Fleming’s petri dish). But it’ll make a terrific site for 3,000 luxury flats, hmmm … don’t you think? Somehow “efficiency” doesn’t get a look-in.

  • Turgon

    Malcolm,
    The why is simple. You are four times more likely to have a bad outcome if you are taken to the small local hospital than if you are taken past it to a larger one.

    That four times more likely to have a bad outcome means things like death, disability and long term hospitalisation.

    I am no apologist for the Tories but the simple fact is that we need to downgrade the smaller hospitals in England but even more so in NI (as there are proportionally more of them and they are smaller). One of the problems is that politicians of whatever hue are scared to say that you are more likely to die by being taken to the small hospital as it may cause panic and undermine everyone’s confidence in their local NHS. In this context Poots has been remarkably brave and is to be commended for it.

    Still by all means carry on trying to impute devious motives for the proposed changes in terms of downgrades. Just remember those arguing for keeping open small hospitals are in actual fact arguing for increased death and disability in their local areas.

    Pointing to the iconic nature of St Mary’s or anywhere else is absolutely irrelevant. The Mini or 2CV are iconic cars. I am afraid in terms of safety, comfort etc. I am much happier with my modern car. The names of yesteryear and emotional attachments to them cannot be allowed to cost the lives of people today. For assuredly costing lives is what keeping small acute hospitals open does.

  • You are four times more likely to have a bad outcome if you are taken to the small local hospital than if you are taken past it to a larger one.

    Gross generalisation. It depends on the complaint and the circumstances. Having centres of excellence for specialist skills is a very different matter; and on that we do not differ.

    … those arguing for keeping open small hospitals are in actual fact arguing for increased death and disability in their local areas.

    They are not. They are arguing for local access to necessary services. Ask them, and you’ll find they too agree that the highest skills and specialisms should be centralised. That does not necessarily apply to (for example) basic A&E.

    Pointing to the iconic nature of St Mary’s or anywhere else is absolutely irrelevant.

    Not when the main argument for closing a modern and successful hospital — moreover one dedicated to pioneering hi-tech simulators and training programmes allowing staff to practice their skills in a safe environment … at a time when studies suggest that 4-16 per cent of patients admitted to hospital are harmed in some way by medical intervention — is to realise its site value, otherwise known as “a tender process to look at the development potential of our estate across all of our sites”.

    Whether Mr Poots is averse to cash considerations is another matter on which I defer to those in the know.

  • Turgon

    Malcolm,
    The four times more likely statistic is from Compton and the review team. It is a generalisation but it is correct. Everyone deserves to go to a centre of excellence with any condition. Even if a child has no more than a cut face s/he still deserves to have it stitched by an expert and not in a “that will do” fashion. It could be the difference between a trivial blemish and a scar with lifetime effects.

    Basic A+E is a nonsense concept: I suspect you fail to understand what a modern emergency department is about. Minor injuries is fair enough but an A+E department is where an ambulance goes to. Currently in NI ambulances go to the nearest A+E. Hence, if they go to a small local hospital with a chest pain patient and that patient is having a heart attack the patient gets less good care than if they were taken for the Primary Percutaneous Coronary Intervention mentioned above. Major trauma is the same.

    No one is proposing closing minor injuries: it is A+Es. A+E should be able to cope with all emergencies. That requires a big department and all the back up facilities. The small hospitals do not have those facilities. That is why you are four times more likely to have a bad outcome if taken to a small hospital than if driven past it to a bigger one.

    One cannot have full services local to everyone or those offering that service will deskill. As such it is safer to be moved to the major hospital.

    You have completely failed to justify small hospitals and pointing to St. Mary’s is a red herring. If its services can be provided elsewhere better and more cheaply elsewhere: sell it off. Who cares if Flemming worked there: we should much more interested in living patients now than dead doctors of yesteryear.

    You quoting studies suggesting harm from medical procedures and then accusing my statistics of being a generalisation is ironic. Exactly why they would be lower at St. Mary’s is unclear. Unless of course it is a centre of excellence but as I have stated above everyone deserves to go to a centre of excellence for whatever is wrong with them. That would minimise the risk of harm from procedures with strategies like ensuring operations are done by a team which does it every week rather than one which does it only occassionally as will happen in a smaller hospital.

  • Lionel Hutz

    I wouldbe hesitant to comment on this having not read the review in full. However, I am someone who has several indirect interests in the reorganisation of services.

    The one point I would like to make is that Health Trusts have been taking actions which result in actively deskilling doctors in regional hospitals. Many of the smaller hospitals needs to be downgraded but it is the downgrading of that middle tier of the likes of craigavon, altnagelvin etc that I have real problems with.

    Year after year more individual types of treatment are being moved to Belfast with the result that posts in these regional hospitals become less attractive. Its a vicious circle. its harder to keep doctors and its harder to attract new ones. The result will be a future downgrading of those hospitals.

    If this review brought about downgrading of local hospitals to shore up the expertise in the second tier, I would be all for it. This would allow a doctor in Craigavon say to have outpatients clinics in Daisy Hill. With the more acute admissions going straight to Craigavon. Thats a happy medium I think.

    But underneath all of this the services in these regional hospitals is being silently downgraded. And thats a bad thing.

    S

  • Turgon

    Lionel,
    You make a very salient point.

    One of the problems sometimes is that the supporters of the small hospitals become so bitterly opposed to the nearby larger unit that they would rather it does not advance lest it offer things their tiny hospital cannot. At times it seems they would prefer everything be centralised in Belfast rather than have the very local service downgraded and a nearby larger hospital expanded.

    Compton seems to be indicating a move away from that and in favour of downgrading the smaller acute hospitals to allow the medium sized regional ones to become centres of excellence in their own right. That makes the most sense but the ill informed hyper local campaigns still need to be overcome.

  • tinman

    Turgon,

    I support your general thesis, that trying to deliver fewer all-singing, all-dancing hospitals will be better in the long run. A broader range of specialties will be available on-site, 24/7 rotas will be more robust, it will be easier to recruit, etc.

    I do have to take issue with your ‘four times more likely to have a bad outcome’ statement, which you come back to again and again.

    The Compton Review actually says: The Royal College of Surgeons has stated that in a fragmented emergency surgical set-up a patient is four times more likely to have a poorer outcome than in a more organised model (p. 27). Note that they are talking only about surgery.

    If you follow the reference in the Compton Report it sends you to a document published by the Royal College of Surgeons of England, The Higher Risk General Surgical Patient. Note that they are only talking about general (i.e. mainly abdominal) surgery.

    I had a quick read through the RCS report and as far as I can see the relevant sentence is this: There are few data which compare our outcomes in the UK to other countries but one study reported that risk-adjusted mortality rates were as much as four times higher in the UK than in the US (p. 6). Note that what they are actually comparing is the UK and the USA.

    If you follow up the RCS reference you find a journal article from 2003 which compares outcomes for non-cardiac surgical patients in the UK and in the US and concludes that risk-adjusted mortality rates following major surgery were four times higher in the UK cohort.

    Now I haven’t read the original article from 2003 (Match of the Day starts in a few minutes) but I would like to point out that what we have here is one study from almost ten years ago suggesting that surgical outcomes are four times better in the US than in the UK. That may have something to do with ‘centres of excellence’ or it may not. It may be transferable to other specialties or it may not. I don’t think you can use it to draw the conclusion that you are four times more likely to have a bad outcome if taken to a small hospital than if driven past it to a bigger one.

    There is already considerably more heat than light in this debate, so let’s stick to what the evidence actually says?

  • Cynic2

    “Year after year more individual types of treatment are being moved to Belfast ”

    …. and that is driven by professional clinical assessment and research. On one level its all a numbers game and the numbers show that the more you specialise and push volume through, for example, surgical teams, the more efficient they become and, and this is the clerical point, the lower the error rate becomes.

    So having Granny’s hip done in Newry may be convenient for the family and feel closer to home but her chances of surviving are significantly higher in a central unit in Belfast that does say 10 hips a day.

    The real problem is that many people in rural areas of NI cannot see over the next hedge, They dont often go to Belfast because there lie dragons. In all of that they are no different to people in Clare of Cornwall but they need to understand that if they want to maximise Granny’s chances of a good outcome, they have to travel> its not just about funding.

  • Turgon

    tinman,
    There are relatively few studies comparing local hospital treatment with specialist care. the one quoted is highly valid. There are also no studies comparing no treatment versus antibiotics for bacterial meningitis. No one would do the studies. The question of specialist services versus local treatment is almost as clear cut.

    The Scottish have shown that long transfer is not dangerous (with much larger distances than ours) and it has been shown worldwide over decades that increasing specialisation is associated with improved outcomes. The problem is ill informed shroud waving and the failure heretofore of politicians to stand up to that shroud waving and force through changes which will improve the survival and health chances for people in rural areas. Much of the problem has been the failure to explain just how substandard non specialist care is. There was always the worry about creating panic and undermining the system. That has allowed the system to plod on with poor outcomes. Now we need to change this.

    It is very simple: be transferred a modest distance, have lower mortality, morbidity and shorter hospital stay or be treated locally with higher morbidity, higher mortality and longer stay and local care costs more as well. It really is as abundantly simple as that. The problem is always local people’s fears often preyed upon and talked up by politicians for their own purposes, varius other interest groups and sometimes by some in the small hospitals consciously or subconsciously to defend their positions.

  • Oh, come on, Turgon!

    The problem is always local people’s fears often preyed upon and talked up by politicians for their own purposes, varius other interest groups and sometimes by some in the small hospitals consciously or subconsciously to defend their positions.

    There’s been enough overstatement here; but that one passes the mark.

    The pressure to retain local facilities is not induced for political advantage: it wells up from the populace. People want to keep their local hospital — it’s where their children (even they) were born. It’s where great-granny died. It’s what they know. It’s where auntie works.

    And why should people at that local hospital not be defensive about their jobs, even their status? Why should we deny them the right to lobby? Or does the Man at the Department always know best?

    Of course, in extremis they expect to be transferred to the super-specialist (by heli-ambulance if necessary). For a simple fracture job, they want the plaster clinic nearby. Ditto for a basic stitch-up — high-octane plastic surgery by that super-specialist too, but nobody in their right mind prefers the mid-August young intern at the prestigious teaching hospital to the nurse who’s been at it for decades.

    Don’t over-egg the cake.

  • Turgon

    Malcolm,

    There is no overstatement in anything I have said. It is based on the Compton review but also personal knowledge: the Compton reviewers know vastly more about health than you do; as do I. If you doubt me ask Mick.

    “in extremis they expect to be transferred to the super-specialist”
    Wrong: treating even relatively minor things in a specialist centre results in better outcomes. Furthermore illness can be unpredictable: much better to be in a centre which can cope with almost anything. The small hospitals are notorious for not transferring people out early enough.

    “For a simple fracture job, they want the plaster clinic nearby”
    Wrong: many fractures are treated by surgery now as it produces better outcomes. In children they are not but again it is better that an orthopaedic surgeon or an emergency doctor with a particular interest in children treats them. If a non specialist treats them they will not die: No. However, that child will not be quite as good at running or whatever. Exactly that scenario 20 years ago finished my sister’s moderately promising career as a cross country runner. Had she gone to a specialist centre she would almost certainly have done better.

    Ditto for a basic stitch-up”
    Wrong. A face or a young girl’s legs or any other bit to be exposed in the general run of the mill of life should be done properly and expertly by an expert. A child’s face is not “a basic stitch-up” It is about self esteem and life chances.

    Heli-ambulance is also totally unnecessary in Northern Ireland.

    “it’s where their children (even they) were born. It’s where great-granny died. It’s what they know. It’s where auntie works.”
    Why should such sentimental nonsense be allowed to cost lives. Maybe great-granny would have lived a few more years with a better quality of life during them had she been moved to a specialist centre.

    The problem here Malcolm is you are trying to argue for an outdated old fashioned approach to medicine: most things have moved on from the 1980s sadly some of NI medicine has not. Furthermore you are arguing from a metropolitan English perspective. Nothing wrong with that except in this context you have no concept of how small and lacking in specialities some of our acute hospitals are. Finally one of us knows what they are writing about.

  • Ah, yes — the experts always know what is good for us. Makes one wonder why they even invite discussion.

    I pretend to be no more than a mere democrat (one who even got himself elected the odd time or three).

    So, with due respect to the all-knowing apparatchiki: until we, the people, vote ourselves out of existence, I think we should be heard occasionally. If that’s foolish emotionalism … tough.

    Over and out.

  • If the job is done properly, clinical jobs will move with the patients to the larger hospitals to cope with the increased demand. In addition, a better Minor Injuries Unit could be supported for more hours in your locality – I would like to see an increased number available 7 days a week and preferably all day – these would take a lot of pressure off A&E if properly resourced. The jobs at risk are those of the administrators.

    I think Turgon could be right about initial transportation to the correct hospital. Are we really saying that our highly skilled paramedics cannot care for and stabilise a patient well enough to ensure their lives and health are in no more danger if they are transported for an hour instead of just 20 minutes?

    Also consider the effect of a patient being delivered to a local A&E and then having to be transferred again for another hour’s drive to a more suitable hospital. Which is better?

    Finally – a point Jim Wells has made a number of times (this is not the first time I’ve agreed with a DUP minister this year – it may well be the last!) Too many people misuse A&E for issues which ought to be taken to a GP (including the out of hours services) or their local Minor Injuries Unit. Change that behaviour and the five acute hospitals will give everyone who needs them a far better service.

  • Turgon

    Malcolm Redfellow,
    “I pretend to be no more than a mere democrat”
    A lie: you told us how fractures should be managed and who should stitch wounds. I pointed out you were simply wrong in all the medical opinions you expressed.

    You then say“the experts always know what is good for us.” Well on this issue yes I do know a lot more than you do about the NI NHS, its problems and how to try to improve it.

    Still do not let a lack of knowledge prevent you from pontificating about what should happen. There is a fine tradition of that on this website.

    Andy B,
    Minor injuries units may well be a help. However, I always fear the child’s face scenario. Which would you rather have stitch your child’s face: a minor injuries doctor / nurse or a plastic surgery registrar / consultant in the Ulster? The danger is that people in the minor injuries units might think they can do just as good a job and “have a go” to ensure the child does not have to go all the way to the Ulster. I suspect the main function of minor injuries will be to ensure the waiting times in the A+E departments do not get too long. That they are long of course is in part due to the inappropriate useage of them by people who should indeed go to their GPs.

  • Cynic2

    “I pretend to be no more than a mere democrat”

    If we allowed full democracy in this some citizens would be demanding charms on the NHS and others would be sacrificing witches to ward off evil spirits. Its not about democracy. Its about effective and efficient servcies

  • Cynic2

    “If that’s foolish emotionalism … tough.”

    Tough for you when its my money you are wasting!

  • Great arguments.

  • Zig70

    I struggle with this. The premise seems to be that the doctors are the resource that we move to. You could turn it and say 23miles is not that far for a doctor to be seconded. Is the issue that doctors migrate to the centre of excellence and won’t depart? Who is serving who? People like having local hospitals. The resource should be the hospital and should be operated in the same fashion as any high asset factory would be. The siting of each resource is then less critical as long as the number of doctors is high enough.

  • Efficient use of the Ambulance Service is critical to making things work. I live in a small town of 12000 and we have one fulltime ambulance. The next similar town is 35km away and they have one ambulance too. When one of the two ambulances is called out, the other is sent equidistant to both towns to maximise the response should another emergency occur in either town.

  • Turgon

    Zig70,
    You are missing several issues: centrally because the doctor is not the resource. It is the team of people whom one needs along with all their equipment and all the other services available in a large hospital. Patients often have the bad taste to have multiple complex problems especially acutely ill ones say after the likes of major trauma.

    Due to the increasing number of things medicine can do for people, medical teams (not just doctors and nurses) have to specialise. This allows them to be good at the things they do.

    To remain good at the procedures these teams need a large number of patients to keep up their skills: do you want your heart operation done by a team that does the operation several times a week or once every six months?

    Since the team needs a large number of patients it needs a large catchment area. Therefore it cannot be local to everyone.

    The possible alternative of moving the team to where the patients are is completely impractical: one cannot move complex specialist equipment and if even if one could have an operating theatre or whatever standing by at each place the team might be needed it would still be a logistical nightmare. Furthermore if hypothetically one moved team and all to say Coleraine for a given emergency what would happen if a patient needed their attention in Larne shortly afterwards?

    Another alternative would be to have so many teams that one could have the full team at each small hospital. Leaving aside the astronomic cost this would be, each team would then see so few patients that no matter how good and how well-trained it was it would de-skill and become a liability to the very patients it was meant to serve.

    The only efficient system and the only one which works for emergencies is to rush the sick patients to a centre of excellence. To ensure the team keeps its skills up there have to be a limited number of such teams and because of the complexity of some patient’s problems there needs to be all the other services of a major hospital on site. Hence, one is brought back to the need to have a small number of centres of excellence and bring the patients to those centres for the initial management.

  • Zig70

    So if you have about 20 cardiologist consultants in the Royal with associated teams and several units. It doesn’t really matter where they are as long as they run effeciently (24/7?) It wouldn’t decrease the quality to spread them around the country if the training was maintained. I’m not suggesting irregular operations, I’m agreeing the effeciency of the unit is key but compton doesn’t see doctors/equipment as a movable resource across relatively small distances.

  • Cardiologists need a pile of equipment which would have to be duplicated across more than 5-6 hospitals in your model. Transporting equipment between sites is an absolute non-starter – it would take far too much time, and would cause people to die while they wait if they go to one hospital while the equipment is at another.

    You would also need extra consultants in particular and other doctors to cover all necessary shifts – more than you would need to cover a doubled workload on a single site. May I remind you that one of the reasons for the suspension of the City A&E was staffing?

    It might not decrease the quality to have cardiology departments in ten different hospitals, but it would cost a hell of a lot of money. Centralise in five and you save a lot on overheads and staff costs for an equal level of care.

    That applies for all acute/emergency medicine. If it’s all on one regional site, the patients will already have been brought there in a blue light ambulance and no time will be wasted taking them to another location to get to the appropriate doctor.

  • The yokel

    Zig’s idea may not apply to heart surgery, but the English NHS has just announced that 25% of patients should be treated at home rather than in hospital. Is the way forward centers of excellence dealing with acute illness, longer term care and routine procedures being the responsibility of the GP either at the local heath center or at home?

  • Turgon

    Zig 70,
    Andy B has already largely answered you. However, to take cardiology it is not even as simple as that. In difficult cases there may be two cardiologists so excessive spreading would be foolish. Furthermore there are different types of cardiologists: some do the stents etc. like Prince Philip had; others do pacemakers and the like; others scan tests etc. Cardiology has various subspecialities and so do all the other major specialities.

    Andy has already pointed out the impossibility of moving equpiment. Continuing with cardiology one should have centres outside Belfast: we already do; Craigavon has a large cardiology department with its own theatres (called cath labs), so does Altnagelvin. Going forwards the Ulster and Antrim may well get them (cath labs). However, that is about the limit of what could sensibly be provided without each unit becoming so small it deskills. That is where I would disagree with Andy B: having cardiology departments in more than 4-5 units would decrease quality and decreasing qualityt in this sense means worse outcomes. Having outpatients and more minor investigations in the former small acute hospitals might be a reasonable way forward but not inpatient care. Even then it creates inefficiencies where the expensively trained team members are paid on NHS time to commute about the country.

    A problem about moving teams is that it is not the doctors one needs to move: it is all the team including but not only the doctors. Also people who work in the same team tend to be more efficient; they can anticipate what their colleagues will need / want next. Efficient health care is about efficient cooperative team working: that is what produces better outcomes for patients.

    The yokel,
    Your suggestiuon is exactly what Comtpon proposes. Think of it as having more (and more complex) community care and also complex hospital care. The bit we need less of is the small acute hospital. Very few people will lose their jobs: just people may have to move jobs from the small acute hospitals either to the larger hospitals or else into the community. This sort of change would provide better health care and would probably also be cheaper. However, the main driver of this in mainland UK at a time when there was large amounts of money being put into the system (10 – 15 years ago) was about improving outcomes not about saving money.