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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