A hospital in every county will not provide the best medical services, and national needs must come before local, writes Prof John Hillery.
Modern Ireland seems to welcome innovation and change and we have become very aware of international best practice in everything, from commerce to medicine. We are very willing to copy what is good and adapt it to our needs.
However, on issues concerning our own national development, we seem to fear that change will come at the expense of local interests.
Health service provision is a prime example of this. The Government is criticised for wasting the product of the boom by not developing a 21st-century health service infrastructure.
However, the mixed reception for centralised cancer treatment services and the ongoing protests against the changes in accident and emergency services around the State suggest that people continue to reject national improvements in favour of outmoded ambitions for a flagship hospital in every county.
Media reports of the reactions of "outrage" from local politicians, doctors and other community representatives chart a knee-jerk reaction to change which does not seem to be based on an informed analysis of what is proposed, what is best practice and what is best for patients.
A recent HSE survey of consumer satisfaction suggests a majority feels there should be an acute hospital in every county. Interestingly, however, respondents also indicated a preference to be treated in a specialist centre if this meant a better outcome for their illness.
These results show confusion in the public mind as to how the best access to and the best outcomes from modern medical interventions are achieved. This confusion has not been properly addressed.
Modern medicine requires specialist teams of doctors, nurses and other skilled staff. It would not be economically possible to have such teams in every speciality in every hospital in the State.
The inability of small hospitals to provide a comprehensive range of medical interventions is not solely due to economic reasons. Specialist staff, medical and others, must be dealing with sufficient numbers of patients with the specific condition to maintain their skills. The environment must be set up to deliver the exact treatment needed for the exact condition.
Modern medicine can achieve much but it is complex and open to error. To maximise outcomes and minimise error, teamwork, with peer review and consultation, is vital. These requirements for safe best practice apply to issues as seemingly straightforward as childbirth and those as complicated as neurosurgery.
Such requirements cannot be met in a dispersed health service made up of small local hospitals trying to cater for all conditions with limited staff and limited exposure to each disease circumstance. Multi-disciplinary assessment and treatment teams based in centres of excellence will meet the requirements. Recent traumatic examples of negative outcomes of other ways of delivering healthcare have been aired in the media.
The much-maligned Hanly Plan proposed major hospitals as centres of excellence with small satellite local hospitals as part of a national system of health service delivery. If implemented and allied to the plans for comprehensive primary care, this will greatly improve access to healthcare when it is needed, by whom it is needed.
Despite the evidence, arguments continue to be advanced against the move to a healthcare system based around centres of excellence. Some seem more related to misinformed fears about threats to local concerns than to an informed knowledge of what is proposed. Many of the arguments that I have heard are based on emotion, not evidence.
Such emotive claims will hold weight until the genuine concerns of the public are allayed. The message that the proposed developments will deliver what the public needs has not been clearly conveyed. The questions that concern the public have not been clearly answered. The answers must include actions that reassure.
The experience of people, especially outside the main population centres, has been that it is best not to trust in the aspirations of policy documents until there is concrete evidence that the aspirations are delivered on. It is beyond belief that the announcement of centralised cancer care services was followed by reports that budgetary savings plans would adversely affect the functioning of at least one of these centres. It is as if those who should be pushing out the change are unaware of how easy it is to undermine public trust in it.
Politicians, doctors and other leaders must give a uniform message, based on evidence, supported by actions, of how the best outcomes for the public will be achieved with a new system. We cannot postpone further the development of our health service. The declared ambition is that Ireland will be a world leader in healthcare delivery. Much time and expertise has gone into developing a plan to deliver on this. The possible damaging outcomes of the alternative have been pinpointed. It is time to go beyond local interests with clear leadership in the national interest.
Dr John Hillery is chairman of the International Association of Medical Regulatory Authorities and past president of the Medical Council.