The most detailed critique of the Hanly Report was published two weeks ago by Dr John Barton, a cardiologist from Portiuncula Hospital in Ballinasloe, and health economist Catherine McNamara.
The Minister for Health, Micheál Martin, issued a point-by-point rebuttal. Each side accused the other of selective quotation from scientific literature.
Dr Barton and McNamara challenged the premise that bigger is better in hospital size, that higher volumes of procedures necessarily lead to better outcomes and that ambulance paramedics can reliably treat emergency cases. They argued for care closer to the community and cited a U-turn in the UK's National Health Service (NHS) policy on smaller hospitals. They suggested that by retaining the existing number of junior doctors while increasing consultant numbers (as Hanly proposes), local hospitals could continue to deliver acute services.
The Minister responded that Hanly had taken no view on optimal hospital size and that the literature was unclear. He quoted a study suggesting that the optimum size lies between 200 and 620 beds.
Both sides drew from the extensive and in places conflicting literature on the relationship of volume of procedures to outcomes. Barton quoted a study from 2001 stating that "there is no evidence to suggest a general relationship between volume and quality of care". This study, however, added that patients treated in high-volume hospitals or by high-volume surgeons had better outcomes for "cancer in the oesophagus, pancreas, and liver, abdominal aorta aneurysms, carotid endarterectomy, congenital heart disease, acute myocardial infarction and PTCA, organ transplantation, and AIDS". While in trauma treatment "no relationship was found between hospital volume and mortality", for orthopaedic procedures "the results are inconsistent". While conceding that surgeons had a good case for supporting centralisation of complex care because higher volumes are associated with better results, Barton argued that for physicians there was no such association.
The Minister responded that the Hanly Report did not assert or attempt to make the case that higher-volume hospitals produced better results but rather that "the best results in treatment are achieved when patients are treated by staff working as part of a multi-disciplinary specialist team . . . in units with appropriate numbers of specialist staff with relevant skills and experience, high volumes of activity and access to appropriate diagnostic and treatment facilities".
The Minister pointed out that the article cited by Barton/McNamara in relation to the shortcomings of ambulance technicians referred solely to one procedure and had continued that "this is not an argument against training ambulance staff in basic life-support skills".
The Minister insisted that the new approach in the NHS to smaller hospitals supported the Hanly analysis. Quoting from the same source as Barton, he cited an NHS pilot programme in a smaller hospital with a minor injuries unit, while the Barton document ignored this example and cited other pilots which maintained acute services.