The Hanly report makes no reference to evidence that county hospitals may be better at co-ordinating medical care than the larger Dublin hospitals,writes Dr Christine O'Malley
The Hanly report is the Government's response to the EU Working Time Directive (EUWTD) for non-consultant hospital doctors. It is also the main plank of the health service reform programme.
The key element of the report is centralisation of acute hospital services into a number of large "centres of excellence". Proponents of the report suggest that centralisation is necessary on quality and cost grounds, and that it is the only way to comply with the EUWTD.
In principle I believe that acute hospital care can be delivered in either a centralised or decentralised hospital system provided it is funded appropriately. Different countries have chosen different routes. New Zealand, for example, has retained a decentralised hospital system. That's despite introducing a 16-hour maximum shift for hospital doctors in the 1980s, similar to the EUWTD.
The Hanly report does not provide convincing evidence that centralisation is the only route in Ireland. For example, the report uses a study of heart bypass operations in American hospitals as evidence for centralising all general medical and general surgical patients in Irish hospitals.
The report suggests that outcomes of care are better for patients treated by consultants with large clinical workloads, but fails to consider that, in Ireland, it is the county hospital consultants who have the largest patient workloads. There is no reference in the report to evidence from within the Irish hospital system that the county hospitals in Ireland may be better at co-ordinating medical care than the larger Dublin hospitals, as judged, for example, by the "door to needle time" treatment of heart-attack patients. On balance, evidence in favour of centralisation or decentralisation in Ireland is lacking.
The main problem in the Irish hospital system, at present, is a lack of bed capacity. The Hanly report reminds us that there is a deficit of approximately 3,000 acute hospital beds in our public hospital system. This deficit exists before any "reconfiguration" of acute hospitals. Each small acute hospital which is "reconfigured" to a "centre of excellence" creates a further deficit of acute hospital beds.
In Nenagh hospital, the most stressful part of my professional role is the inability to transfer patients to specialist services in the Regional Hospital in Limerick or to national specialty units in Dublin and Cork. For example, when I have an unstable cardiac patient in the coronary care unit of Nenagh General Hospital, I will discuss the patient with our regional cardiologist who readily accepts that the patient should be in the regional cardiac unit in Limerick. However, when I contact the bed manager I am told there is no bed available to transfer the patient. We may be obliged to treat the patient in Nenagh for several more days.
As regards trauma patients, in Nenagh we believe in "stabilise and transfer". Major trauma patients should be stabilised in Nenagh General Hospital and transferred, perhaps within the hour, to the trauma centre in Limerick or to the neurosurgical unit in Cork. We are able to stabilise the patient but have difficulty carrying out a speedy transfer due to lack of beds in Limerick or Cork. We may be obliged to keep the patient in Nenagh against the judgment of the local clinicians and against best clinical practice.
David Hanly stated in the briefing to the north Tipperary GPs that approximately 300 new acute hospital beds would need to be added to the Regional Hospital in Limerick, in order to implement the Hanly report in the mid-west pilot site area. This number comprises 250 beds to replace the acute beds lost by "reconfiguring" Ennis, Nenagh and St John's hospitals to the regional site, and a contribution to reduce the existing overcrowding in Limerick.
I have calculated that in the Dublin pilot site area, approximately 300 new acute hospital beds would have to be added to St Vincent's Hospital to replace the 220 beds lost by "reconfiguring" St Michael's and Loughlinstown hospitals, plus a contribution to reduce existing overcrowding in St Vincent's.
The terms of reference of the Hanly report excluded capital costs. This is surprising considering the major infrastructure requirements to implement in the pilot sites alone. The health estimates do not appear to have reserved money to initiate these major capital projects next year. The roll-out of the Hanly plan across the country will involve a further major hospitals building programme, as 35 per cent of all acute hospital admissions in Ireland are to the county hospitals. These patients will have to be accommodated in new wards at the "centres of excellence".
The revenue or running costs of the Hanly plan are also high. Under Hanly, secondary care general hospitals are being abolished and a tier of medical care is being removed from the health service. In future, patients will move from their GP (primary care tier) straight to tertiary care in high-tech large hospitals.
There is no evidence that this is justified on clinical care grounds and it is obviously more expensive. An appendicitis case does not need to be treated in a tertiary care hospital where the overheads are higher.
In addition, the Department of Health figures show that the county hospitals are more efficient as well as more cost-effective than the larger Dublin hospitals. A typical medical patient would spend either six days at €390 per day in a county hospital (total €2,340) or eight days at €560 per day in a Dublin teaching hospital (total €4,480) for the same work. Under the Hanly plan all patients would be treated in tertiary care level facilities and, therefore, at the higher cost.
As a resident of north Tipperary, I also have concerns about the rump of emergency care services proposed for us when the current A&E service and acute admissions move to Limerick.
During the briefing at Nenagh hospital, the Hanly group outlined the proposed nurse-led A&E service. Under questioning and in subsequent discussion, it became clear that there may be problems with this proposal. We were informed that "a fellow who gets a crack on the head at hurling" can be seen in the nurse-led A&E department in Nenagh and X-rayed there. It emerged, however, that it is probably a breach of the EU Directive on Radiation Protection for a nurse to request the X-ray.
In addition, it is likely that it is medico-legally unsound for an advanced nurse practitioner to practise 20 miles or more remote from the supervising A&E consultant. After all, we are not allowed to staff these units with doctors who are postgraduates but still in training.
The remainder of the emergency care services in north Tipperary will depend on the proposed paramedics in the Ambulance Service who will administer clot-buster drugs to heart-attack patients in their homes and stabilise trauma patients at the roadside before transfer to the "regional centre of excellence". We should consider that for a patient who lives in Thurles, for example, the nearest hospitals, under the full roll-out of Hanly, are likely to be in Limerick and Waterford, both 50 miles away. That is the equivalent of transferring a Dublin patient to Portlaoise for acute hospital care. It will put a great responsibility on the Ambulance Service, when acute hospital services are relocated.
These proposed changes to emergency care services are enormous for those of us who do not live in cities. A builder seeking planning permission for a major development is expected to produce an environmental impact statement. There should be a patient impact statement to assess the impact of these changes on the towns and villages of Ireland.
The introduction of advanced nurse practitioners in A&E departments and paramedics in the ambulance service are interesting proposals, but the experiment should be carried out in an urban area where ambulance response times and travel times are short and where there is a strong network of acute hospitals nearby to deal with problems that may arise. At that stage, it may be viable to introduce these ideas outside our cities.
I believe the main benefit to date of the Hanly report is that it has stimulated intense debate about our health service. We should continue the debate before embarking on any experiments.
The Taoiseach has said it will take 10 years to implement Hanly. He's right because of the infrastructural requirements alone. But the EUWTD starts next August and our hospitals are in crisis now. We don't have the luxury to wait 10 years. But let's get it right for our health service.