Madam, – The idea that smaller hospitals should lose their emergency departments because they have been deemed “unsafe”, following the Health Information and Quality Authority report into tragic cases at Ennis General Hospital, seems irrefutable. But appearances can be deceiving, as any frontline physician will tell you.
The latest modus operandi of those hoping to close costly local hospitals is to employ the (apparently) reasonable concept of “critical clinical mass”: thus, clinicians need to manage a certain minimum of cases to achieve the proper standard, the benchmark typically being a centre of excellence in North America.
But this emphasis on “practice makes perfect” disregards other crucial ingredients of patient care: facilities, free flow and – believe it or not – friendliness.
Not inconsequentially, it ignores the reality that big hospitals can be dangerous too.
Only last year, doctors in a large emergency department, in Galway, estimated that 20 patients per annum might be dying avoidably due to perennial overcrowding in the unit. These figures were extrapolated from international studies into chaotic conditions in big and small hospitals (recall that the 2003 Toronto Sars outbreak began in an over-crowded emergency department).
Of course, such overcrowding is most notorious in Ireland’s largest hospitals. And “free-flow” (to beds, operating theatres or procedure rooms) is still a distant dream in many of our “regional” institutions. Chronic under-resourcing (how dreary that very phrase has become) means that, by American criteria, we are even further from having an Irish Level 1 Trauma Centre (fully accredited) than we were in 2003.
But most importantly, as someone who worked in one of the UK’s biggest emergency departments (begat by closure of several local Liverpool hospitals in the days of Thatcherite “merger-mania”), I remember how the resulting sky-scraper was dubbed Fawlty Towers by the inimitable Scousers. What they were getting at was its unfriendly, industrial scale.
Indirectly, but unforgettably, I realised that size matters in medicine: “too small” may imply sub-optimal, but so also may “too big” (and remote). After all, what really counts when one is ill is kindness. And this often cannot be generated in “inorganic” mega-hospitals.
The frequent consequences of merger-mania in the UK were misery, congestion and delayed treatment, often far from patients’ homes.
Unsurprisingly, some departments imploded and solutions were found by deploying experienced nurse practitioners to local hospitals and a politically imposed maximum four-hour limit to emergency department stays (with penalties for hospital executives that concentrated minds wonderfully).
So, by all means the Minister for Health should “adjust” smaller emergency departments, but not before adjusting the conditions in the “centralised” units. And the Minister should focus on the universal need for a familiar smiling face. Let us have carers who have the time to care and the moral support of a loved one in our hour of need. Health economists may have factored these basics out in their many dubious prescriptions, but Mother Nature has not.
DR CHRIS LUKE,
Consultant in Emergency
Medicine,
Mercy University Hospital,
Grenville Place,
Cork.