Should acute hospital services be centralised?
YES:
We should be more concerned if the doctor or team looking after us in hospital were not used to dealing with our condition, or had had little time for refresher training, or for holidays. We will continue to encounter analogous situations in our healthcare system until our health service is reformed. The result of this reform must be a national structure with full development of primary care, delivery of routine assessment and treatment in local hospitals or clinics and the centralisation of acute hospital services with the necessary emergency transport infrastructure to ensure rapid transfer of patients in emergency situations.
Acute healthcare has become and will continue to be increasingly specialised. This specialisation does not just apply to the doctors but also to nurses, paramedical specialists and to the environments in which they work. International evidence shows that the best outcomes for patients who are acutely ill or who have complex chronic conditions are achieved by specialist teams in specialist settings. Such teams and settings can only be realistically provided in a system where acute hospital services are centralised.
One reason for centralisation of acute hospital services is to maximise scarce resources but, more importantly, it is about the maximisation of staff competence for patient safety. Competence is gained initially through training. Competence is maintained in staff by ongoing education, training and peer review.
It is difficult for a doctor (or other clinician) to stay competent in dealing with a certain condition if they only deal with a few such cases a year. Such is bound to be the case in a health system made up of dispersed small hospitals that are trying to be all things to all people with small numbers of staff who have exposure to small amounts of a broad and diverse range of medical conditions. This requirement for safe practice applies to issues as seemingly straightforward as childbirth and those as complicated as cardiac surgery. In a system with centralised hospital care and specialist teams, there is sufficient throughput of cases to ensure that doctors, nurses and other clinicians get sufficient exposure to relevant conditions to maintain their competence.
Modern medicine can achieve much but it is complex and open to error. A critical mass of expertise is necessary to allow for the peer review and consultation necessary to minimise error and maximise outcomes for patients. Peer review takes many forms. It includes formal processes such as audit and case conferences. It also includes the informal quality control that occurs through clinicians observing each other at work and asking questions of each other. In a system made up of small dispersed hospitals there can only be small amounts of staff (sometimes none) with knowledge of proper practice in a certain specialist area.
Due to lack of a critical mass of expertise, the formal processes become more difficult and weaker. The informal processes available are also weakened, as there may be no one with the expertise to be consulted on a particular case. Another problem is that it is very difficult to question the practice of a colleague when they are the only expert readily available and where one may run the risk of alienating the only ally on other work issues on a day-to-day basis.
Continuing education is necessary for clinicians to maintain their competence. For this to happen in a meaningful way, there must be time to attend educational events and time to reflect on one's own practice.
In situations where a small group of staff are trying to provide a broad set of services, such time is difficult to find. The absence of one member of a specialist team puts increased pressure on the other members and may even lead to the temporary discontinuation of services. This is a problem as regards holiday and sick leave also. The provision of locums is difficult. It is rare now to find a person of equal skill to the permanent professional to act as a locum. Centralised acute care means that there are enough permanent staff available at all times to prevent the absence of any one team member compromising patient safety.
Modern medicine must be about the most effective treatments delivered as quickly as possible in the safest environments by the most skilled people. Centralisation of acute hospital services is a key component of the delivery of safe, successful health care.
It is urgent that doctors, other clinicians and policy makers allay current public anxieties by explaining this and working together towards the delivery of a modern, accessible and effective health service in Ireland.
Dr John Hillery is a consultant psychiatrist and chairman of the International Association of Medical Regulatory Authorities.
