The Pfizer/ Irish TimesHealth Debate on hospital centralisation showed that the two sides are deeply divided
THE CENTRALISATION of acute hospital services will destroy the public health service, according to one Co Clare GP. Dr Michael Harty made his comments during the third of the Pfizer debates held in association with The Irish Timesat Limerick Institute of Technology last week.
The debate on the motion, “That this house believes that centralising acute hospital services is in the interest of patient safety”, attracted an audience of almost 200 people from across the midwest region.
Much discussion centred on the midwest where the re-configuration of hospital services caused public outrage after it was introduced on April 6th.
One of the most controversial aspects of centralisation in the midwest was the loss of 24-hour AE services at Nenagh and Ennis General Hospitals.
It was implemented on foot of a recommendation in the HSE’s Teamwork/Howarth report, which proposed that the Midwestern Regional Hospital in Limerick would be the only hospital in the region with a 24-hour A&E department.
St John’s in Limerick city, Nenagh and Ennis General Hospitals will become local centres of excellence dealing with minor injuries, says the report.
Speaking against the motion at last week’s debate, Dr Harty, who is co-chairman of Clare/North Tipperary GP Action Committee, described the centralisation of acute hospital services as “dangerous and irresponsible” and claimed it “would destroy the public health service. Centralisation is not a solution to our health service difficulties. It will make the situation worse, much worse,” he said.
According to the Co Clare GP, the Government could not apply a “one size fits all” approach to medical services in both rural and urban settings.
He said the centralisation policy in the midwest placed patients at unacceptable distances from acute life-saving medical services at an already “overworked and overwhelmed” central hospital in Limerick.
Dr Harty went on to describe the centralisation programme as a national policy and claimed Bantry, Mallow and Tralee hospitals were next in line for “downgrading and eventual closure” as acute hospitals.
“Look at what is happening to Monaghan, Cavan, Navan and Louth hospitals as services are centralised in Our Lady of Lourdes in Drogheda,” he said.
Dr Harty also claimed that while Ennis and Nenagh casualty departments were now closed for 12 hours every night, the future plan was to close them completely. He said all acute surgical emergencies and all inpatient surgery would cease on July 1st and claimed this would be followed by the withdrawal of anaesthetic services, critical care and all acute medical care.
“Ennis and Nenagh will be downgraded to day-care and nursing-home facilities, which could not be termed hospitals in the conventional sense of the word,” he said. “Limerick AE was unable to cope with its pre-existing workload, prior to centralisation, and it will be an impossible situation when all surgical cases in the midwest descend on its doorstep,” he said.
Dr Harty said A&E at the Midwestern Regional Hospital in Limerick was “overcrowded” and “regularly contravenes all acceptable control and health and safety regulations”.
He said senior A&E staff identified this fact in December 2008, four months before the transformation commenced.
But chairman of the Reconfiguration Project Board, HSE West, Paul Burke, said since centralisation in the midwest, there had been an increase of just four patients in Limerick A&E.
Mr Burke, a consultant vascular surgeon, also believes centralisation does “not mean closing local hospitals or taking away services, but merely changing the way these are delivered”.
“There has been an increase of two ambulances in Limerick from Clare every day, but less than one every second day from north Tipperary and there has been an average of two extra admissions to the Regional hospital every day.”
The average waiting time from time of registration to admission in the fifth week after the changeover was reduced from seven hours 34 minutes to seven hours 11 minutes. “For someone with a walk-in injury to time of discharge, the wait time has gone down from five hours and nine minutes to four hours 52 minutes,” he said.
Mr Burke accepted that these times were still too long, and that it was unacceptable to have 20 patients waiting on trolleys in Limerick. But he argued that the HSE would tackle “much more aggressively” all the factors that contribute to these delays.
According to Dr Cathal O’Donnell, consultant in emergency medicine, Midwestern Regional Hospitals, Limerick and Ennis, 80 per cent of people attending emergency departments can be dealt with locally.
“Acute medicine and minor injury can be safely dealt with in smaller hospitals for the simple reason that the volume of patients presenting in those categories is big,” he claimed.
Also in support of the motion was Dr O’Donnell who said A&E at the Mid Western Regional sees about 55,000 patients a year while A&E in Ennis and Nenagh see about 18,000 and 15,000 a year respectively.
He also referred to the “many misconceptions” surrounding the concept of the “golden hour” which guarantees a better outcome if patients are brought to hospital within a vital 60-minute period.
“It refers only to trauma or injury. It was never meant to apply to medical emergencies like pneumonia or strokes or a diabetic emergency,” he explained.
He cited evidence from the Centre of Disease Control in Atlanta, a US Federal organisation, that has devised a criteria called “trauma bypass”, that enabled paramedics to identify patients with the most serious injuries who required high levels of care at larger centres. He said research found that by bypassing smaller hospitals, mortality was reduced by 25 per cent.
“For every four patients who are transported under this criteria, one patient will live who would have otherwise have died,” he explained.
“Thirteen months ago we implemented that protocol in this region in the Teamwork report amid very significant opposition and predictions of widespread death. In the last 13 months we’ve transported an average of five to six patients a month by-passing local hospitals in Ennis and Nenagh. If you accept the figure of 25 per cent, what that means is that in this area between 10 and 15 people are now alive who might otherwise have died,” he said.
Dr O’Donnell said he was involved in the care of some of these patients and he was “very confident” that nothing bad happened to them because they didn’t go to the nearer hospital.
Cardiac surgeon and Irish Timescolumnist Maurice Neligan said people had no difficulty with the centralisation of some services, including cancer care, but argued that these services were only being centralised in the public sphere and not in the private hospitals that were "springing up".
Mr Neligan also warned that the Government did not have the money to fund the proposed changes. “In this kind of circumstance it is prudent to hold on to what you have,” he said. “You cannot guarantee and plan for something for which we may not have the money to build for 15 or maybe 20 years. We’ve got a major problem and it’s not going to go away so there doesn’t seem to be a point in talking about expansion,” he added.
There was loud applause when Mr Neligan highlighted the danger posed by bugs like MRSA when hospitals were running at “110 per cent capacities.You will lose more patients by hospital overcrowding than you will ever lose by coming in in an ambulance,” he continued.
After much contribution from the floor, the motion was defeated by a small majority.