Analysis: Conflicting views are emerging between doctors and communities against the Hanly hospitals reform plan and its advocates. Medical Correspondent Dr Muiris Houston examines key issues in the debate
By publishing a critique of the Hanly report and offering a possible alternative plan for our health system, Dr John Barton, consultant physician at Portiuncula Hospital, Ballinasloe, Co Galway, and health economist Catherine McNamara, have moved the debate on the future of the Republic's health service to a new level.
They have the reference material used by the health experts in writing the report of the National Task Force on Medical Staffing (the Hanly report).
A summary of their findings was presented to the new Health Service Action Group at a meeting in Kill, Co Kildare at the weekend.
The Irish Times has obtained a copy of their analysis, which states in a preamble: "The main concept for hospital services proposed by Hanly is centralisation and is a paradigm more suitable to the past than the future. The following will hopefully confirm that Hanly is not the only prescription for our hospital services."
In a section on "misuse of volumes and outcomes research to support centralisation", Dr Barton and Ms McNamara allege most of the research in this area utilised by the Hanly authors used hospital administrative data "which does not give enough detail about the severity of patients' ill health to ensure we are comparing like with like".
Referring to a report by Halm et al, which they describe as a systematic review of all English language-published research on the volume (of patients)/outcome relationship for the period 1980-2000, the critique says: "The Hanly team's mistake with this reference was their failure to follow through to the final report of the same study, which was published in the Annals of Internal Medicine in 2002."
According to Barton and McNamara, the review's main conclusion was that the technical quality of research in this area of healthcare is poor. "The evidence relating higher volume to better outcomes was very mixed, with only five procedures showing a positive relation between the two. These were pancreatic and oesophageal [gullet\] surgery, paediatric cardiac surgery, treatment of AIDS and surgery for abdominal aortic aneurysm."
The authors also criticise the Hanly group for extrapolating better outcomes for certain surgical procedures in hospitals with larger volumes to healthcare as a whole.
Although the critique does not reference its sources for the following statement, it says: "There is also substantial international evidence that for common medical and surgical conditions, such as pneumonia, heart failure, gall bladder disease, inguinal hernia and many others, smaller hospitals can provide care that results in outcomes equivalent to larger hospitals but in a more economically effective fashion."
The critique highlights its alternative interpretation of a key British document, published in 2003, Keeping the NHS Local - a new direction of travel. According to the critique, the UK document states "the section of our society most likely to be affected by the strategy of centralisation of acute services are the elderly and the disadvantaged".
Pointing to Irish evidence that small hospitals can provide quality care, Barton and McNamara say they recently carried out an audit of the care of 1,164 patients who presented with chest pain. "When we compared our figures with large and small teaching hospitals in the US for [appropriate\] discharge medications in patients with myocardial infarction [heart attack\], we found that our rates of prescribing for \ drugs... was in some cases equivalent to and in others better than large US teaching hospitals."
In a section on in-patient beds, the document says the Hanly proposals "illicitly" take the 3,000 additional hospital beds which the National Health Strategy has identified the system already needs and "apply them to their proposed changes" inherent in the move to a smaller number of large hospitals.
A chapter titled: "An alternative method of solving the problem of the European Working Time Directive", says a strict implementation of the directive "will, in all likelihood, result in reduced services to patients and longer waiting lists".
It calls for a consultant to junior hospital doctor ratio of 1:1 which it acknowledges would mean employing 1,700 more doctors compared to the number proposed by Hanly. But the authors also offer an alternative solution which "would require an acceptance of change on behalf of doctors" and involve some of their duties being carried out by allied health professionals. They argue that by providing highly trained nursing staff in the form of clinical nurse specialists, advanced nurse practitioners, anaesthetic and surgical assistants and physical assistants, "a quality hospital service can be provided".