Madam, - I refer to a report by Dr Muiris Houston, Medical Correspondent, entitled "Canadian findings back up anti-Hanly argument", which was published in your edition of March 12th.
The report refers to a paper by two Canadian authors, Dr David Urbach and Dr Nancy Baxter of the Institute for Clinical Evaluative Sciences in Toronto, which has been published online in the British Medical Journal (BMJ). The authors of the paper draw from research published by Urbach, Bell and Austin in the Journal of the Canadian Medical Association in May 2003.
The research is based on an estimation of the absolute number of post-operative deaths that could potentially be avoided if five major surgical procedures in Ontario were restricted to high-volume hospitals. Outcomes for over 31,000 patients are studied.
Dr Houston writes that the Canadian research "will add weight to the argument of those opposed to the Hanly model". He notes that critics of the Hanly Report have "focused much of their criticism on the assumption that high volume equates with better patient outcome".
Firstly, Hanly does not assert that larger volume is the sole factor in producing better outcomes. Nor does Hanly focus on small groups of surgical or other procedures. Instead, Hanly states: "There is convincing evidence that the best results in treatment are achieved when patients are treated by staff working as part of a multi-disciplinary specialist team and that better clinical outcomes are achieved in units with appropriate numbers of specialist staff with relevant skills and experience, high volumes of activity and access to appropriate diagnostic and treatment facilities."
Secondly, instead of lending support to those opposed to regionalisation of specialist care, the Urbach research concluded that regionalisation of four out of the five procedures studied would actually result in fewer deaths.
In the BMJ, Urbach and Baxter note that this might be because "shared structures and processes in hospitals that do a high volume of any complex surgical procedures may account for improved surgical outcome". This message is very similar to that put forward in the Hanly Report.
They highlight the strong empirical evidence of volume-outcome associations for many complex procedures that would support a continuing volume-based regionalisation. They conclude that because their research doesn't support centralisation of individual procedures, "a more rational strategy might be simply to regionalise all complex operations at large hospitals".
The authors then outline an alternative to regionalisation of all complex operations, similar to that set out in the Hanly Report. They note that increased allocation of resources to smaller hospitals and targeted quality improvement programmes might reduce variation in short-term surgical outcomes across hospitals.
The message in the Hanly Report is clear: Decentralise a large proportion of care to our smaller hospitals, as long as it can be done safely. Then concentrate complex procedures that benefit from high volumes in units best able to provide them.
The research cited in Dr Houston's article supports the Hanly Report's recommendations, rather than its critics. - Yours, etc.,
MICHEÁL MARTIN, TD, Minister for Health and Children, Dublin 2.