It would be a betrayal of patients to give them inferior service for the sake of keeping local hospitals open, writes Mary Harney
Everyone working in every health setting can unite around the objective of ensuring patient safety. Patient safety is affected by many factors, but in relation to surgery, one thing is very clear: the compelling international evidence is that volume and specialisation of surgical procedures affect patient safety and outcomes.
If a surgeon or a surgical team is not performing a particular operation frequently or have not specialised in particular operations, patients' chances of survival are reduced. For example, in relation to breast cancer surgery, we are making progress towards specialisation for safety.
The proportion of patients treated by consultants doing more than 50 procedures per year increased from 23 per cent in 1997 to 58 per cent in 2003.
But still 308 of 1,800 patients had their surgery performed by consultants doing fewer than 30 procedures.
Of the 76 consultants who carried out breast surgery in 2003, 45 carried out fewer than 10 procedures a year. Thirty-seven consultants performed five or fewer such procedures.
These figures must be seen in the context of many pieces of authoritative cancer research from Britain. For example one tells us: "Patients treated by low workload surgeons had poorer survival. The risk of death was increased by 15 per cent and by 10 per cent for patients managed by surgeons with workloads less than 10, and between 10 and 29 cases per annum, in comparison to patients managed by surgeons with workloads of more than 50." ("Surgeon workload and survival from breast cancer", British Journal of Cancer (2003) 89, 487-491)
A New England Journal of Medicine review made a compelling case that high-volume units for 14 different cancer or cardiovascular procedures had lower mortality rates for all procedures.
There are other research papers suggesting improved outcomes for Aids treatment, aortic aneurysm surgery, total joint replacement and paediatric heart surgery in high-volume centres.
High-volume centres attract better clinicians and support staff, thus improving quality.
Better outcomes for patients - that is, increased safety and quality - simply compel us to organise our services and our hospitals differently. We must assess and compare outcomes based on evidence, and let that determine the organisation of hospitals and the recruitment and training of specialists. There can be no other responsible course of action.
No minister for health could justify a policy that accepted patients in one part of the country having lower survival rates from surgery than patients in another part, even for the sake of keeping some procedures or consultants in local hospitals. It would be a betrayal of patients to give them an inferior service for the sake of being local.
Most patients I know want to get the best chance to get well, much more than they want to be in a particular hospital building.
This is not an issue about resources. Even if we had unlimited resources, it would not be safe to have large numbers of surgeons in a particular hospital performing certain procedures very infrequently, because the population served by that hospital did not give rise to many such cases. Surgeons would become de-skilled and patient safety would be compromised.
So in terms of hospitals and services, I can best summarise Government policy as the following: we will provide as many services as possible, as locally as possible, and as safely as possible.
For as long as we can remember, accusations have been made about plans to downgrade hospitals. Sometimes this can sound like an argument for "no change, ever, in anything, at any hospital". This is unrealistic. There have to be plans and there has to be change.
What I am absolutely clear about is that we simply cannot, and will not, plan to downgrade patient safety by a policy of no change, or the wrong change.
It would be absurd if we cared more about hospitals than patients, more about staffing than service, more about resources than results.
One point that has been lost in the debate about hospitals is that in many instances there will be more services, not fewer, being provided closer to people in community settings rather than in hospital buildings, for example, dialysis, cardiology and respiratory services.
There will be change, but no downgrading of services or of safety. At each step along the way, it must be change for the better for patients. It will not be a case of one step back now, two steps forward sometime later.
The Government and the Health Service Executive are agreed: no service will be changed at a hospital before a demonstrably better, safer, higher-quality service is in place for the people of each region in question. The HSE under Prof Drumm will implement only those services and changes that will improve care and outcomes for patients.
I believe the public want a health service based on the principle of patient safety first. I hope for leadership from consultants and other clinicians to advance patients' interests in this way.
Reorganising hospital services is not about reports, management consultants, financing or manpower planning. It is about patients and providing safe, quality care throughout the country.
Mary Harney is Minister for Health and Children