18 March 2004 Edition
Hospital groups gather to take on Hanly
BY ROISIN DE ROSA
A conference in Kill earlier this month brought 16 representative hospital action groups together to form an organisation to campaign for a quality health service for all. Representatives of Hospital Action Groups came from Clonmel, Ennis, Kilkenny, Louth, Longford, Mallow, Mayo, Monaghan, Mullingar, Naas, Nenagh, Portlaoise, Roscommon, Tullamore, Wexford and Wicklow.
These groups fear that if the Minister for Health implements the Hanly report, as has been adopted by the government, their local hospitals will be run down to day care, five-day a week, largely out-patient institutions, without A&E and 24-hour care.
Under Hanly, the current network of 38 general acute hospitals for the 26 Counties, already desperately overstretched, would be reduced to just 12 hospitals, running 24 hours per day, seven days a week. "We would end up with one of the worst ratios of hospitals to population in Europe. The current health care crisis will pale in significance to the new one," Dr John Barton, consultant cardiologist at Portiuncula Hospital in Ballinasloe, Co Galway, warned the meeting in Kill.
The Hanly report was written in response to a government request to work out how best to implement the European Working Time Directive (EWTD), which requires that from August, junior doctors must work fewer hours per week. Currently, the average working time of junior doctors is 75 hours at a stretch. This has to fall to 55 hours or the government faces EU fines.
The answer, conveniently provided by Hanly, is to concentrate the full 24-hour health provision in just one acute care hospital per region, backed up with a paramedic ambulance service to cope with the problem many would have to travel much longer distances to get to hospital.
Dr Barton delivered a devastating critique of the report, challenging the very basis of Hanly's argument. These are the propositions that the media, and governments, have encouraged all to believe: that large centralised hospitals give better care and better outcomes for patients; that large hospitals are more cost-effective and efficient, that there are economies of scale; that distance of patients from hospitals can be overcome through ambulatory care in an ambulance, and that the new hospital structures proposed in Hanly are inevitable as the only way that the EWTD can be implemented. Hanly is presented as the only solution.
As Catherine McNamara, a health economist, argued, "while these arguments in Hanly may appear to be convincing and plausible, in fact every one of them is deeply flawed".
The basis of the 'national' health strategy was set out in 2001. It says: "A health system that supports and empowers you, your family and community to achieve your full health potential. A health system that is there when you need it, that is fair, and that you can trust. A health system that encourages you to have your say, listens to you and ensures that your views are taken into account."
As Catherine McNamara points out: "Unfortunately, in the Hanly report there is no sign of patient-centred approach or any attempt to consult with the public, elected representative or with patients, although there were many consultations with deliverers of health care. She said the Hanly group "managed to persuade themselves that it would be illegitimate to have ongoing consultations with the patients or the public in drawing up their report, an extraordinary definition of politics which no political scientist would accept.
"The Hanly approach is more typical of the medical paternalism which was out of date 50 years ago, where the experts make all the decision and the public is meant to acquiesce meekly. It runs counter to the basic philosophy of the national health strategy."
That strategy, spelling out basic principles of health care in the state, goes on to say: "Access to health care should be fair. The system must respond to people's needs rather than have access dependent on geographic location or ability to pay." By centralising hospital services, it is the poor and the elderly, the very people who do not have access to transport, who will suffer most, the very people who above all need supportive and individual care, which cannot be achieved in large hospitals.
Disenfranchising the elderly
Research proves that bigger is not better, that aside from the 5% of cases that require specialist care in specialist units (for example cancer and neurosurgery), hospitals lose in all categories as you move up the scale above 150 to 200 beds. Hospitals are not factories.
John Barton points out in his report that 60% to 70% of admissions are for non-surgical conditions and growing. This proportion of the patient population, predominantly the elderly, becomes in effect, disenfranchised under Hanly. "I simply do no find such recommendations acceptable as a caring physician," he said.
Hanly argues that further distance to travel will have no adverse effects. As Catherine McNamara says, the report is wrong in this statement. "There is good evidence that A&E treatment within an hour of an accident or heart attack can save many lives. Furthermore, the new ambulance service, which is a key to Hanly proposals, has been shown in a comparative research study to lead to a higher rate of deaths of patients on the way to hospital than the ordinary service."
In the Six Counties, to get the appropriate balance between centralisation and local care there is a basic principle that access times to emergency care and consultant-led maternity services should be no longer than 45 minutes. In New Zealand it is 30 minutes.
"How many major hospitals in the Republic can be accessed within 30 minutes, or for that matter one hour from the scene of serious injury, requiring attention within the golden hour, or a pregnant mother requiring maternity help? Surely Monaghan is another example of the way we should not be delivering our health service."
John Barton and his colleague John Flynn in Ballinasloe address the continual media hype that overall the problem with the health service is that consultants are holding it to ransom to preserve their highly lucrative positions as specialist consultants.
"It's politically inspired 'consultancy bashing'," says Dr Barton, "as if we are to blame for the appalling state of our health system. It's obvious. No one more than ourselves, the consultants here in this hospital, want additional consultants appointed. But we can't create these posts, and the Department through indolence, or incompetence, or penny saving, refuses.
"They are closing our local hospitals by subterfuge. We are currently scheduled to lose two consultants. Where does that leave our A&E at Portiuncula Hospital, no matter what protestations the government may make in the run up to election time?
"What is required is properly resourced facilities and qualified staff, which our health service has been denied for the past two decades, as exemplified by inadequate numbers of senior doctors, beds and equipment and a flourishing private hospital system and private diagnostic equipment system."
Barton points out that the 26 Counties would be near or at the bottom of the EU and OECD tables in the ratio of doctors to population. If the 3,600 consultant (specialists) are appointed as Hanly recommends, then the 26 Counties will have 9 specialist per 10,000 population. The US, France, Germany and Holland have anything between 10 and 22 specialists per 10,000.
Backtracking with intent?
The government now appears to be backtracking. Statements reported from a spokesperson for the minister said that although Hanly remains in place, "Martin has taken on board the concerns of the people and has directed that 24-hour medical cover be provided in all hospitals as a matter of principle".
Dr Barton said: "So it would appear that the minister and the government is moving away from Hanly. There is another agenda. I don't trust them anymore. It seems to me that government is more interested in your vote than it is in you and they care more about your vote than they care about your health."
This opinion is strongly reinforced by Ahern's admission that the government will not be able to honour their general election commitment to eliminate waiting lists by June of this year.