Are rural areas losing out because of the reconfiguration of emergency and acute care?

Are rural areas losing out because of the reconfiguration of emergency and acute care? We may need to reexamine how those decisions are made, writes Noel Baker.

THE Phoenix, the name of the new national children’s hospital, was selected by staff of the three existing paediatric hospitals. “What’s it got to do with the staff, what it’s called?”

John Browne, professor of epidemiology and public health at University College Cork, asks.

Instead, he believes that a wider poll, of the public, would have resulted in the hospital simply being called the National Children’s Hospital. That prompts him to query “what would be the optimal way to do that?”

An online straw poll would raise the spectre of a Boaty McBoatface scenario, the unsuitable name that topped a poll among the UK public for a new polar research ship. Prof Browne says that a a number of options should be given, and then voted on.

This theory underpins much of the research he has been undertaking with his colleagues in UCC, including a new study that all TDs will receive in the post this week.

According to the article, ‘Perspectives on the underlying drivers of urgent and emergency care reconfiguration in Ireland’, the basis on which emergency health services are provided in this country might be flawed.

It is debatable if they are as good as they could be.

The study involved 175 interviews with stakeholders across all the hospital groups, be they ‘internal stakeholders (doctors, nurses, those working within regional HSE management structures) or external stakeholders (public and private ambulance representatives, GPs, private hospital representatives, civic groups, and local politicians).

It analyses the reconfiguration of urgent and emergency care around the country — including the closure of smaller emergency departments (EDs) — and the various perspectives around those decisions.

Among its conclusions is that there is “an emerging consensus that merely presenting communities with evidence to justify planned changes is not enough to persuade them to support reconfiguration and may, in fact, contribute to public opposition by reinforcing the notion that ‘expert’ opinion is more valuable than the views of the public.”

There is a “confused and dysfunctional public discourse about urgent and emergency care provision in Ireland”, with internal stakeholders largely wedded to the “follow-the-evidence model of decision-making”, despite the “narrow focus on evidence about volume-outcome relationships for a smaller number of [health] conditions.”

Prof Browne is one of six academics who undertook the research, which has been mailed to all TDs.

The cover letter referred to the possibility of a divide between how the reconfigured services benefit urban areas rather than rural areas.

It asks for a debate on possible solutions, and queries whether we have been looking in the right areas for them.

One example is the different hospital groups and how peculiar geography has driven service delivery: one hospital group takes in Tallaght and chunks of the Midlands;Waterford is in the same group as Cork, but not as Wexford; one swerves through Cavan and Monaghan towards Louth, but does not incorporate Meath.

Prof Browne questions why so many hospital groups are anchored in Dublin, but also include these “vast hinterlands”. This has resulted in the downgrading of smaller EDs and acute services in the regions and the centralising of complex care to larger tertiary hospitals in the cities.

According to the study: “There has been little attempt to reconfigure urgent and emergency care in Dublin city”, adding that “the country now has radically different models of provision in different regions, and these variations do not seem to be related to underlying geographical constraints.

The south-eastern region, for example, currently has four emergency departments and a population of 511,070 (one per 127,767 persons), while the mid-western region has one emergency department for a population of 385,172.

These regions have very similar geographies and population densities. County Dublin, which is largely urban, has six emergency departments and a population of 1,345,402 (one per 224,233 persons).”

Prof Browne says: “You start from the perspective of ‘what does the population need?’, rather than ‘is this hospital any good’?” He believes smaller hospitals in larger hospital groups come under greater scrutiny, with a sense of increased pressure and questions over their longer-term viability, even though “people still live there [locally]”.

He wonders if there are other considerations. For example, the view that EDs are primarily about time-sensitive trauma, such as heart attacks and stroke, whereas they can also deal with other issues, such as acute asthma or COPD. “I do not see the evidence in the literature that they [those conditions] should all be treated in larger hospitals,” he says.

A previous study in which he was involved indicated that where you live can affect your chances of surviving a major health emergency.

The ‘Study of the Impact of Reconfiguration on Emergency and Urgent Care Networks’ used data on 16 serious conditions that require emergency treatment, such as heart attack and stroke.

It suggested that up to 1,000 lives a year could be saved if every county had the same outcomes as Dublin. In any case, he believes the primacy of these urban EDs and acute services means that many are effectively “walk-in primary care centres”, adding to waiting times for everyone.

“These kinds of reconfigurations have created barriers to access for people in rural areas,” he says. The demand for ED services has grown “massively”, and he believes that while there has obviously been population growth, the population growth in a city like Dublin is among younger people — those less likely to need EDs and acute care for health conditions such as heart attacks and strokes.

“We see constant promises, regarding resourcing primary care, but it’s not happening.”

What of the other possible drivers of how our emergency services are configured? “There is a vague suspicion that senior consultants do not want to work in these smaller hospitals, and that’s true, I think,” Prof Browne says.

Does the likelihood of being unable to adequately staff these hospital departments lead to them being downgraded or closed? Does that mean pay scales should be changed to sustain them? And what of the links between hospitals and universities, where medics train? Could that not continue, even if the hospital groups map was redrawn?

The article examines the configuration of these services in relation to the taxpayer, the patient, the consumer, and the voter.

The last category will pique the interest of TDs. One external stakeholder says of the symbolic status of the local hospital: “It’s got to do with almost the town’s worth and its identity and its self-importance.”

An internal stakeholder is more sceptical: “People are horrified when you raise with them ‘well, actually, it’s not fit for purpose’. They don’t care. It’s there to employ people.” And another commented: “It’s all about votes.”

According to that person, supporting the closure of a local ED was “political suicide”.

One hospital campaigner said that because local politicians want to avoid being blamed by the public for the demise of a hospital, it ends up “slowly strangle[d] to death” through neglectful practices, such as not filling empty consultant posts. Political damage is minimised by allowing hospitals to “wither on the vine”.

The research is a fascinating platform for a broader debate as to the shape and look of our hospital services, but it does not provide a clear answer. Yet Prof Browne believes that any “critique of localism” focuses on rural areas.

He says junior health minister, John Halligan, for example, was right to campaign for a second cath lab in Waterford. The research is not aimed at bashing ‘experts’, but he says too many decisions are taken without wider consultation with those affected, or without broader social factors being considered.

He wants the needs of the population and the geography of an area to outweigh other considerations, such as staff declining to live in certain areas, or the needs of medical schools, or the needs of local politicians, or “medical empire building”.

He says independent, regional, health planning bodies would be suitable for discussing the needs of a population and the requirements of an area’s geography, and he says that centralisation of some services, such as cancer care, has worked fantastically.

But your chances of survival from a heart attack or stroke may depend on how long the ambulance has to travel to the urban ED. “The planning should not be done by the providers,” he says.

He refers to local media reports, regarding changes to services at Portlaoise Hospital, prompting the question: “To what extent were people who live in the Midlands party to that decision?”

According to the research: “While it is unlikely that a ‘perfect’ approach exists, there is evidence that certain factors are associated with positive public engagement.

The best outcomes have been found in cases where the engagement process started at the early stages of planning, the public were offered opportunities for genuine interaction, the process was led by clinicians involved in delivering the service in question, and public representatives were engaged with.”


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