Reconfiguration can be good for your health

Posted in Articles by saraburke on September 29, 2010

See here for article by from the Irish Times on 27 September last ‘reconfiguration’ or below. A new low-key, bottom-up healthcare initiative might at last deliver safe treatment to patients if budget cuts don’t derail it. Comments most welcome.TO RECONFIGURE or not – that is the question. “Reconfiguration” is HSE-speak for changing the roles of local hospitals or closing down certain hospital services.

The reconfiguration quandary is not a new one. In 1936, 1968 and 2003, government- commissioned reports recommended the rationalising of hospitals, as there were too many hospitals providing poor quality care to too few people. Every attempt to reorganise hospital care was sabotaged by spineless politics, most notably in 2004 when Bertie Ahern promised 24-hour medical cover in all acute hospitals at the Fianna Fáil Ardfheis, weeks in advance of the local elections.

Local communities want to hold on to local hospitals and they are right. Hospitals mean jobs, they mean healthcare nearby and there is a trade-off between access and quality care. Are we more likely to travel to a hospital that is closer? If the hospital is far away, do we actually make it there for critical care? What about bad roads, real difficulties in getting into hospitals, the absence of care in our communities? Each of these is a valid concern.

There have been renewed efforts by Mary Harney and the HSE since 2005 to bite this incendiary bullet – either you fund hospitals so they are safe with sufficient staff, or you relocate some services to fewer bigger hospitals and change the role of smaller ones.

The former is not an option. Given our population and geographical size, it did not make sense to have 30 hospitals providing cancer care. Neither does it make sense to have over 30 hospitals providing comprehensive acute care and emergency departments. So call it what you like – reconfiguration (centralisation) is the only option to make many, although not all, hospital specialities safe.

The HSE however (and its political masters) are often their own worst enemy; the northeast HSE region is a master class in how not to reorganise hospitals. The HSE commits itself to keeping services open, then commissions a review, which recommends the closure of certain hospital services on the basis of “safety”.

Local activists describe it as “closure by stealth” and they are right. If a hospital is systematically underfunded, then staffing levels become unsafe and there is the perfect excuse to close services.

After many high-profile incidents, some with fatal outcomes, the HSE decided the northeast needed a new regional hospital.

On April 4th, 2008, the day Navan was announced as the location for the new regional hospital, then Minister for Foreign Affairs Dermot Ahern from neighbouring Dundalk said “there was not a red cent in government coffers to fund the hospital” and that the report recommending Navan as the location would sit on a shelf and gather dust. He was correct.

There are no plans, money or commitment for a new hospital in Navan. Meanwhile, services in the existing hospital are being systematically “reconfigured”.

The main experience in areas that are being “reconfigured” is that some services are removed from local hospitals but other safe services are not replaced there, as should be the case. Although it is official policy to “reconfigure” local hospitals and beef up primary and community care, this is not reflected on the ground in budgets and services. Take the northeast again: hospital budgets are being cut, but so too are community services. This, combined with the northeast having fewer GPs than the rest of the country, results in overstretched and potentially unsafe services.

Even in services where the HSE in the northeast has blazed a trail, such as Cavan-Monaghan community mental health services, these services are now cut back to the bone, rendering much of their pioneering work unsustainable.

There is no question but Irish hospitals need to be “reconfigured”, but this must be done in the best interests of quality patient care. That may mean having to travel for some care, as happens now with cancer which is provided in just eight specialist centres. However it should also allow people to get the best possible care as close as possible to home.

This will require much more care, such as routine diagnostic tests, day surgery, respite, rehabilitation and chronic disease care being provided in local hospitals and services in the local community.

Dr Barry White, the HSE’s national director of quality and clinical care, is changing the way healthcare is provided by introducing “clinical programmes” which promise to deliver just that. Under the mantra “no harm, no wait, no waste”, Dr White is determined that the type, location and provider (GP, community or hospital) of safe care will be decided exclusively on the basis of clinical need and best practice.

Dr White’s ambitious work is modelled on what Prof Tom Keane initiated in cancer care. Prof Keane’s singular focus on the best care on the basis of need, if successful (and it looks like it is), in effect introduces high-quality cancer care, where access is based solely on medical need, not ability to pay.

As cancer tsar, Prof Keane operated on the basis that if the public service is the best and safest place, then people will act with their feet and choose care in the eight specialist centres. Quality and accessible public healthcare makes opting for the private system, out of fear and long waits, redundant.

However, the programme led by Dr White is even bolder, based on the concept of “clinical justice” – every patient has a right to treatment. He is seeking to introduce the cancer model across all diseases and conditions, across all healthcare locations – big and small hospitals, community services, primary care – for the whole population.

Starting with the most common diseases and conditions (asthma, diabetes, heart disease, stroke) and the areas with the longest waits (neurology, dermatology and rheumatology), the initiative is “bottom up” engaging doctors, nurses, allied health professionals, even patients and users of services.

If the clinical programmes go according to plan, they will result in more healthcare, not less, in all local hospitals – just different types of care. They will assist with deciding what happens where in the best interest of quality patient care – in other words what gets “reconfigured” and where.

Alongside this, Mary Harney launched on Thursday last (September 23rd), the Patient Safety First programme which brings together a broad range of initiatives, which jointly should ensure better patient safety.

The proof of patient safety will be if Dr White, and the cadre of clinicians whom he is leading, manage to pull off what has tripped up every political health chief until now. Let’s hope this low-key, ground-up approach can finally deliver safe patient care to the Irish people.

And here’s hoping that the crude, savage budget cuts pledged by Government don’t banjax the best chance yet this country has had of having a safe, quality, universal, public health system.

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