A small hospital's perspective

MEDICAL MATTERS: Much of the debate at the recent annual meeting of the Irish Medical Organisation (IMO) centred on health reform. Several keynote speakers opposed Mary Harney's proposals to develop private hospitals on the grounds of public hospitals, even though the move would free up 1,000 beds for public patients.

New IMO president Dr Christine O'Malley says private hospitals cannot replace public hospitals because they do not treat patients with urgent problems such as heart attacks, strokes and those in need of urgent operations.

Pointing out that emergencies make up three-quarters of admissions to public hospitals, she says: "The reality is, it is easy to divert money to the private hospitals but the patients can't follow."

Dr O'Malley, who is a consultant geriatrician at Nenagh General Hospital, one of the smaller hospitals in the State, offers an alternative view of life at the medical coalface to those who work in large teaching hospitals in our main cities.

When the Hanly report was published, it proposed the Republic's small hospitals would be redesignated. As a result, they would focus an elective day surgery and elective medicine, with no onsite medical presence after 5pm or at weekends.

Emergencies would bypass these hospitals to be treated in the nearest regional hospital. And while the Hanly report has yet to be implemented, it is clear that its aspirations have never been abandoned.

A recent report from the Nenagh Hospital Action Group, of which Dr O'Malley is a leading member, offers an alternative view of future hospital care. While the report, Small Hospital, Big Service deals particularly with the future of Nenagh hospital, it also looks at broader national issues and how they affect small rural hospitals.

One of these is how safe are acute hospitals? While acknowledging that certain specialist surgical procedures lead to better outcomes when performed at high volume centres, ("high volume providers have a significantly better outcome for complex cancer surgery, specifically of the pancreas, oesophagus, stomach and rectum"), the Nenagh report quotes evidence suggesting that overall there is no direct link between volume and patient outcome. "[ Studies] found that individual surgeon skill was more important than the size of the unit and that small clinics and large units following the same protocol got similar results," it says.

As recent events in the Health Service Executive northeast area have shown, the inter-hospital transfer of patients is an area of significant concern for staff working in small acute hospitals. The Small Hospital, Big Service report says there are three factors that have led to needless deaths - "The way that the service in peripheral units has been compromised by being cut too far; the referral centres [ larger hospitals] are under so much pressure they cannot accept a patient in need; and the back of an ambulance is expected to replace an acute hospital."

From a small hospital's perspective, the best way to protect patients from risk is for it to retain the ability and the services to deal with all emergencies on a 24-hour basis.

"For small acute hospitals, one of the biggest contributions that could be made would be to introduce a clear, agreed, national protocol of one-call transfers to larger centre," the report says. It also calls for a redefinition of the term "critical mass of services" to mean the critical range of services that a hospital must provide to ensure that it can safely accept acute patients.

While the small hospital sector will never attract the glamour headlines associated with new medical breakthroughs at larger units, it is a vital part of our existing health system. It is important we hear and listen to the small hospital perspective on health service reform.

Further to my recent column on the risks of developing deep vein thrombosis (DVT) while flying, an expert review of the benefits of wearing compression stockings has found that people who wear them have one-tenth of the risk of developing a DVT on long-haul flights compared with people who do not.

A review of nine studies involving 2,800 people who went on flights of seven hours or more, by the Cochrane Library, a source of high quality health information, found that 50 people developed a DVT. Some 47 were not wearing stockings, while the other three were.

Prof Mike Clarke of the UK Cochrane Centre says: "This review shows that airline passengers travelling for long distances can expect a substantial reduction in the incidence of symptomless DVT if they wear compression stockings."

The Cochrane Library can be accessed via the Health Research Board website at www.hrb.ie

Dr Muiris Houston is pleased to hear from readers but regrets he cannot answer individual medical queries.