SECOND OPINION:In many cases, the centralisation of children's surgery causes undue stress and is unnecessary, writes LIAM KIRWAN
IT IS AGREED the Republic needs one tertiary specialist children’s hospital. This institution should cater for the generality of children’s illnesses in the capital but should also draw patients requiring highly-specialised care from the entire country.
In surgery however, the number of children requiring such “highly specialised care” is few enough.
The majority of children’s surgery falls into the intermediate category – indeed much of it is day surgery.
There is no need for more routine children’s surgery to be centralised. Such general paediatric surgery has always been done in a number of general hospitals around the State and there is published evidence from several of these that the standard for certain index operations was high.
Now however, because of the gradual retirement of surgeons who undertook this work, this is about to change with disastrous consequences for the families outside of Dublin.
Increasingly, children are being shipped out by hospitals previously competent to deal with their surgery. The stress, discomfort, dislocation and expense caused to families, often with several other children, are ignored.
This is just not right.
Let us be clear – this is not about money, we did it better when we were poor.
It afflicts not just smaller hospitals but also significant university institutions.
And all presided over by a Health Service Executive (HSE) which purports to want “more services provided locally” (Sara Burke, The Irish Times, December 2008) and by a government Department of Health and Children.
Several factors contribute to this impending disaster.
First, there are the changing demographics and attitudes within medicine and the complete failure to face or manage these.
Surgeons and anaesthetists conveniently decide, in the absence of a national policy, to discontinue children’s work previously commonplace in their institutions.
This dereliction is facilitated by surgical training programmes which by the absence of a children’s surgery module, are not fit for purpose.
Then there is the impenetrable remoteness of the HSE which, in the face of interminable reports and meetings, fails to develop a strategy.
Are we to face a situation where every small child in Ireland with appendicitis, hernia (and much else) must go to Dublin, often at night and by ambulance at great expense?
It is of course incumbent upon those who complain to propose solutions.
The first option is to restore the status quo which prevailed until recently. In this model children’s surgery would be done by programme trained general surgeons in a limited number of hospitals with full paediatric departments.
Appointees to such units should have completed a children’s surgery module or be required to do so on appointment before commencing. Such paediatric surgery experience has indeed great value in adult surgery and is never a waste as may be suggested by objectors.
No retiring surgeon who did children’s surgery should be replaced by one who does not. Such an arrangement would be tenable and cost neutral.
Such units, limited in number, would have adequate throughput and would work closely with a National Children’s Hospital.
Proper governance arrangements would comply with reasonable medico-legal requirements.
The second and more purist option is to appoint paediatric surgeons to larger university hospitals. While this might serve larger population centres it will not solve the national problem and many children previously adequately treated near home would still have to travel.
Furthermore, it would be expensive and now is not an opportune time to propose expensive solutions.
Two additional points should be made.
First, the excellent graduates of our Irish surgical training programme must be used for and made fit for this purpose. The programme must be altered accordingly to include children’s surgery.
To proceed piecemeal and advertise posts in paediatric surgery without training our graduates in this way will, by our high salaries, attract the flotsam of international surgery with unpredictable result.
Second, our authorities, in addressing this problem, must seek the counsel not of their usual sources but rather of those outside of Dublin who live with and understand the issue.
The children of the nation are not being cherished equally. Laissez faire must stop. Can we please have a policy?
Liam Kirwan is a professor of surgery at University College Cork and a member of the Executive Management Board of Cork University Hospital. He is author of Political Correctness and the Surgeon, Authorhouse 2008