Medium-sized hospitals can achieve efficiencies which a reformed health system should be trying to emulate, writes Muiris Houston
As we wait for the much-delayed publication of the recommendations from the National Task Force on Medical Staffing (the Hanly report) - the last of three key reports on the future of the health system along with the Brennan and Prospectus reviews - it is worth reflecting on why Hanly has been delayed and where the review process will go next.
One of the causes of the delay in publishing the report is simply a reflection on the pace of Civil Service life. It is the same frustration which caused Prof Niamh Brennan to question the slow progress in implementing her commission's recommendations.
Hanly has been with the Department of Health since June; according to the Minister, Mr Martin, the delay in publication is nothing more than a need to have key players involved and a desire to present the findings in an appropriate way.
But there are other considerations. Hanly produced a first draft in February. Much leaked (as indeed have subsequent drafts), it contained a major bombshell: it wanted only 12 major hospitals in the Republic dealing with acute admissions and trauma.
This conclusion was driven by its desire to see medical staffing arrangements reversed: it wanted many more hospital consultants and relatively fewer junior doctors in order to achieve a consultant-delivered health service. Concentrating resources in major hospitals would also ensure high standards of care, it argued.
This first draft caused a number of interested parties to sit up and react. The Department of Finance balked at the prospect of building 12 1,000-bed hospitals in the present fiscal climate. The more politically astute members of the Hanly Task Force could see that such a proposal would never get past local politicians and interest groups.
Representatives of the Irish Medical Organisation then insisted on a line-by-line analysis of the first draft, which meant a significant delay in the process but which has arguably resulted in a more realistic final version.
If the latest leaks concerning Hanly are correct, the final document has lost all references to detailed national hospital and staffing levels.
Instead its recommendations focus on the two pilot areas where its recommendations will be tested out, the Mid-Western Health Board and the South West Area Health Board of the Eastern Regional Health Authority.
It is also significant that yesterday's Cabinet meeting was the third in succession where Hanly was discussed. Part of the reason for this is undoubtedly a packed agenda.
However, The Irish Times understands that the report has been dealt with and that discussions between Ministers are continuing about its financial and political implications.
Two contributions to Monday's Irish Times provide an interesting context to Hanly and the other reform documents. Finbar Lennon, a consultant general surgeon in Our Lady of Lourdes Hospital, Drogheda, in a piece headlined "Medical profession failed Dr Neary's patients", considered the implications of the Neary case for Irish medicine.
Referring to the fact that many clinical units still have very small consultant establishments, he said: "In such units, consultants are over-worked and have little opportunity for continuing medical education. As a result of having service commitments, some consultants are deprived of time for reflection and analysis of their own and their units performance."
A poorly performing consultant in such a unit can go undetected, Mr Lennon added. Fair enough, but when he says that, because of the risks, many such (small) hospitals should now concentrate on delivering elective healthcare, is he making a quantum leap in looking for a solution to a medical, rather than a health-system, problem?
Why not introduce a system of competence assurance similar to the licensing of pilots, with regular checks on individual doctors' performance?
The Health page on Monday carried a feature on St Luke's Hospital in Kilkenny. It described a highly functional hospital 70 miles from the dysfunctional care currently provided by Dublin's major hospitals. This writer spent the best part of a day observing the 317-bed in action.
Using the concept of a medical assessment unit (MAU) separate from the accident and emergency department, acutely ill patients are processed and admitted to an appropriate ward within three hours of arriving in the unit.
Clearly a dream from a patient's viewpoint, the collegiality and close involvement with each other's patients of the five medical consultants in St Luke's were striking.
In addition, nurses, doctors and allied health professionals worked seamlessly in an impressive display of multi-disciplinary team work.
From a cost perspective, the setting up of the MAU was not a large undertaking. Utilising existing buildings, the main cost was equipment. Most of its staff were relocated from within St Luke's.
What is especially sobering about Kilkenny in the context of Hanly is that, under the first draft of the task force report, St Luke's would have lost its acute medical facilities to the regional flagship unit in Waterford. With 15,000 admissions in 2002, compared with Waterford's 22,000, both Kilkenny and Wexford General Hospitals would have been downgraded. In other words, acute admissions to Waterford would rise dramatically, with a probability that it would face the kind of problems now experienced by Dublin's teaching hospitals.
In fact, a closer look at figures for the South Eastern Health Board shows that, from January to June 2003, 2,680 general medical (as distinct from surgical or sub-speciality) patients were admitted to Waterford Regional Hospital.
However, the smaller general hospitals at Wexford and Kilkenny looked after 2,994 and 3,472 people in the same period. This suggests an efficiency of throughput which a reformed health system should be trying to emulate rather than strangulate.
While the likes of Monaghan and Bantry hospitals have too few admissions to escape major reform, the lesson from Kilkenny for other small and medium-sized hospitals is clear. Set up strategic alliances with one another, introduce concepts such as medical and surgical assessment units and develop multi-disciplinary team working.
Watch the efficiencies flow from simple changes and make it impossible for any logical reform of the health system to downgrade your facilities. With satisfied patients and staff and uncomplaining political representatives, what minister for health would dare close you down