Efficiency gains from smaller hospitals

Dr John Barton is a very honourable man. He is inquisitive, rational, well-read and incisive. The debunking of myth is a most important activity in medicine. Since the deaths of Dr Petr Skrabanek and Professor James McCormick of the Community Health Department at Trinity College Dublin, there are no systematic iconoclasts in Irish Medicine. John to some extent fills some of that gap. He is the most knowledgible person in Fine Gael on health service systems and has taken a keen interest in the subject for some time. I have also taken an interest in this subject for some time. The letter he wrote to the Irish Examiner (Friday 30th April)is to his usual high standard. It helps to address some of the fallacies associated with large Irish hospitals and Health Service Executive policy towards them. As long as lean studies are not carried out on the administrative superstructures in Irish Hospitals, the overstaffing of middle management will remain endemic and probably worsen. Managers managing managers managing other line managers , all with secretaries! Anyway, Dr Barton’s letter follows and is self explanatory.

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Hospitals policy the legacy of a failed political system.

ON RTÉ radio news a few weeks ago, Dr Chris Luke correctly highlighted the crisis in staffing our A&E departments but also took the opportunity to agree with his interviewer that the closure of smaller hospital A&E services may be no bad thing and would bring about economies of scale and improved quality of care.

He indicated that more resources would need to be invested in the larger hospitals before the transfer of services from smaller units.

While I agree that the concentration of services in larger hospitals provides improved patient outcomes for certain conditions such as breast or oesophageal cancer, heart surgery or severely injured patients in road accidents, the research on many common medical conditions does not necessarily support centralisation to larger hospitals and economies of scale in hospital size are reached at a relatively small hospital size. There is, unfortunately, a limited knowledge among influential members of the medical profession, politicians and HSE officials regarding these issues and, as a consequence, people have been subject to a successful campaign suggesting the only place to get quality care is in a larger hospital.

The health economist, Prof John Posnett, director of the York Health Economics Consortium, has written extensively about economies of scale and concentration of hospital services:

* No evidence of a beneficial effect of the general concentration of services in larger hospitals

* Economies of scale are reached at a hospital size of between 200 and 400 beds beyond which economies of scale reduce and costs increase.

* Hospital services should be local and easily accessible.

* Mergers of hospitals are a way of eliminating excess capacity and reducing costs.

* The evidence showing hospitals with higher patient throughput have better patient outcomes is too crude to be useful in planning hospital services.

Prof David Urbach at the Centre for Clinical Evaluative Sciences in Toronto, Canada, has indicated that a more efficient use of resources may be gained by improving the quality of care at smaller hospitals through investment in development of care processes at those institutions, rather than concentrating resources in larger ones as is occurring at present.

Access to a local hospital service may be lifesaving and improving the quality of care at smaller rural hospitals should be a health policy priority. While I do not deny the need for change in provision of hospital services, it is a pity that in the planning and reorganisation, the level of mediocrity commonplace in Irish public life is once again all too evident and may result in a poorer hospital service than that it seeks to replace.

Many patients, including the frail elderly, continue to spend days on trolleys in our public hospital A&E departments, a disgraceful indignity, the legacy, among other factors, of our failed political system.

Dr John Barton
Physician
Portiuncula Hospital
Ballinasloe
Co Galway