Expert queries HIQA's hospitals policy

A former member of the board of the health safety body HIQA has queried its policy in relation to the safety of services at smaller hospitals.

HIQA reports have been instrumental in the downscaling of services such as A&E, major surgery, critical care and medical care at some smaller hospitals and their transfer to larger centres. However, Dr Michael Barry has queried the criteria being used to implement hospital 'reconfiguration' decisions.

In a recent letter to HIQA's Chairman Pat McGrath, Dr Barry said he had become increasingly concerned about the 'general message that appears to be coming from HIQA in relation to the smaller hospitals and its implications for the health system.'

In response, however, HIQA has defended the criteria it uses for its recommendations on hospiital reorganisation on safety grounds.

Dr Barry said his main concern related to the message that improved health outcomes are automatically linked to being treated in a major, high-volume hospital and the fact that this was being used by the HSE to 'reconfigure' smaller hospitals with lower patient volumes.

Referring to the decision to downgrade services at Ennis Hospital following a 2009 HIQA safety report, Dr Barry said around 90% of patients attending that hospital were acute general medical patients.

"The majority of acute medical patients do not need the resources of a largery tertiary referral centre, " he said in the letter, released to irishhealth.com under FOI.

Dr Barry said the relationship between health outcomes and patient volume are far from clear-cut.

"When we account for factors such as differences in prognosis, their correlation between health outcomes and hospital size are minor or even absent. This is particularly true for acute medical admissions, which account for over 85% of emergency medical admissions to our perhiperal hospitals."

Dr Barry, who is Director of the National Centre for Pharmaceconomics, said he accepted that patient volume was a strong predictor of outcome for a number of high-risk surgical procedures.

However, he said recent research showed that treatment of common conditions such as pneumonia in high volume hospitals may be of lower quality than in low volume hospitals.

Dr Barry added that with conditions where there might be slightly better outcomes in high volume centres, such as in the treatment of heart attacks, the evidence suggests that this improvement is not necessarily related to 'high-tech' interventions but to the appropriate use of heart medicines.

He added that there is evidence that a 'volume threshold' exist , whereby a further increase in the number of patients being referred to a hospital no longer results in an improvement in health outcomes.

Dr Barry said evidence showed that health outcomes in major medical conditions were related to hospital resources, whereby hospitals that spent more had lower inpatient mortality, and this did not vary by region or hospital size.

He said it was misleading of HIQA to base the process of hospital reconfiguration on the concept of the 'volume/health outcome relationship.'

Dr Barry's brother, Fine Gael Cork East TD Tom Barry, forwarded the letter to Health Minister James Reilly in mid-July, around the time that the 24-hour ED at Roscommon Hospital was being closed down.

Deputy Barry suggested to the Minister that the evidence showed that the relationship between bigger and smaller hospitals with regard to patient safety was not as clear-cut as suggested.

He told the Minister he had no problem 'being part of the implementation of tough decisions' on hospital services, but it was important that these decisions were made on the basis of all of the facts being taken into account.

Deputy Barry told the Minister the information he had been given by Dr Barry 'may...buy us time to deal with this (hospital reconfiguration) in a more controlled fashion than has happened in the past week.'

Dr Reilly subsequently passed the letter on to his senior officials and to HIQA Chief Executive Dr Tracey Cooper.

Dr Cooper, in response to the Minister, rejected the implication made that HIQA's recommendations on safe hospital care were solely focused on the issue of patient volumes.

She said volume of patients was just one element that needed to be taken into account. Other elements included skill mix and competencies of clinical staff; the type of specialty services being provided in a hospital; interdependencies of internal and external hospital services; resources and facilities available and evidence regarding the model and type of services bring provided.

These, Dr Cooper said, were also critical in determining if services can or cannot be safely provided in small hospitals.

She said while HIQA recommended in its 2009 Ennis and 2011 Mallow reports that the HSE review models for the delivery of safe critical, emergency, surgical and medical care at these and other small hospitals, the reports did not imply that low volume hospitals are less safe for non-complex low acuity medical conditions and certain types of surgical procedures.

Dr Cooper said Dr Barry, when he was a HIQA board member, raised similar issues as in his recent letter around the time of the publication of the Ennis report in 2009, and these were 'duly considered'.

She said this report recommened that the HSE establish a model for medical care to ensure that as wide a range of less complex medical services as possible be delivered in identified smaller hospitals.

Dr Cooper said new safe healthcare standards being drawn up by HIQA will, together with the Ennis and Mallow recommendations 'lead to the optimisation of the type and scope of services that can be safely provided in small stand-alone hospitals to ensure that the public get the safe, reliable and sustainable health services they need and deserve."

The HSE is due to present Dr Reilly by early next month a framework document outlining which services will remain at 10 identified smaller hospitals and which will move to larger centres, and when this will take place.

The framework is also to identify which local, less complex services can be added to the smaller hospitals. The report is due to be considered by the Cabinet sub-committee on health next month.

Of the hospitals on the list, 24-hour ED has already been removed from centres such as Ennis, Nenagh and Roscommon Hospitals

According to a HSE document drawn up in July, Mallow's ED will be redesignated as an urgent care centre from November, while Loughlinstown Hospital in Dublin is also due to have its 24-hour ED changed to an urgent care centre.

Minister Reilly has recently denied reports that Portlaoise Hospital would also be downgraded as part of the reconfiguration process.

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[Posted: Tue 27/09/2011]