Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
Greater Common Good
- Shiv Mohan Bhanot (28 January 2004)
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Emergency services in the developing world
- Adnan A. Hyder (29 January 2004)
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bigger is not better
- DAVID G CURRIE (5 February 2004)
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Centralisation of Surgical Services and Local Community Opinion
- Patrick M TRUST (8 February 2004)
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Bigger Is Not Better
- Jean Cooper (18 February 2004)
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Shiv Mohan Bhanot, Consultant Urologist King George Hospital, Goodmayes, IG3 8YB
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The issue of reconfiguration of surgical, emergency and trauma services has been addressed by Andy Black in the BMJ of 24/1/2004(1). The policy paper from the Senate of Surgery of Great Britain and Ireland was made available on the web on 24/1/2004(2). It is said that the intention is to initiate a debate. There appear to be some presumptions made by Mr Black which are obviously based on the Senate policy paper. For example it is presumed that fewer, larger, better equipped and better staffed hospitals will lead to better health for those being treated. The importance of lack of ease of access and lack of knowledge of local factors has been omitted. The evidence for better surgical outcomes in high volume units compared to low volume units is needed as a matter of urgency. And does marginally better measured surgical outcome translate into better health for the community ? Mr Black states “The arguments are cogent” but stops at European Working Time Directive and stops. The issue of dependencies of departments has been completely omitted. All clinical specialties depend on other specialties for patient catchment, patient referral, joint and multi discplinary working. The optimum dependency of a clinical specialty has not been evaluated. Reconfiguration of culturally different departments may lead to alteration of departmental dependencies. There may be occasions where individual patients may be placed under risk because of such alterations. It is interesting that General Medical Council has not yet been formally involved in this debate. Why ? In the absence of evidence it is wise to use the common sense. And who can represent common sense better: the Senate, Mr Black, or the common people ?. It is quite sad to note that the Kidderminster saga has been labelled as a debacle ! Where science is imperfect, for an incomplete aspect of a whole why should holistic public approach not dominate the issues. The Greater Common Good methods aimed to justify building a dam on the bank of river Narmada (3). The Senate has summarised their methods in justifying their recommendations The Senate paper should have invited a critical comment but BMJ only provided the one sided editorial by Mr Black. It is sincerely hoped that there is a debate based on common sense by the common people and by the common surgeons treating the mass of common patients. Mr Shiv Mohan Bhanot MS FRCS
References: 1.Andy Black. Reconfiguration of surgical, emergency, and trauma services in the United Kingdom . BMJ 2004;328:178-179 2. Senate of Surgery of Great Britain and Ireland. Reconfiguration of surgical, accident and emergency and trauma services in the UK. Glasgow, 2004. www.rcpsg.ac.uk/recreport.htm (available from 24 January 2003). 3. Arundhati Roy. The greater common good. www.narmada.org/gcg/gcg.html Competing interests: Working in a department subject to reconfiguration |
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Adnan A. Hyder, Assistant Professor & Leon Robertson Faculty Development Chair Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe St., E-8132, Baltimore, MD 21205, USA
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The editorial by Black on reconfiguration of emergency services in the UK is important for reflections on the same issue in the developing world.1 The recommendations stated towards the end of the article have unintended appeal for low and middle income countries. Emergency services and acute care is a major gap in the focus of the health sector in the developing world and the following issues need to be highlighted to promote a global dialogue on how best to confugure (rather than re- configure) such services. 1. Traditional investments in the health sector in the developing world have been biased towards urban areas, large tertiary facilities, and specialty services to the detriment of primary and acute care. This allocative problem needs to be addressed by ministries of health and finance. 2. The use of non-physican personnel (as mentioned by Black) is critical for the developing world. Shortages of skilled manpower, lack of training, poorly defined career structures, are the types of issues plaguing human resources in the health sector of developing countries. It is time to assess the potential contributions of other cadres of health professionals for emergency care, analagous to the community health workers of Primary Health Care. 3. Building infrastructure would be important in the different settings of hospitals, clincs and district facilities. Defining essential equipment and functions seems like an appropriate task for agencies such as the World Health Organization. 4. Finally, capacity development for responding to emergency care should be a critical component of any effort in this direction in the developing world. Training individual physicians is not enough; building emergency care systems will be needed to make a quantum change in responding to the needs of people. It is time to recognize the great need for acute care in the developing world and call for more investment and efforts in building appropriate systems. Persisting maternal mortality, rising cardiac deaths, and the burden of trauma are all conditions which should be manageable in the developing word, as in the UK, by an appropriate emergency medical system. References: 1. Black A. Reconfiguration of surgical, emergency, and trauma services in the United Kingdom BMJ 2004; 328: 178-179 [Full text] Competing interests: None declared |
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DAVID G CURRIE, neurosurgeon Aberdeen Royal Infirmary, AB25 2ZN
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Andy Black's paper was a welcome intervention in what is proving to be a destructive tendency in Scottish medicine and, I suspect, in UK medicine. There is a depressing trend in Scotland to see centralisation (sometimes euphamistically described as creating "managed clinical networks") as a reasonable solution to all the ills that currently afflict us. These include the New Deal, the Consultants Contract, the GPs contract, the European Working Time directive - all man-made artifacts and all preoccupied with the welfare of doctors, not patients. There is a view that unless something can be done to the standard of the Mayo Clinic it should not be done at all. This endangers our small and not so small district hospitals and our specialist services in the regions of Scotland and ultimately leads to the absurd conclusion that we have only one or two hospitals. We should, instead, be looking at how we can improve medical services where our people live. We have to do this to encourage the survival and the development of our regional and rural cultures. Fewer and bigger hospitals is certainly not the answer. Other European countries recognise that and I expect that our electorate will as well. If they dont some of us will be sure to tell them. Competing interests: None declared |
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Patrick M TRUST, Principal in General Practice Medical Centre, 46 Bank Street,Alexandria. G83 0LS
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The leading article by Andy Black on Reconfiguration Of Surgical and Emergency Services in the UK exudes common sense. Our locality of Lomond has lost both Accident and Emergency Surgical services within the last 4 months and local General Practitioners(GPs)have had tremendous difficulty in securing safe services for our local population. This comes on top of loss of Maternity services last year at our local DGH - the Vale of Leven Hospital. We have been very badly served by surgeons who with their Royal Colleges insist on retreating to so called centres of excellence, with little thought of the price paid by the population deprived of hospital services. Administrators have no choice when when confronted by surgeons who cannot or do not have the will to think'out of the box' where rural, or small town, communities are concerned. Administrators do have the choice of supporting concerned GPs trying to provide safe cover for their patients. The support is not always forthcoming and GPs are left struggling to provide a service with colleagues in the ambulance service who are not adequately consulted on proposed changes and their effect on the locality. Important groups such as the police are not even consulted on proposed changes to local emergency services. We are now left struggling with only grudging financial backup and inadequate training for yet another new role - we anticipate being able to obtain training with BASICS as this training is already used by all the rural GPs in Argyll. Patients are waking up to the reality of loss of services and are voting out the politicians with examples in England,Scotland and now Northern Ireland. It has been interesting in the West of Scotland to see the power of patients' being harnessed. GPs are now working with patient groups,hospital consultants and ambulance staff to discuss how local services can be delivered. Patient power has delayed the closure of emergency and surgical services in Fort William and this example may be the way forward for co-ordinated action by concerned communities.(see www.tbag.org.uk) PATRICK TRUST General Practitioner Competing interests: None declared |
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Jean Cooper, Retired DY12 1NH
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Bigger is not better David G. Currie, 5th Feb. From the patient’s perspective, I can testify that bigger has certainly not been better for the population of Kidderminster and district. The downgrading of Kidderminster Hospital and the re-organisation of hospital services in Worcestershire (including a new PFI hospital in Worcester) has resulted in a disastrously worse service for Kidderminster patients and, I believe, for Worcestershire as a whole. There are fewer beds, waiting times have lengthened, operations are cancelled frequently, notes are mislaid and patients have to travel all over the county, causing difficulty and distress to patients and relatives, especially the elderly. Some cancer patients are having to wait 6-8 weeks after diagnosis for their operations: before the downgrading of Kidderminster Hospital this waiting time was 2 weeks. There are still serious financial problems, despite finance being the reason for the original exercise. I wonder if the politicians and planners realise how much damage their actions have caused in this area ? The Kidderminster saga continues. (Mrs) Jean Cooper Competing interests: None declared |
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