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The excellent review of Medical Services in Dumfries and
Galloway by Richard Smith describes the "disproportionate time and energy"
in "a battle over surgical services." It highlights the difficulty in
providing specialist services to rural areas. (1)
Following the reduction in consultant surgical input to our rural area, we
looked at how cancer patients had their condition managed. In a rural
practice of 2,700 patients 32 cases of cancer were identified over a two
and a half year period between January 1st 1997 and 31st July 1999. The
district general hospital was 72 miles away from the surgery. Two tertiary
referral hospitals were 90 and 140 miles away.
11 out of the 32 patients died of their disease over that period. The
average distance travelled by patients attending referral hospitals was
919 miles. Travel to the local hospital (usually about 20 miles) was
excluded from these calculations. Using conservative estimates (assuming
transport by private car), this would take more than 20 hours. The 11 who
died travelled an average of 1,168 miles. The time they travelled
increased to nearly 30 hours. Only 6 of the patients used ambulance
transport as their sole method of transport and 3 used a mixture.
Ambulance transport was only used when other transport was unavailable.
Time taken by the patient transport services varied but one 84-year-old
patient described a 7.5 hour one way journey from Edinburgh to Stranraer
(180 miles with detours to drop off other patients) during her
radiotherapy treatment. In a car this would still have taken 3 hours.
Patients who died survived an average of 165 days from diagnosis. They
spent an average of 22 days travelling to or in these remote city
hospitals (remote being the patient's perspective), more than 13% of their
remaining life. This figure refers only to hospitals more than 65 miles
away (not less than 3 hours return travel from home, relatives and
friends).
The increasing centralisation of cancer services(2)(3)(4)(5) currently
without evidence of benefit (6) will place an extra burden on patients
already frail from cancer or the effects of treatment. One third of
Scotland is regarded as rural. (7) Applying our figures to all practices
in Wigtownshire would involve 300,000 miles of patient travel a year and
5,800 inpatient days more than three hours travelling for patients,
friends and relatives. At least four Stranraer people have been killed in
traffic accidents while visiting patients in the last fifteen years.
Solutions to this problem could be very simple. Thought and care regarding
follow up, changing hospital attitudes and better management arrangements
could reduce travel significantly. Many long journeys were for suture
removal, wound inspection or other minor procedures. Clinic bookings being
made at specific times for isolated geographical areas could allow
transport arrangements to be more efficient and allow sharing. Better use
could be made of community hospitals and staff. Mobile facilities for
imaging investigations or treatment may also have a part to play. Many
patients had to travel to Edinburgh for radiotherapy and chemotherapy
rather than Glasgow, which is much closer. Telemedicine seems to have made
little impact on travelling. (8)
The reorganisation of surgical services from our remote area has left a
hiatus that the district general and teaching hospitals have yet to fill.
Meanwhile rural patients are suffering from the financial penalty of
having to travel very large distances, further compounded by social and
emotional deprivation distant from relatives home and friends.
Those who propose the centralisation of services on the basis that it
becomes easier for consultants to provide high quality care should
consider the patient's perspective. Rural patients are increasingly
disadvantaged by having to seek surgical and oncology opinions at very
great distances. It can only be a matter of time before patients are wise
enough to doubt that the penalty of imprisonment for 13% of their
remaining life in a distant and lonely hospital is not worth any benefit
from unpleasant and painful treatment. Nor need they commit families and
friends to expense, inconvenience and risk by agreeing to be admitted to
these hospitals.
There is evidence that patients are happy to travel for highly specialized
services, but also that where cancer services are provided locally the
uptake of treatment increases. (7) All rural GPs know patients who have
declined care because of the types of barriers described by our study.
There is an emerging awareness of lack of information about such matters.
(9) Where people ignore the proof of repeated personal experiences from a
variety of sources and concentrate on evidence chosen to suit their case,
we have to strain to be optimistic.
A Gordon Baird MB ChB MRCOG FRCGP
Helen D Wemyss RGN RSCN
C Mary Donnelly MB BCh MPH MRCGP
Nigel T Miscampell MB BCh MRCGP DCH DMH
1. Smith R. The NHS in Dumfries and Galloway: straining but
optimistic. BMJ 199; 319:1123-7
2. Designed to care: Renewing the National Health Service in
Scotland. Scottish Office Department of Health. 1997. HMSO
3. Health of the Nation: A strategy for health in England Department
of Health 1992 HMSO
4. Expert Advisory Group on Cancer (1995) A Policy Framework for
commissioning Cancer Services: a report by the Expert Advisory Group on
Cancer to the Chief Medical Officers of England and Wales, 1995.
Department of Health. HM Stationery Office: London
5. Scottish Cancer Co-ordinating and Advisory Committee (1996)
Commissioning Cancer Services in Scotland: report to the Chief Medical
Officer, Scottish Office Department of Health. HM Stationery Office:
Edinburgh
6. Smith R. Reconfiguring hospital services. BMJ 1999 ;319:797-8
7. Campbell NC, Ritchie LD, Cassidy J, Little J. Systematic review of
cancer treatment programmes in remote and rural areas. Br J Cancer
1999;80:1275-80.
8. Kunkler IH Rafferty P, Hill DM Henry M, Foreman D. Telemedicine.
Proved acceptable in pilot study in oncology in Scotland. BMJ 1997;
314:521
9. Scottish Executive Health Department. Fair Shares for all: Report
of the National Review of Resource Allocation for the NHS in Scotland.
Edinburgh: Scottish Executive, 1999
Rural Cancer study
Dear Sir,
The excellent review of Medical Services in Dumfries and
Galloway by Richard Smith describes the "disproportionate time and energy"
in "a battle over surgical services." It highlights the difficulty in
providing specialist services to rural areas. (1)
Following the reduction in consultant surgical input to our rural area, we
looked at how cancer patients had their condition managed. In a rural
practice of 2,700 patients 32 cases of cancer were identified over a two
and a half year period between January 1st 1997 and 31st July 1999. The
district general hospital was 72 miles away from the surgery. Two tertiary
referral hospitals were 90 and 140 miles away.
11 out of the 32 patients died of their disease over that period. The
average distance travelled by patients attending referral hospitals was
919 miles. Travel to the local hospital (usually about 20 miles) was
excluded from these calculations. Using conservative estimates (assuming
transport by private car), this would take more than 20 hours. The 11 who
died travelled an average of 1,168 miles. The time they travelled
increased to nearly 30 hours. Only 6 of the patients used ambulance
transport as their sole method of transport and 3 used a mixture.
Ambulance transport was only used when other transport was unavailable.
Time taken by the patient transport services varied but one 84-year-old
patient described a 7.5 hour one way journey from Edinburgh to Stranraer
(180 miles with detours to drop off other patients) during her
radiotherapy treatment. In a car this would still have taken 3 hours.
Patients who died survived an average of 165 days from diagnosis. They
spent an average of 22 days travelling to or in these remote city
hospitals (remote being the patient's perspective), more than 13% of their
remaining life. This figure refers only to hospitals more than 65 miles
away (not less than 3 hours return travel from home, relatives and
friends).
The increasing centralisation of cancer services(2)(3)(4)(5) currently
without evidence of benefit (6) will place an extra burden on patients
already frail from cancer or the effects of treatment. One third of
Scotland is regarded as rural. (7) Applying our figures to all practices
in Wigtownshire would involve 300,000 miles of patient travel a year and
5,800 inpatient days more than three hours travelling for patients,
friends and relatives. At least four Stranraer people have been killed in
traffic accidents while visiting patients in the last fifteen years.
Solutions to this problem could be very simple. Thought and care regarding
follow up, changing hospital attitudes and better management arrangements
could reduce travel significantly. Many long journeys were for suture
removal, wound inspection or other minor procedures. Clinic bookings being
made at specific times for isolated geographical areas could allow
transport arrangements to be more efficient and allow sharing. Better use
could be made of community hospitals and staff. Mobile facilities for
imaging investigations or treatment may also have a part to play. Many
patients had to travel to Edinburgh for radiotherapy and chemotherapy
rather than Glasgow, which is much closer. Telemedicine seems to have made
little impact on travelling. (8)
The reorganisation of surgical services from our remote area has left a
hiatus that the district general and teaching hospitals have yet to fill.
Meanwhile rural patients are suffering from the financial penalty of
having to travel very large distances, further compounded by social and
emotional deprivation distant from relatives home and friends.
Those who propose the centralisation of services on the basis that it
becomes easier for consultants to provide high quality care should
consider the patient's perspective. Rural patients are increasingly
disadvantaged by having to seek surgical and oncology opinions at very
great distances. It can only be a matter of time before patients are wise
enough to doubt that the penalty of imprisonment for 13% of their
remaining life in a distant and lonely hospital is not worth any benefit
from unpleasant and painful treatment. Nor need they commit families and
friends to expense, inconvenience and risk by agreeing to be admitted to
these hospitals.
There is evidence that patients are happy to travel for highly specialized
services, but also that where cancer services are provided locally the
uptake of treatment increases. (7) All rural GPs know patients who have
declined care because of the types of barriers described by our study.
There is an emerging awareness of lack of information about such matters.
(9) Where people ignore the proof of repeated personal experiences from a
variety of sources and concentrate on evidence chosen to suit their case,
we have to strain to be optimistic.
A Gordon Baird MB ChB MRCOG FRCGP
Helen D Wemyss RGN RSCN
C Mary Donnelly MB BCh MPH MRCGP
Nigel T Miscampell MB BCh MRCGP DCH DMH
1. Smith R. The NHS in Dumfries and Galloway: straining but
optimistic. BMJ 199; 319:1123-7
2. Designed to care: Renewing the National Health Service in
Scotland. Scottish Office Department of Health. 1997. HMSO
3. Health of the Nation: A strategy for health in England Department
of Health 1992 HMSO
4. Expert Advisory Group on Cancer (1995) A Policy Framework for
commissioning Cancer Services: a report by the Expert Advisory Group on
Cancer to the Chief Medical Officers of England and Wales, 1995.
Department of Health. HM Stationery Office: London
5. Scottish Cancer Co-ordinating and Advisory Committee (1996)
Commissioning Cancer Services in Scotland: report to the Chief Medical
Officer, Scottish Office Department of Health. HM Stationery Office:
Edinburgh
6. Smith R. Reconfiguring hospital services. BMJ 1999 ;319:797-8
7. Campbell NC, Ritchie LD, Cassidy J, Little J. Systematic review of
cancer treatment programmes in remote and rural areas. Br J Cancer
1999;80:1275-80.
8. Kunkler IH Rafferty P, Hill DM Henry M, Foreman D. Telemedicine.
Proved acceptable in pilot study in oncology in Scotland. BMJ 1997;
314:521
9. Scottish Executive Health Department. Fair Shares for all: Report
of the National Review of Resource Allocation for the NHS in Scotland.
Edinburgh: Scottish Executive, 1999
Competing interests: No competing interests