Heat not light

Tweet This week has seen the publication of proposals by two of Wales' health boards for changes to the way some services are delivered.  Political reactions have, more or less, been entirely predictable, and based more on political considerations than on any relating to health.  It’s one of those situations where all of the politicians in all of the parties know that there have to be some changes whilst politically they all want to appeal to the sensitivities and sentiment of electors across Wales rather than risk losing votes by saying why they support some change.

That is not to say that the health boards necessarily get everything right, and that there is no scope for debate about some of the detail.  And the lack of trust which has grown as a result of previous attempts to rationalise services – sometimes for financial rather than health reasons – has left a legacy of suspicion about motives and rationales which leave a strong motivation for those opposed to any change.

Having sat through a number of meetings where some of these issues have been discussed, three things in particular have become clear to me.

1. There are people who are inpatients in our hospitals who need not be.  With proper organisation and by putting the funding in the right place, their care could be delivered in the community – usually in their homes – with sometimes better outcomes; almost invariably with more dignity and independence for the patients; and often at lower cost.
2. There are a number of complex cases and specialities, sometimes involving expensive equipment and needing particular expertise, which can be delivered more safely and with better outcomes from a small number of centres than by attempting to replicate services in every hospital in Wales.
3. Medicine is becoming increasingly specialised; specialist skills need to be maintained and developed by handling a sufficient number of cases, and doctors in some specialities are in short supply.

Those three points seem to me to be unarguable; the question is about which changes need to be made to respond to those factors, and whether – as a suspicious public fears – the changes being proposed go further than is necessary simply to respond to those three factors.  That question needs more attention and debate than it is getting from knee-jerk political reactions phrased in emotional terms about ‘saving our services’.

Those proposing the changes are not infallible; and I’m not assuming for one moment that they have got it all right.  But simplistic opposition to any and every proposal is not the best way to get the health service we need and deserve.

More than spin needed

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In Saturday’s Western Mail, Matt Withers turned his attention to the perennial question of changes to the delivery of hospital services in Wales, and raised some key points.  It’s a thorny issue, and it’s difficult to get to the right answer.

Politically, any attempt to remove services from local hospitals will be painted as centralisation, and is certain to stir local protests.  But, as Matt points out, there are serious concerns that the current situation is actually unsafe in certain respects, and that isn’t really a political issue.

It often looks as though the professionals themselves are split on the issue; whilst some express their fears about centralisation, others equally sincerely express their concerns about patient safety.

As far as I’m aware, no-one is suggesting that all hospitals in Wales should have a team of qualified brain surgeons on hand.  The annual number of cases simply does not require that level of provision.  Generalising from that, it is clear that there is, therefore, a willingness to accept that certain specialised types of care are best provided in a smaller number of hospitals which have the expertise and the facilities to cope with them.

Again, as far as I’m aware, no one is really suggesting that district hospitals in Wales should cease providing a good level of general surgery and medicine covering most of the illnesses which affect significant numbers of the population.

The problem is in drawing the line between the two.  Whilst we all want to be treated as locally as possible, how many of would really prefer to be treated by a team who’d never seen a case like ours, instead of by an experienced team which dealt with a number of cases each year, just in order to be more local?  Give me the expertise any day.  And that question is what should be at the root of the government’s case for change.

To read some of what the professionals and politicians are saying, the failure of the government to convince us that they’re drawing the line in the right place is a ‘presentational’ problem; all they need to do is find a better way to put their case and we’ll all be convinced.  (Or even, as the WM article suggested, simply find the right time between elections where they won’t suffer too much political grief as a result.).  I think they’re deluding themselves.

Against a background of previous attempts to centralise services, in what generally looked as proposals more motivated by financial considerations than by health care considerations, it should be no surprise to anyone that there is a good deal of suspicion about any proposals emanating from the government.  There have been previous proposals which were about centralising whole services rather than just the most complicated and unusual of cases, and it often appears as though those proposals are simply being recycled under a different banner.  They’ll need more than good PR to shift that perception.