Regional thoracic medical centres.
Authors: C M Ogilvie
Journal: Thorax (1986)

Thebasic hospital medical services intheUnited Kingdomarecentred ondistrict general hospitals. Thereasons fornotproviding aparticular facility in every district hospital areseveral. Thedemandfor that facility mayberelatively infrequent ortheprovision ofitwouldentail either amajor capital outlay inequipment andaccommodation orlarge revenue consequences interms oftrained staff. Theleaders of eachspecialty mustdetermine which facilities should beavailable ineverydistrict hospital andwhich should beprovided inonly oneortwocentres ineach region. There are, however, reasons other thaneconomic forthecreation ofregional specialist centres. Those specialties that donotrequire expensive ormassive equipment andagreat amountofspace tendtobecomedispersed amongseveral different hospitals and arethus denied theopportunity ofcreating acentre of excellence. Inthis respect, thoracic medicine isata disadvantage incomparison, forexample, withcardiology. Thecardiologists recognise twotypes ofspecialist: thegeneral physician withaninterest in cardiology based inthedistrict general hospital (type B)andthefull time cardiologist based inaregional cardiac centre where themoreexpensive resources are contained (type A).Thelatter isenabled tobuild a centre ofexcellence inhisspecialty notjust byvirtue oftheequipment andspace available tohimbutbecause thecentre canattract laboratory, nursing, and other ancillary staff whospecialise incardiology. There arefewthoracic medical centres ofthis kind andmostofthose thatdoexist havebeensuperimposed onatuberculosis sanatorium oracardiothoracic surgical unit. Thoseintheformer group are underthreat on thespurious groundsthat tuberculosis-their original raison d'etre-is no longer aproblem. Thethoracic medical centres inthe latter groupareliable tosuffer fromtheincreasing demands forcardiac surgery andforthecardiac medical backupthat this surgery requires. Itshould berecognised that there arecertain essential thoracic medical facilities that cannot bemade available inevery district hospital butmustbeprovided forevery region; alist ofthese hasbeendrawn upandapproved bytheCouncil oftheBTSanditis published onp496. Insomeregions these facilities-if available atall-are scattered around several district hospitals, wherethechest physicians mayalready haveamajor commitment togeneral medicine. There isacasefortrying toconcentrate certain special functions alongside thoracic surgery inonecentre large enough tojustify theappointment offull timechest physicians aswell aspathologists, radiologists, physiotherapists, andother technical staff whospecialise inthoracic diseases. Studies inBritain andelsewhere havealready shownthat patients withcystic fibrosis supervised atamajor centre fare better thanthose attending local clinics, andthesamemaywell betrue formorecommondiseases suchaslung cancer. But, quite apart fromthese immediate clinical advantages, there isalso agreater opportunity forpostgraduate education, research, andadvancement ofthespecialty incentres where experts fromdifferent disciplines share acommoninterest inthoracic diseases. Centres ofthis kindarenotjust aneconomic necessity to avoidduplication ofequipment orstaff; theyare needed forthewelfare ofourpatients andforthe future ofourspecialty.