Personal Views: Doctors must debate hospital closures
Authors: Richard Lehman
Journal: BMJ (2006)

”Doctors back mass hospital closures” said the front page head-line of the Observer on 17 September. To many doctors this will have come as a surprise. This issue has never been the subject of a full national debate in the profession. Over the past 15 years there has been much talk of centralising services and many local campaigns over individual threatened local hospitals but little systematic collection of evidence to inform decision making. Instead, the process has been driven largely by financial pressures, by the European Working Time Directive and its effects on junior doctors' staffing, and various recommendations from the royal colleges about the levels of staffing and activity that would allow posts to be accredited for training.

Inevitably these pressures have driven hospitals to amalgamate services, at some cost to local accessibility. Equally inevitably such moves are deeply unpopular with patients, who may have to travel considerable distances for acute care that used to be on their doorstep. The services most likely to be cut or merged throughout Britain are paediatrics, obstetrics, and emergency services—the very ones that patients particularly want to be near. The Guardian (www.guardian.co.uk, 13 Sep, “Right on with reform”) finds the new NHS chief executive, David Nicholson, “determinedly optimistic about winning public support for change if consultation is managed properly.” Mr Nicholson said, “Trusts have to ask: are the clinicians on board; will they stand up and argue the case; can the trust demonstrate the health benefits of a configuration of services; and can it say how many lives will be saved, to set against the claims that will undoubtedly be made by protesters that lives will be lost?”

This is a tough call for clinicians and trusts. Local papers will be full of stories from “protesters” who feel that their own life or that of a child depended on prompt treatment at their local hospital. But from where will the trust and the clinicians get the evidence to contradict them? Do we know the safe ambulance transit time for a child with septicaemia or respiratory arrest? Data may well show that such patients generally have better outcomes in specialist units, but what is the countervailing effect of delay in access? Transit will always be the time of greatest danger, however well trained the paramedics and ambulance crew.

This applies especially to transfer of neonates in need of resuscitation (Archives of Disease in Childhood 2005;90: 729-32 [PubMed]). And that presents a dilemma for trusts that seek to maintain a lower level of local service by substituting a midwife led birth unit for a consultant led obstetric service. Such units only accept “low risk” births, but emergencies inevitably occur, requiring transit to the nearest consultant led facility. Figures for transfers in labour and for neonatal transfers vary widely. In the Kidderminster area the midwife led Wyre Forest Birth Centre, which took low risk deliveries after the local obstetric unit was closed, was shut down after six unexpected neonatal deaths in less than three years. The overall safety of midwife led units is under scrutiny from the National Institute for Health and Clinical Excellence (NICE) and was recently questioned by James Owen Drife, professor of obstetrics and gynaecology at Leeds (BMJ 2006;333: 51).

There is a stark choice between safety and “choice” in childbirth. Home birth becomes more risky the further it is from an obstetric unit. If NICE pronounces negatively on the safety of midwife led units then mothers will not have this choice either. They will all be expected to travel to the nearest hospital with obstetricians, paediatricians, and accredited anaesthetists. If considerations of cost are allowed to predominate that may be a very long distance. This issue is one of several that need to be debated urgently before a further wave of such changes sweeps the country. It cannot be timed or located to suit electoral convenience.

In the current political climate it would take considerable optimism to expect that health policy might be governed by evidence alone. It is the urgent responsibility of our professional leadership to mark out where the evidence lies, what it says, and where it is lacking. We need clearer guidance from the Royal College of Obstetricians and Gynaecologists, the Royal College of Paediatrics and Child Health, and indeed the chief medical officer on issues such as safe transit times for paediatric and obstetric emergencies. At present the colleges seem more concerned with the training agenda of teaching hospitals than with service provision in district general hospitals, despite the invaluable experience that such hospitals offer. We need more creative thinking from the colleges and the larger trusts on shared site working and flexible training rotas to allow working at dual sites and local accessibility.

It is time for GPs to reassert their role as patients' advocates, defending the principle of local care for local people. If doctors do not take an active role in questioning the present direction of policy then the public will rightly see us as more interested in our own career structures and hours of working than in providing a safe and accessible service.