The news today is full of stories about people in rural Cornwall being unable to access immediate investigation and treatment for stroke which results in poorer outcomes compared to their city dwelling contemporaries who will have their heads scanned, their thrombolysis up and running and be back in the queue at the chip shop before you can say “brain attack”. Outraged members of the countryside are spitting with rage at the inequality of this, stroke charities insist that something must be done. Not wanting to be left in the shadows, cancer is also bumping it’s gums and pointing out that you will be diagnosed later if you are from the middle of nowhere.
I have a different view on this, which is that it is unaffordable and insane to want every hospital to have every possible expert physically there all the time in case someone needs their attention. We cannot staff and equip small hospitals in the same way as Bighospitals.
People in the UK have a perverse love for their local hospital, where they were probably born and had their broken arm seen to when they were 12. They declare the surgeons there “very good” with no grounds for that assertion. The chances are that the surgeons there are average surgeons (something none of us think we are) and are competent and reasonable individuals. It is most unlikely that they are the best, most unlikely that they are offering cutting edge treatment and most unlikely that they have the best outcomes. This is not because they are different in any way but because they will not have the back up of umpteen specialist cancer nurses, a 20 bedded ITU, a 40 bedded HDU, CT scanners that run night and day and in house dialysis and interventional radiology.
How can we convince the public that they want an operation from someone who does that particular operation all the time backed up by a team that looks after people like them all the time? I might be able to do a liver resection (I’ve seen enought of them and done a few with someone talking me through it) but I am clearly not the best at it and if you want the optimal short term and long term outcomes from your surgery then you really want the best as opposed to the nearest person wielding the knife.
In the UK this approach is political suicide. If the government announced centralisation beyond what we already have there would be much public wailing. If you even suggest to the public that you plan on closing a so called A&E department staffed by a bunch of staff grades, GP’s, junior doctors and nurse practitioners with a Skype link to the nearest hospital for tricky questions (I kid you not, this happens) and ask the public to travel 9 miles to the nearest Bighospital where a team of 17 consultants and 40 juniors and a CT scanner in the department await them, you get a riot. Nobody wants the best treatment if it means a drive to get there. They all want to travel five minutes up the road and access the best care in the world, 24 hours a day, 7 days a week, free of charge.
I wonder if Jeremy Hunt or any health secretary will ever have the balls to say to the media and the country that this is impossible. What we should be doing is improving the rate at which these services are accessed, improving the transfer of patients to and from the best centers. If you have a stroke in Cornwall, helicopter or ambulance services should be able to get you to the right place to receive your thrombolysis. Similarly with cancer investigations, if you need a CT scan your GP should be able to access that and arrange it accordingly.
Bighospital takes people from a large geographical area, they often lament traveling to us and ask why nobody at their local hospital can do the liver transplant they need or why they can’t have a stent in their superior mesenteric artery their either, as though these skills are commonplace. North Americans seem to be more in touch with the concept of healthcare being expensive, that it requires highly skilled individuals who have trained for decades, that you want the best surgeon, best hospital, best nurses and expert anaesthetists doing your operation. We in Britain seem to prefer the nearest person.