Friday, July 8, 2011

Thoughts on Roscommon Hospital

Much has been made in recent days about James Reilly's plans to close down the A&E service in Roscommon Hospital. He claims that the unit is unsafe and that patients are at more risk by being treated there than by traveling to Galway, Longford or Castlebar. This resulted in FG TD Denis Naughten losing the whip after voting against the government on the issue.

In my mind there are two major issues at play here. Firstly there is the conflict between the rationalization of services to provide economies of scale and the requirement for geographical spread of services to ensure no patient is too far from acute services. Secondly there is the political issue of promising rainbows and unicorns before an election and then not being able to deliver.

There are studies that show quite clearly that the further away from an A&E a patient becomes ill, the more likely the outcome will be bad. Therefore it makes sense to try and dot hospitals around the country in strategic locations so that people are not too far from help. In the current situation, closing Roscommon may lead to people driving to Galway for assistance. Having driven that road only a few months ago in some pretty heavy rain I can assure you that it is not something that you would like to do with a sick child or heart attack victim in the back seat. Double that length of time if you have to call out an ambulance and you can suddenly see why the people of Roscommon are up in arms about keeping the hospital open.

However, the flip side is that an A&E that doesn't see many patients will not have the experience and practice at dealing with serious problems. The figures speak for themselves in the Roscommon case where mortality rate was over three times higher in Roscommon than in Galway. In an ideal world, every city and town would have top class health (and education and transport and ...) infrastructure and services. But it doesn't work that way. There is a finite pot of resources and it can only make sense to invest heavily in areas that will provide the maximum return - ie where the population catchment area is sufficiently large.

People have to live with the choices they make. If you choose to live in a lightly populated area you can't expect the same level of services as those who live nearer each other. Density is king, and when you compare Dublin at nearly 1400 people per km^2 and Roscommon at 25 per km^2 you may begin to see where the problem comes from. I've been called on my urban bias before and accused of not understanding the rural way of life. And yes, maybe it's true. But you make choices in life and one of those choices is where you live. Living in Dublin 5, I can't have an expectation of waking to mooing cows and fields of corn outside my window. Likewise, if I lived in a rural area I couldn't have an expectation of rapid public transport, high-tech hospitals and third level education on my doorstep.

Politically it is also true - people have to live with the TDs they elect. The TD also has to live with the electorate and should stand by positions held in the run up to the election. That is why I have some grudging respect for Denis Naughten. It will be interesting to see ho long he remains outside the whip and if he will vote against the government on any other issues. It is not good enough for TDs to say the people have spoken and elected them to the Dáil if the premise on which they were elected is false. In any other sphere that would be a breach of contract and render the whole relationship void. Pity our politicians can't be held to account in that way.


  1. I wonder is there a place for a rotation system. If a quiet ER makes for ill-prepared staff, then move all the staff in Galway but have them do N days a week in Roscommon, enough to cover time-critical cases. Base ambulances there but have the ambulance crews decide on which hospital they deliver to based on severity and in consultation over the radio with docs in the hospital.

    Let it be known that anyone arriving at Roscommon with all limbs attached will end up waiting hours forever to be seen.

    Somewhat more expensive than closing it entirely but still maybe cheaper overall than killing 3x as many people.

    Any idea what the absolute number of deaths was?

  2. All I've been able to find in media reports is the mortality rate for arrivals. Haven't seen absolute numbers but I'm guessing Galway has more than three times the number of patients and so and overall higher number of deaths.

  3. I think thats a pretty fair assessment. One slight issue in the paragraph at start, people in Roscommn can't travel to Longford as there is no hospital there, Longfordians already have to travel to Mullingar.

    The point on density and population is also a fair one. But you are right about the dangers of travelling long distances and theproblem with ambulance call-out.

    In my view we need to look at not closing A&E departments but accepting different levels and categories. If one has a sick child or a heart attack etc, it is proven that even paramedic assistance can greatly improve chances of survival. The problem is with callout out times and finding addresses in rural areas being so long this benefit is questionable. However if you can get the patient in a car immediately and drive them to a nearby service then youhave a much better chance.

    So is it so difficult to develop a feeder service. For instance, due to population etc Roscommon cannot have the same A&E as Galway. However, why not have an A&E feederservice open 24 hrs in Roscommon. Emergency patients can be driven there and assessed, given whatever preliminary treatment possible to stabilise then driven by ambulance to Galway.

    This would cut out individuals driving like panicked maniacs themselves to get to a hospital far away. It would mean you dont need highly secialised staff in Roscommon, and it would mean that you save vital time by the patient coming to the medical centre and being looked at.

    People justifiably fear the idea of long journeys undertaken in cars with no medical assistance. this way ambulance time, doctors time and journey times are all cut. Without saying to people this facility is closed, if your child gets sick tonight, get in your car and head to Galway.

    Just a thought.