Sunday, 11 January 2009

Centralisation is not necessarily better

All that glistens is not gold and all that is centralised is not better, two facts that I'm sure many of you would agree with. The strange thing that I've noticed in recent years is how the government is very keen to centralise things which are better done locally, while they are keen to keep things local when they should be centralised, these poor decisions are sometimes just down to stupidity, on other occasions more cynical motives are lurking.

The fact that any doctor has to get a CRB check every time he/she changes NHS Trusts speaks volumes for the complete lack of joined up management of this problem, this should not be happening. I know people who are having more than one of these criminal record checks every six months, it's a complete pain in the arse for the doctors and a massive waste of NHS money. Occupational health checks are also all done locally and there is no way of easily transferring one's records between NHS trusts, this is something that would be perfectly suited to a centralised system, alas the strife continues for NHS staff who have to put up with the ridiculous bureaucracy every single time they move between hospitals.

Trauma is an example of something that should not be centralised en masse, by this I mean that it is important to keep local hospitals open with functioning AE departments and a surgical capability to deal with trauma, it is not wise to centralise all trauma care. Some aspects of trauma should be centralised, the evidence and common sense indicate that major poly trauma patients do much better in specialised trauma units, that's hardly a surprise. However there is not the evidence out there to say that centralising all trauma to specialist centres, while shutting local hospitals and opening more minor injury units manned by under trained 'practitioners', is a good idea.

Health care decisions are rarely simple, decisions regarding individuals and policy frequently involve the balancing of various complex risks, one solution is rarely perfect and risk free. For example centralising all trauma will result in certain benefits, especially for the sickest poly trauma patients, however the fact that a lot of minor trauma will no longer be seen by a doctor with some experience will certainly result in some harm. Weighed into this argument, one must also consider the fact that our Ambulance service and transport capabilities are simply not able to provide the capacity to support more and more patient transfer miles which the further centralisation would inevitably involve.

Our health care system is moving more and more towards the huge inequalities of the American system, the case of trauma care is a salient example. In the US if one is lucky enough to get to a big trauma centre then you'll get great care, however unfortunately for the patients nothing much exists of a size that is in between these huge centres and the tiny cottage hospitals staffed by a handful of staff who are simply not used to handling anything remotely challenging. Overall one gets the distinct feeling that on average the American patient may well not be that much better off, and remember their transport to the specialist centres is considerably better than ours.

The problem is that once one heads towards more centralisation, it becomes very very hard to stop, it's a bit like the point of no return. This is because once a local hospital starts to lose certain specialist surgical services such as trauma and orthopaedics, it's AE department becomes less backed up and less sustainable, the house eventually crumbles. I have personally seen examples of this locally. In this way a good local AE department is lost, and replaced by a group of useless 'minor injury units'.

I say 'useless' because they can at best do very little more than a GP, however they are frequently manned by staff who lack the expertise to know what is simple and what is not as a GP can. I have first hand experience of seeing old and frail patients grossly mismanaged by staff who have been thrown way out of their depth. How on earth can one assess head injuries safely without being able to do a neurological exam properly, it cannot be done, these units are just plain unsafe at times.

The problem is that you will only find what you look for and when our new centralised centres are assessed I'm sure they'll provide an excellent standard of care. However no one will be looking for the cases which have been mismanaged by the minor injuries units that would have been properly sorted in a hospital AE department, no one will be measuring the harm done by delays in transporting patients between units when many of these trips could have been avoided in the past by having more expertise kept that little bit more locally. This government wants to dumb things down and save money, so a few superficially shiny specialist centres will look good as propaganda despite the fact that less people will actually get to see a doctor following their trauma. All that is centralised is most definitely not gold.

1 comment:

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