Well, let's have a look at the evidencethat is described in the longley report.
** Please note. August 2012. The above link appears no longer to be active. However I have found the links to the four documents comprising the report on line as follows: Summary, Access, Quality and Safety and Workforce
First, though, what's the bottom line? In my view it doesn't support most of the Health Board proposals. The only really strong evidence is that in favour of improving on-site management leadership and motivation. Read on.
It's actually four documents - Summary, Quality and Safety, Access and Workforce. In amongst these is the evidence that there is a problem, evidence that may or may not favour centralisation, and
Then download my document
"A Look at Longley"
evidence for measures other than centralisation, across all the various specialties.
Throughout, Professor Longley is punctilious in stressing that this is the evidence, that it may be unreliable (to quote: "It is in the nature of this evidence sometimes to be frustratingly vague, inconclusive, contradictory, or simply non-existent"), and it is up to the reader to decide what to do with it.
I think it is important to do just that. Why? Because that is what the Welsh Assembly will be doing, and we know that they will place their own political slant on it. So we must be able to judge whether they are right or wrong in their claims.
Actually there has already been one claim, that the report supports the centralisation of Emergency Surgery (but it's not clear from the article whether that claim is made by the journalist or the Government - read it yourself). So see below (or, much better, read the original document!) to help you decide whether you agree.
(Addendum mid-July 2012. I'm ignoring the recent controversy surrounding allegations of collusion to 'sex up' the report. I just want to see whether the evidence described regarding the most crucial issues does actually support what we believe are the Government and Health Boards' ideas.
It has to be pointed out, though, that some priorities allocated to some of the evidence are, to me, strange, and may give those just skimming the Summary section the wrong impression. For example the prominence of the RAMI charts in the Summary document, as opposed to other outcome data [RAMI being highly unreliable, see below] may mislead the reader. And the back seat given to what seems to be the strongest evidence of all [that on organisational culture, also see below] may make you miss its importance if you are not studying the document in depth. It's not mentioned as a topic in its own right until page 42 of the Quality and Safety document.)
Evidence that there is a problem ... or is there?
Wales healthcare performance is worse than in England as assessed by the Risk Adjusted Mortality Index ("RAMI"), surgery deaths are worse than in England and variable between health boards throughout Wales, and staffing is difficult so that services might collapse.
● Prof. L. is cautious about the RAMI data - he points out that there may be other reasons for differences, not necessarily due to quality of care. For example there may be less hospice care in one area, so patients dying of cancer may do so more often in hospital. ● Furthermore, a little research shows that RAMI DOES NOT ASSESS CLINICAL PERFORMANCE. Actually, it assesses CLINICAL CODING. That is something that is notoriously unreliable and variable from hospital to hospital. Click the links to the right to understand this further. It seems we should be more than cautious about RAMI. We should disregard it altogether. ● Obviously we need other, more reliable ways of looking at performance, and anyway RAMI is not available everywhere (perhaps we should be thankful for that). For example, age-adjusted mortality is shown later in the report (page 44 of the Quality and Safety document actually), and according to that, Wales is the second best in the UK. And that is not necessarily due to poorer performance than England, it may be due to worse disease. Anyway, Scotland is much worse. So we are not as bad as it seems from the RAMI. ● We understand that Welsh health is generally worse than in England, but staffing ratios may be the same or worse. So our staff may be more stretched - and that is known to affect mortality. I understand from Prof. L. that comparative staffing ratio data simply aren't available in official statistics so at the moment we can't be sure one way or the other.It's already happening!
See this excerpt from Senedd TV.
Why is all that important? Because the Welsh Assembly Government (or WAG for short) may over-emphasize our supposed poor performance (and that's highly uncertain because of the serious unreliability of the data available) to convince the public to accept centralisation even though that (in our rural area) may cause more problems than it solves. People need to know that things may not be as bad as painted by the WAG - and that needs to be balanced against our rural needs.
Re the other two problems - variable results, and staffing difficulties - see below.
General Surgery. Variation in mortality between Health Boards ... or is there?
For example both Abertawe Bro Morgannwg and Hywel Dda have about 1.3 times greater RAMI than Cardiff and Vale Health Board.
Well, considering what we now know about RAMI, does this have anything to do with performance, or is it just about hospital coding?
● Prof. L. is cautious about this for the same reasons as above. It may not be due to quality of care. For example there may be less hospice care in one area, so patients dying of cancer may do so more often in hospital. ● The question has to be asked: "why has one Health Board whose main component is two teaching hospitals - ABM in Swansea - have the same result as Hywel Dda which is considerably worse than another teaching board - Cardiff and Vale?" Same video excerpt as above.
Variability in RAMI highlighted.
Lesley Griffiths thinks its accurate.
After reading this, do you? ● Let's face it, for exactly the reasons given in the previous paragraph, this is seriously unreliable information and SHOULD NOT BE USED FOR CRUCIAL DECISIONS ON HOSPITAL CONFIGURATION.
So, yes we need to know exactly why there is this variability. It may not reflect on quality of care, but on efficiency of hospital coding (for example). By itself it is not adequate reason to centralise.
"Is poorer access inevitable to ensure good quality and safety?"
Professor Longley asks this question and then goes on to highlight the Scottish model. ".. in most of the country [Scotland] - including most of the remote areas - people with life-threatening emergencies can be reached within 45 minutes in all but the most extreme weather conditions, and provided with world class stabilisation and transfer to hospital as necessary."
. However, what he doesn't tell us is that Scotland has extremely poor results in trauma management. Their mortality from trauma is two and a half times that in England (in 2010 there 1300 deaths in their population of just over 5 million, compared with 5400 in 51 million in England). This information was highlighted in a report on Trauma Care in Scotland from the Royal College of Edinburgh published in May 2012 (too late for the Longley Report).
So clearly the issue is not so simple. It may be that the "45 minute" access time is to hospitals not suitable for care of the most severely injured patients, who are then more likely to die. But what about the majority of trauma cases, who do not require major trauma centre care? Are they ALL going to be deemed suitable for helicopter transfer, and has that been costed?. Clearly there are many issues to deal with if consideration is given to emulating the Scottish transfer system, and that is not addressed in the report.
General Trauma and Emergency Care. Difficulty providing 24 hour consultant cover.
Staffing pressures may make the service difficult to sustain. There is evidence that gathering human and financial resources into larger units should make it possible to meet clinical standards which could not be afforded or met in smaller units.
Let's have a look at the evidence referred to by Professor Longley ...
● It's a study called "Reconfiguring Hospital services - Lessons from South East London". Download the SE London report (pdf). ● This paper was written by Keith Palmer, a former investment banker. ● When you look at it, you find that the problem was in a roughly triangular area ten by ten by ten miles - about 50 square miles - containing seven acute hospitals. ● Hywel Dda is very different - it covers over 1800 square miles and has only four acute hospitals. ● Prof. L. himself points out that services that meet clinical standards and consistently follow recommended pathways make the most difference, whatever the size of the unit ... smaller hospitals often show better compliance. We understand that in West Wales both Neath Port Talbot Hospital and our local Milford Haven "supersurgery" are PFIs. This has to raise anxieties in view of a Daily Telegraph report on 1st November 2012 about PFI bailouts. (thanks to Heather Scammell for finding that report). ● Finally, and perhaps most damning, the South East London reconfiguration hasn't worked! Two of the hospitals involved - Queen Elizabeth in Woolwich and Queen Mary's in Sidcup - are part of South London Healthcare whose financial deficit has recently been reported as having spiralled out of control. This has been linked to their having been developed as PFIs. See this BBC news item and the follow-up to that. Also click on the image to the left to see how they are trying to close a neighbouring hospital to pay off the deficit. Also see the "catch-22" of funding reconfiguration.
So, yes, we have a problem. But trying to centralise may not be the answer - it may create more problems than it solves, by destroying the "Golden Hour" for many of our residents. It would be trying to apply an urban solution to a rural problem (and it hasn't worked anyway!). And attention to standards and pathways at grass roots level can do the trick - see "Organisational Culture" below.
Trauma. Evidence for centralisation.
Patients with severe multiple injuries have a greater chance of survival if transferred directly to a major trauma centre (that means Swansea or Cardiff).
Well, true but ...
● People may misunderstand this to mean that all injuries would be best treated in a local "centre", even if they are not that severe. ● A "Designated Trauma Centre" within Hywel Dda is something that has been suggested by our Health Board. ● But there's no evidence that will make any difference to outcomes, and people where trauma services have been closed will suffer, even die.See my "Trauma Centre" page.
So, yes we must have better decision-making on the ground - and the small proportion of patients with severe multiple injuries must be helicoptered direct to Swansea or Cardiff. But the majority who don't need this care still need access to care within the "Golden Hour" - at their local A&E. And that's a lot of people. Compare our "Profile of Health" with others. We have a high rate of traffic accidents in Pembrokeshire.
Emergency General surgery. No evidence for centralisation.
Major supporting services should be available on site together - this means Acute General Medicine, Coronary Care, Acute General Surgery and major operating theatres, Orthopaedic trauma (broken bones), Anaesthetics, Intensive Care, X-Rays, CT scan, Ultrasound, Laboratory services including Haematology, Clinical Chemistry, Blood Transfusion, Paediatrics if children are treated in the Emergency Department. A critical mass of patients can also be met using the managed clinical network across geographical areas.
Prof. L. is here quoting from national guidelines from various sources, and highlighting that a network approach can resolve geographical difficulties. He isn't producing evidence anywhere in this section that favours centralisation of this service. More detail on this in "A Look at Longley" And there are recent reports (published too late for the Longley Report) that suggest smaller more remote hospitals can even have an advantage over larger ones in managing Emergency General Surgery. So it is difficult to see how the claim mentioned above in Wales Online can be substantiated from this section.
In fact Prof. Longley summarizes his findings on this field (in his Summary document, page 3) as follows:
● "General Trauma and Emergency Care. There is evidence for some patients (such as patients with ruptured abdominal aortic aneurysms) of outcomes improving as unit size increases, but it is not statistically significant. Services that meet clinical standards and consistently follow recommended pathways make the most difference, whatever the size of the unit. There is increasing evidence that outcomes are better when there are more senior doctors on site 24/7 and this is becoming increasingly difficult to achieve in smaller units.".
Inter-dependencies between the specialties.More detail on this in "A Look at Longley"
Professor Longley highlights in several places in his Report that specialties depend on one another and has listed which they are - an example is given above.
This is something that needs stressing because neither the Health Board nor the WAG have formally acknowledged its importance (though private conversations with senior members of the Health Board have revealed that at least some of them realize it). We call the services that depend on eachother "Core Services" and have placed a lot about them on this website.
Surgical Core Services. No evidence for centralisation.
There is good evidence linking patient outcomes and individual surgeon volume, rather than hospital volume ... for much of general surgery, these volumes could be achieved by clinical networking rather than concentration on single hospital sites.
There is a great deal of work on volume-outcome relationships in various types of surgery, and it all points in the same direction which is that in Colorectal and Orthopaedic Surgery (two of our vital Core Services) See my "Centralisation" page. at Withybush Hospital, the hospital and surgeon volumes are easily enough to fulfil the thresholds for quality provided by the evidence.
Organisational culture. Lots of evidence that it affects outcome including mortality and even infection rates.
That is a direct quote from the report. Similar points are made again and again in many places throughout the report. Access the evidence here Having tracked down many of the sources, I can confirm that this evidence is very impressive. Factors such as:
● Staff Engagement ● Staff Advocacy (that means staff recommending their own institution to their friends and family) ● Well-structured Appraisal ● Well-structured Teams ● Regular review of performance ● Good development opportunities ● Support from immediate managers ● Opportunities to influence and contribute to improvements ● Good communication ● A feeling that you are valued by colleagues ● ... the list goes on.What happens when the organisational culture fails?
All have been shown in extensive surveys to affect outcomes, and that includes hospital mortality. Furthermore staffing ratios - number of doctors per hospital beds, and proportion of unqualified nurses of the total - and percentage bed occupancy, have all been shown to be linked to hospital mortality rate.
May 2013. Read about the recent NHS Wales Staff Survey. Hywel Dda Health Board need to act on it. My "take" on this is that it is one of the most important findings from the report. Grass roots organisational culture is crucially related to outcomes. improving it does not require centralisation or much expenditure, but good management and leadership. Ultimately it is the people on the ground who can make a difference. And what about recruitment? Well, people are attracted to well-run organisations.
So is that the main message we should take away from this report? It is up to you to decide!© Peter Milewski 2012