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Opinion: 'The HSE should reverse centralisation policy to avoid disastrous waiting lists'

Dr Naveed Abbas argues that peripheral hospitals should return to doing more complex surgeries once this emergency has passed.

Dr Naveed Abbas Surgeon

AS SURGEONS, OUR worlds have been turned upside down.

All elective surgeries, endoscopy and local anaesthetic cases have been postponed indefinitely. Some essential cancer surgeries and emergencies are still being performed, but by and large things have come to a bit of a standstill.

Many of us have taken up redeployment roles as per the hastily made HSE Covid-19 policy. The media every now and then will publish the plight of someone in pain due a painful hip or knee needing surgery. But everyone knows that right now, the fight is in providing acutely sick patients with oxygen. To test, test, test. To isolate, while we try to find out how to kill this bug.

We have been in this storm for over two months now. Two months of lockdown and restricted travel. But it is a two-month backlog of patients as well. We had no idea what was going to happen, and no one can be blamed for it.

But if we do not plan for the future, we are fools.

With all this talk of re-opening the economy and shops and restaurants, we must not forget that a lot of people would rather like a pain-free night over a takeaway. And that is not surgery for hips and knees alone.

‘New normal’

Elective surgeries will likely be trickled back when safe.

This should not distract us from the fact that in this emergency, a dam was built. The water behind; a flood waiting to hit us.

Talking simple math, there is already a 16% increase in the number of patients waiting for elective surgeries. That’s for the two months already gone. How and when elective work will resume is a totally different thing altogether. But we could see our already stretched waiting lists, become overwhelming quickly.

Public patience has already worn thin as a result of people being cooped up for so long. Envision the reaction of worn-out patients whose procedures were already postponed if they are told that they might have to suffer pain for even longer after all this is over.

It’s not a pretty vision.

Planning ahead for these patients is essential.

Everyone is aware of how poorly the HSE has been funded in recent years, though the government will argue otherwise. Numerous measures were taken in the name of austerity. And despite coming out of recession, some of them were never rolled back.

One of the more controversial decisions from the HSE was the redirection and concentration of services to Dublin and other major cities.

Currently, anything that is remotely classified as being a ‘little challenging’ is sent across to Dublin, including emergency services. No cancer work of any kind is taken on in regional hospitals as that too is centralised. 

This effectively means hospitals in Dublin and other major cities are swamped with patients from peripheral hospitals.

Capable surgeons and staff were reduced to doing nothing more than mid-level work. There are some doctors in these facilities who are in menial posts for 20 years. There is absolutely no training in these hospitals and no regulation of training either. Withdrawal of hospital and community based services and staff, also resulted in many facilities working at levels well below capability.

What is more worrisome is that patients living in these catchment areas now have to go on even more competitive waiting lists than before.

Instead of spreading working capacity, the HSE chose to concentrate it.

There was a cache of data at the time suggesting surgical outcomes were better in high volume centres. That is true across the world. We are not a large country, so everything we do is amplified; but perhaps nowhere has there been such a mass closure of services and demotion of hospital standings as here in Ireland.

A more thoughtful and long-term approach would have been to upskill these hospitals with rotational work in large volume centres. Instead, there was mass efflux of doctors from these centres in an attempt to get trained in high volume centres or even abroad.

The vacuum left was filled with temporary staff from overseas without any real prospect at furthering their experience or careers. This bordered on almost cynical injustice.

Every cloud has a silver lining though.

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This pandemic has given the whole globe, not just Ireland; a rude awakening.

The life and health of people should be foremost in the minds of government as they prioritise their responsibilities. Everywhere, governments are clambering to fund their health systems. Most of them, if not all have been overwhelmed in one way or the other.

We took a punch to the teeth as well. But this has led to an important change. Having recognised, belatedly, the importance of regional services, this time the HSE chose to arm them. Ventilators were made available, staff were recruited, visa restrictions were modified. Money has been thrown in a desperate attempt to save lives.

We were not prepared, but we are better placed now then we were at the start.

Let’s not waste this opportunity to use the capability we already have on offer. Regional hospitals have had the fortune to be upgraded to manage this deadly disease. 

We should ensure these temporary and hasty upgrades are permanent, including intensive care units and local community services so we are future proofed.

We can also expand the scope of surgery in regional hospitals. We can allow these peripheral hospitals to deal with more complex surgeries and emergencies as per competence (although who decides competence is another issue for another day). 

There will be incredible pressure on the HSE in the coming months. By reversing its centralisation policy in a tiered and planned manner, it can avoid being overwhelmed when the time comes.

We all hope that this ends soon. We all hope the improvement will be permanent.

“Speak only when your words are more beautiful than silence” – Ali: Dr Naveed Abbas is a Registrar in Surgery.

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About the author:

Dr Naveed Abbas  / Surgeon

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