Saturday, August 27, 2011

Losing a battle to win the war

Marilyn Monroe put it rather crudely, "When rape is inevitable, lie back and enjoy it." but I can see the point she was making.

Surprisingly, public policy decisions are not made on the merits of the cases being examined. There may be geographical points to make, but usually politics will win out.

At the moment Government is keen to close some of the pediatric cardiology units in the UK, in order to rationalize provision. It is universally agreed that size is important; if you don't do enough procedures your results won't be as good as those with more experience. The unit at Oxford has already gone on this basis.

It is also universally agreed that of the current units in the UK, the best unit is at Southampton and that the worst units are at Leicester and Leeds. Despite this under ant future configuration the Department of Health seems set on closing the Southampton unit. Unfair? Life's not fair.

They could delete the Bristol unit instead, but after the scandal at Bristol some years ago, much political power has gone into re-establishing and improving it and it would be a loss of face to lose it now. To ask patients from the north to travel to the south for their treatment would also be politically embarrassing.

Back in 1987 I was given the task of opening the new hospital in Bournemouth. There would be a lot of extra capacity as there was already a district general hospital at Poole, seven miles away. The plan (at least the plan of the managers) was that Bournemouth should become a hospital for geriatric patients while Poole should house the acute services like Accident and Emergency, Obstetrics, Pediatrics, Ear Nose and Throat, Orthopedics, Ophthalmology and Cancer Services.

That year was the hardest of my career. In a Committee loaded 5-2 against me I developed high blood pressure. I was twice offered a bribe to drop my opposition, once covertly and once blatantly. It would have raised my salary by 50%. I spoke to my old friend, John Trapnell, who told me to ignore the temptation; these things would come to me in time anyway. In the end I recognized that the political pressure would inevitably triumph. If the carrot didn't work, then the stick would be applied. It was certain that they would get their headline demands, but that did not mean they should have total victory.

I had to concede that there could only be one site for acute trauma involving broken bones and therefore acute orthopedics would have to be at Poole, but the great increase in work was in hip and knee replacements and the orthopods would actually prefer to keep that separate from the fractured hips and road traffic accidents for reasons of infection control. Given the age of our population we became the second largest joint replacement facility in Europe. When we examined it, we found that the majority of patients coming through the emergency department were medical patients. If Poole were going to concentrate on specialized departments the majority of medical beds would have to be in Bournemouth. That meant that Cardiology, Diabetology, Gastroenterology and Respiratory medicine would all be led from Bournemouth and similarly for surgery with large departments of colorectal, breast, and urological surgery. Because of the local personnel already employed, pancreatic and upper GI surgery were also secured. Because of the age range of our population it made no sense to have an artificial division at age 60 or even 80, though our previous geriatric hospital could now be converted to a rehabilitation service for the young chronic sick, the old and the post joint replacement patients. It could also house the palliative care services.

Talking of cancer service, there are some branches that make very use of radiotherapy and these didn't need to be centered at Poole. So we managed to get hematological cancer, urological cancers and gastroenterological cancers centered at Bournemouth. We had to concede that maternity and pediatrics went to Poole but we made a virtue of a midwife-led obstetrics service for uncomplicated deliveries should be at Bournemouth and we kept gynecological cancer. In the end by giving them their headline demands we ended up with a bigger, more complete and generally based hospital than Poole and one with a much better reputation.

So Southampton might have to give in over its pediatric cardiology, but by goodness they ought to play hard to get and take the Department of Health for every penny that's going.

I understand that my old department is under threat again from Poole. There is a proposal that in-patient hematology for the whole county should centralize at Poole. With David Oscier and myself retired this may well mean that the mice are going to pull political strings and again this might be an occasion when conceding headline demands may be the better option. Bournemouth could win though by getting control of all low-grade hematological diseases - CLL, SLVL, MDS and myeloproliferative syndromes and myeloma, to ensure that they are all done to a high academic standard rather than in the cheap as chips way they may be done elsewhere in the county.

1 comment:

Brian Koffman said...

Politics is the art of the possible. So is cancer therapy.

Both share the rare chance to break out what is possible now and by doing it, create a hitherto unimagined and bettered new reality.

But mostly it is the art of possible.

I learn something new about you all the time. I am grateful for the lessons you share.