The Health Service Executive has made significant errors of judgment in attempting to reorganise cardiac care in the southeast. Beyond the evident increase in the regional mortality rate, the obvious political scheming around what should be a technical, evidence-based exercise brings into question trust in those charged with reforming our healthcare system.
Waterford received written commitments in 2013 from the minister for health at the time, James Reilly, his department's secretary general, Dr Ambrose McLaughlin, and Prof John Higgins for the necessary expansion of cardiology and retention of full southeastern catchment population for the service. These were set aside without debate in the 2016 Programme for Government negotiations. Instead an independent review was commissioned, from Dr Niall Herity, a Belfast-based cardiologist, into the need for a second cardiac catheterisation laboratory at University Hospital Waterford.
Flaws in this process have pushed the issue back into the realm of parliamentary politics and street protests. Questions remain about the selection criteria for the reviewer. Without reference to Dr Herity's personal probity or independence of mind, his employer, Belfast Health and Social Care Trust, is too close to the HSE to make him appear sufficiently independent, as cardiac-care services are increasingly provided on an all-island basis. There are also deep misgivings about his terms of reference, prescribed by the Department of Health.
Report’s two fundamental flaws
There are two fundamental flaws with the Herity report.
First, Dr Herity used an administrative district that neither the HSE nor the Central Statistics Office recognises. In reducing a region of more than 500,000 people to 290,000, his inter-alia exclusion of St Luke's General Hospital, in Kilkenny, and most of its catchment – associated with tertiary services at University Hospital Waterford since the creation of the health-board structures, in 1970 – would leave almost 180,000 people without access to 24/7 cardiac care within the "golden hour", the period after a medical emergency during which treatment is most likely to prevent death.
Second, Dr Herity makes much of the British Cardiovascular Intervention Society standard that a cath lab must carry out at least 100 procedures a year. Health Equality for the South East can find no clinical reason for this minimum. A number of studies assert zero link between number of procedures and outcomes. Two key differences between the British and Irish health systems make the 100-procedure lower limit unsuitable here: Britain has five times the population density of Ireland, and Britain has patient choice. Ireland's acute-hospital system largely has a monopoly provider and little competition or cost and quality controls.
There is also very significant evidence that distance to cardiac-care services deeply affects survival rates. A study in the UK in 2007 suggested that each additional 10km travelled increases absolute mortality rates by 1 per cent. A Danish study in 2010 found that mortality rates rise from 15.4 per cent when treatment starts in less than an hour, to 23.3 per cent when it starts between one and two hours after the emergency, to 28.1 per cent between two and three hours. One might conservatively envisage an additional 6.3 deaths a year in the absence of 24/7 regional services. Recent events graphically underline this.
Clung to as justification
We self-evidently live in a political landscape where expert reports are clung to as justification for actions or set aside if inconvenient. But why would the HSE and Department of Health try to avoid one-off capital spending of €2.4 million to save the additional 6.3 lives a year? Perhaps the 2012 decision extending Limerick's cath-lab service arose from its good fortune in having two senior Ministers. Perhaps the current Government wants to constrain the benefits afforded to Independent TDs such as John Halligan and enjoy the symbolic resistance to what it misleadingly identifies as parish-pump politics.
At some stage the Herity report might be mentioned in a coroner’s report. In the meantime, if the Minister, Department of Health and HSE continue with a post-truth approach to evidence and expertise in configuring acute services, do not be surprised if we get a healthcare system that continues to be expensive and inadequate and that fails to provide consistency in access, equity and outcomes.
Matt Shanahan is a member of Health Equality for the South East