Travelling further may be good for your health

It looks increasingly likely that FutureFit will finally bring some proposals to a public consultation in October.

I anticipate that there will be significant interest in the effect of travel times to hospital on patients with time-critical illness and injuries. There have been many references to the golden hour in social media.

The literature on the effects of distance to hospital and mortality is mixed and it is difficult to compare results across different countries and health systems due to differences in practice. The 2007 paper by Nichol et al is often quoted . You can read the whole paper here if you are interested. Nichol looked at data from more than  10000 seriously people who were taken to hospital by ambulance in England between 1997 and 2001. Their data showed that increasing travel distances to hospital was associated with an increased risk of death, perhaps no surprise there. Importantly the authors say in the paper “Changes in performance in recent years or new policies that have changed to both increase distances and either improve care at the more distant facilities or improve the effectiveness of prehospital care could attenuate the potential effect of increased journey distance upon mortality.”

So what are the implications of this for reconfiguring our local health system in Shropshire? I think we should think of travel time as one component of the time between the onset of an illness and starting effective treatment. Other important elements to consider are dispatch time (ie time from calling 999 to an ambulance arriving), the time between arrival at hospital and seeing a senior clinician and the quality of the care received on arrival at hospital.

The reorganisation of stroke services in London and Manchester showed that centralisation of services resulted in a reduced risk of death despite some patients having to travel further. In Shropshire centralising hyperacute stroke services at the Princess Royal Hospital has also led to a better service and improved outcomes.

There is a similar story for the centralisation of the treatment of patients with heart attacks which has lead to a 22% reduction in mortality. In Shropshire patients having a heart attack will usually be taken by ambulance to heart attack centre in either Stoke of Wolverhampton.

In 2012, a network of major  trauma centres and trauma units was set up in England.  Evaluation of the results of the first few years of the trauma network has shown a dramatic increase in the rates of survival for the most seriously injured patients.

So there are precedents nationally  for travelling further to improved services leading to improved outcomes. Locally in 2012 we centralised services for emergency general surgery at the a Royal Shrewsbury Hospital, within a year this had reduced the risk of death by 18%. In addition this made the service popular with consultants and trainee surgeons meaning that we can recruit when we need to. Now we just need to do the same for our other services ………..



Cancellation of Planned Operations in the NHS

Mark Cheetham consider=ultranationalist colorectal and general surgeon Shrewsbury Telford Shropshire Midlands
Cancelled operations

The problem

Clare Marx (President of the Royal College of Surgeons) and Chris Hopson (CEO of NHS Providers) has rightly pointed out the problem of planned operation being cancelled due to lack of beds (see Sunday Times Letters 12/2/17). From the patients’ perspective, to have surgery cancelled at short notice is extremely frustrating and at worst leads to ongoing pain and deterioration, ultimately with a poorer outcome. When planned operations are cancelled, our surgical trainees sit idle when they should be honing their skills to become the next generation of consultant surgeons. Financially, NHS hospitals are hit with a double whammy; they incur the costs of laying on elective theatre sessions without the income to support them and then later in the year many will lay on additional sessions at extra cost to clear the waiting list.

What can we do then?

There is another way. Of course, we need to fund health and social care adequately. We also need to reconsider how we deliver planned surgical care within the NHS. Over the last three years, we have developed a programme to reshape the delivery of healthcare in Shropshire. This programme (called Future Fit) will see one of our two hospitals specialise in providing planned care and the other becoming a specialist Emergency Centre. The vast majority of planned surgical operations can be safely performed in a hospital which does not take emergency admissions. Separating planned surgery from emergency admissions has clear advantages including a greatly reduced risk of cancellation of surgery, better patient experience and better outcomes. A small number of specialist hospitals in the United Kingdom have, for many years, provided a high quality of surgical care with a low risk of cancellation of operations specifically because they are insulated from the pressures of emergency admissions; it is time that such services are available to the whole population.