Issue 3.
Trust Reconfiguration - Good or Bad for Clinical Effectiveness?
Trust reconfiguration is now well on its way in Wales. In most areas including Bro Taf
the consensus is moving towards fewer, big trusts. The impact of this on clinical
effectiveness will be vital to the well being of patients in future. Indeed the reasons
given by the government for the reconfiguration was that it would be good for patient care
and save money on bureaucracy.
There is little evidence for the risk or benefit of different
sizes of administrative unit for efficiency and certainly none in relation to
effectiveness of medical care. There is some evidence for the benefit of more specialist
centres over less specialist. Indeed these studies form the basis of the Calman/Hine
Report on the treatment of cancer. The best known of these relates to breast cancer. A
number of studies have shown, for instance that specialist units are better than
non-specialist units in the treatment of breast cancer. The important word here appears to
be specialist rather than big. Units with specialist teams do tend to be in the larger
hospitals, but not always.
Figure 1 shows data from a Scottish study comparing specialist and
non-specialist units in relation to their success at treating women with breast cancer. It
should be said that this was not a randomised controlled trial so that the possibility of
bias is not ruled out. However other studies have suggested, for instance, that surgeons
who treat more than 30 patients a year do better than those who treat less.
There is also evidence that patients with hip fractures do better in
specialist centres.
On the other hand there has been evidence to suggest that hospitals
with more than 600 beds do less well than smaller hospitals. There is also a concern among
community trusts about to be swallowed by their hospital neighbours that winter
emergencies and pressures on waiting lists will swallow all of their development money for
years to come.
Nasal Go-Faster Stripes
There were several small studies on the effect of external nasal dilators presented at
the American College of Sports Medicine Annual Congress in Cincinnati last year. None
showed any benefit to athletic performance.
Two of the studies looked at continuous aerobic activity, the other two studies looked
at the effect on recovery time from a short burst of anaerobic activity, which equates to
repetitive sprint sports (hockey, rugby, football). Two of the trials used placebo strips
of tape which were as effective as the nasal dilators, the other two trials simply
compared performance with and without the nasal dilators.
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Inappropriate psychiatric outpatient referrals update
The psychiatrists at East Glamorgan Hospital (Rhondda Trust) were
concerned that the excellent audit that they undertook and reported in last issues Quince
might have made them vulnerable to criticism, especially the non-attendance rate.
We believe that anyone willing to have their practice observed is due
nothing but praise. The problems of non-attendance at psychiatric outpatients are not
confined to East Glamorgan.
Figure 2 shows the data from QS1 data 1996-97 for mental illness adult
outpatients. The figure shows new and total non attenders. The Rhondda Trust is obviously
not the only one with problems in this area.
Several of the trusts have audited their non-attendance rates. It would
seem sensible for them to get together and discuss ways of improving this. Patients who
miss their appointments may well be getting into trouble in the community.
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Welsh Office Small Grants
The half-day conference at Hensol on the 26th January was a
great success. The audience was treated to a wide range of fascinating topics from a
diverse range of disciplines. They all had in common a commitment to improving their own
practice while maintaining busy professional practices.
The day was such a success that it is hoped to collect the
contributions together in a monograph, together with outlines of those projects, which
received grants, but were unable to take part in the conference.
It is hoped that, as a result of the success of the experiment, further
small grants will be made available in future to people wishing to improve their own
clinical effectiveness.
'Doctors tend to gather where the climate is healthy, where the water is
clean and where people are employed and can pay for their services'. Ivan Illich
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