The relevance of geography to cardiac care in the South-East

​Darren O’Rourke
​(Doctoral student at the Department of Geography, Maynooth University)

People in Waterford and the South-East will be very familiar with the community demand for 24/7 cardiac care for the local population and with the popular campaign that has grown from this call. There have been public demonstrations, lobbying of local and national politicians, including Ministers, reports commissioned and reports contested. At the heart of this issue is the way we (spatially) organise our public health services.
 
My PhD research at the Department of Geography at Maynooth University is directly relevant to this. My area of research interest is the politics of major health service change and particularly the way the public are involved in change processes. My research recognises the current processes of change as deeply problematic and aims to find out if there is a better alternative.
 
In many respects, the challenge faced by the community in Waterford and the South-East is similar to the challenge faced by communities in Dundalk, Mallow, Ennis, Roscommon, Bantry, Monaghan and Loughlinstown, previously, when it was proposed to close their local emergency departments. The similarity in terms of the nature of the service (urgent and emergency) and the importance of geography and proximity is clear. The community in Portlaoise are currently engaged in a similar with respect to the Emergency Department at the Midlands Regional Hospital Portlaoise.  
 
The Case is Made
On the one hand, leading doctors, health service managers and Government politicians point to the necessity to centralise services. The case is made in the interest of safety (doctors need to see a certain volume of patients of a particular type to maintain their skills), in the interest of cost and efficiency, and/or in the interest of staffing (“we cannot recruit sufficient numbers of staff to regional centres”). Reference is made to “international best practice” and “centres of excellence” and evidence from home and abroad is presented to support the case.
 
On the other hand, communities, often supported by local clinicians and politicians (usually from Opposition parties) contest each of the arguments put forward by those who want change. Communities argue that patients will, in fact, be put at risk by being further away from essential services. They will argue that the local hospital services are not only essential in terms of providing timely access but that they have an intrinsic, economic and symbolic value to the region/local community.
 
In Ireland we have numerous cases of communities engaging in very high level debates regarding the provision of services. I immediately think of the case of Dr. Patrick McHugh in Roscommon Hospital who challenged the Minister for Health’s assertion that cardiac patients attending at Roscommon had mortality rates four times worse than those attending Galway University Hospital. I think too, of the case put forward on an RTÉ Primetime programme by Dr. Ray Griffin of Waterford Institute of Technology which directly challenged the HSEs assertion that cardiac patient transfers from University Hospital Waterford to Cork and Dublin hospitals could be achieved in less than 90 minutes.
 
What’s important, for my research, is the appreciation and recognition of the differences of perspective and opinion between those seeking change and those resisting change. My research aims to look at the process of health service change. As a geographer I am interested in the importance of “place” and “locality”. After reviewing the Irish and international literature, I believe it is important to look at health service change, not as a technical exercise of drawing lines on a map and saying “we’ll move this service here and that service there”. Instead I agree with a number of famous researchers who see health service change as an inherently political process (particularly if we understand politics in the broad sense as “the way we get on in the world”).
 
There has been considerable research conducted internationally, particularly in the NHS in Britain, but also in New Zealand, Australia and Canada, that show us that trends towards centralisation of hospital services are not unique to Ireland. Nor is community resistance. High profile examples of community resistance to proposed health service changes are documented in places as far apart and diverse as Kiddeminister and London in Britain and the rural Maori community of Hokianga on the north island of New Zealand.
 
My research will be conducted over 3 phases. Over the course of the 3 phases I will work not only with colleagues at Maynooth University and University Collage Cork, but with international colleagues at Oxford University and University College London in Britain and the University of Auckland in New Zealand. Researchers and policy-makers are very interested in these issues because they recognise deep (and costly!) difficulties with the current processes of major health service change and, like me, wonder if there is a better way forward.
Phase 1
In the Phase 1 of my research, I will compare historical policy documents from Ireland to examine how they approached the challenge of planning health services across the country. These documents include the:

1. Hospital Commission First General Report (1933-34)
2. Report of the Consultative Council on the General Hospital Services (1968)
3. Report of the National Task Force on Medical Staffing (2003)
4. Houses of the Oireachtas Committee on the Future of Healthcare Sláintecare Report (2017)

 
When reading the policies and the debates that followed them, I will be guided by a specific framework for policy analysis developed by Australian academic Carole Bacchi, and ask the following questions:

1. How has the “problem” of planning our health services in a fair and equitable way been represented in these policies?
2. What assumptions underlie this representation of the “problem”?
3. How has this representation of the “problem” come about?
4. What is left unproblematic in this problem representation? Where are the silences?
5. What effects are produced by this representation of the “problem”?
6. How and where has this representation of the “problem” been produced, disseminated, and defended? How has it been and/or can it be questioned, disrupted, and replaced?

 
This particular approach to analysing policy allows the researcher to examine and challenge the underlying assumptions of particular policy proposals. It also allows us to see if there are alternative policy options that have been ignored or dismissed and to consider why this might be the case.
 
Phase 2
It has been suggested that involving the public – not just health service managers and clinicians and politicians but ordinary members of local communities – in decisions about how health services are planned leads to better-informed decisions and better outcomes (for patients, the public, politicians, clinicians and health service managers alike).  This idea is not new and stems from the idea that we each have something useful “to bring to the table” when big decisions are being made. It is argued that involving the public can:

1. give the public a better understanding of the challenges faced by health service managers and clinicians (to deliver safe and effective care within strict budgetary constraints for example)
2. give health service managers and clinicians a better understanding of the priorities and preferences of service users and local communities

 
In Phase 2 of my research, I will conduct an extensive review of the international literature to examine:

1. How patients and the public have been engaged in decisions about major health service change in the past (in Ireland and internationally)?
2. How this patient and public involvement has affected decisions about major health service change?
3. Which methods of patient and public involvement have had the greatest impact on decisions and which are likely to be sustainable/repeatable?
4. How have differing opinions about major health service change between patients, the public, politicians, clinicians and health service managers been negotiated and resolved?

Similar to phase 1, the findings of phase 2 will be of immediate interest and relevance to people in Waterford and the South-East.
 
Phase 3
In the final phase of my research, Phase 3, I intend to bring together all of the knowledge and ideas generated in phases 1 and 2 to ask the full range of people interested in our health services how they believe the current process of major health service change could be improved.
 
I will speak to a wide range of people including: members of the public, members of hospital campaign groups (such as the Still Waiting Campaign in the South-East), hospital doctors and GPs, local politicians and national politicians, health service managers and health service workers.
 
In this phase of research, I will employ a particular approach which allows participants to look at different models of public involvement and select their own particular preferences. In this way we can begin to identify the principles and characteristics of “good involvement” in major health service change.
 
Concluding Comments
In addition to my position as a Doctoral Student at Maynooth University, I am also a local County Councillor for the Sinn Féin party in County Meath and a member of the Dublin North East Regional Health Forum. There is significant overlap in my political and research interests. Like all quality research though, mine must be conducted to the highest ethical standards as set down and overseen by the Maynooth University Ethics Committee. All of my research will be publicly available (interim results in 2019 and 2020, final results expected 2021).
 
It is hoped that this research project will contribute to a deeper understanding of the politics of major health service change and point towards a better (more inclusive?) way forward.
 
Such an outcome would be of interest and use to local communities, health service decision-makers and policy-makers of all political persuasions