Perspectives on the underlying drivers of urgent and emergency care reconfiguration in Ireland

Abstract

SummaryBackgroundThere is an increasing tendency to reconfigure acute hospital care towards a more centralised and specialised model, particularly for complex care conditions. Although centralisation is presented as “evidence‐based”, the relevant studies are often challenged by groups which hold perspectives and values beyond those implicit in the literature. This study investigated stakeholder perspectives on the rationale for the reconfiguration of urgent and emergency care in Ireland. Specifically, it considered the hypothesis that individuals from different stakeholder groups would endorse different positions in relation to the motivation for, and goals of, reconfiguration.MethodsDocumentary analysis of policy documents was used to identify official justifications for change. Semi‐structured interviews with 175 purposively sampled stakeholders explored their perspectives on the rationale for reconfiguration.ResultsWhile there was some within‐group variation, internal and external stakeholders generally vocalised different lines of argument. Clinicians and management in the internal stakeholder group proposed arguments in favour of reconfiguration based on efficiency and safety claims. External stakeholders, including hospital campaigners and local political representatives expressed arguments that focused on access to care. A “voter” argument, focused on the role of local politicians in determining the outcome of reconfiguration planning, was mentioned by both internal and external stakeholders, often in a critical fashion.ConclusionOur study adds to an emerging literature on the interaction between a technocratic approach to health system planning advocated by clinicians and health service managers, and the experiential “non‐expert” claims of the public and patients.

The drivers and impact of emergency care reconfiguration in Ireland: Results from a large mixed-methods research programme

“…Emergency care reconfiguration was a pillar of a 2006 system-wide policy to 'transform' healthcare delivery in the then newly established HSE. 9 Prior to reconfiguration, 35 hospitals operated full 24/7 EDs for all age groups, and a further three children's hospitals had 24/7 EDs. A part of the reconfiguration programme involved closing or 'redesignating' EDs at smaller hospitals to urgent care centres and local/minor injury units.…”

“…Internal stakeholders stated that this concern was based on 'international evidence' about the relationship between volume and outcome. 9 However, this evidence only covers a small number of conditions, such as major trauma and stroke, most of whom already bypass or are transferred from smaller hospitals. The evidence, therefore, maps poorly to the policy arena because it does not speak to the majority of patients that are impacted when EDs are closed or downgraded.…”

“…External Emergency care reconfiguration in Ireland stakeholders were sceptical about the likelihood of efficiency gains, listing a range of unanticipated costs and administrative wastage that they had observed post reconfiguration. 9 It is noteworthy that most ED reconfiguration in Ireland has occurred in rural areas, where significant investment in pre-hospital services is required to alleviate the harms associated with reduced access. Reconfiguring services in urban areas, particularly Dublin where nine EDs continue to operate in close proximity to each other, would appear to offer greater scope for efficiency gains, without necessarily affecting the timeliness of access.…”

“…External stakeholders highlighted the problems with imposing a hub-and-spoke model on different geographies, and the fact that smaller hospitals were capable of providing high-quality care for most patients requiring time-sensitive care, particularly older patients with conditions that are best managed closer to their homes. 9 The role of geography in designing Ireland's regional emergency care systems was not clear. Factors such as rurality played a role in some regions, but these factors were applied inconsistently across the country.…”

A sociology of public responses to hospital change and closure

“…, Parkinson ), assuming that there exists some wider known collectivity to be represented. While a few articles identify conflicting groupings within the community (Abelson , Kirouac‐Fram , Pescosolido, Wright, & Kikuzawa, ), heterogeneity is often de‐emphasised as authors move towards conclusions which describe “the” public reaction.…”