Moving services back into the community

It is essential that the development of community-based services must be undertaken with the support of and appropriate links to general hospital services as required. writes Dr. Dermot Power.

Over the years, the role of acute general hospitals evolved in an unplanned fashion resulting in their performing multiple functions previously delivered through local clinics, dispensaries and surgeries. This was particularly true in urban areas where patients were encouraged to attend hospital for blood tests, wound dressings, minor illnesses etc, previously the remit of the local GP or Health Centre. The causes of this dysfunctional development were multiple and their enumeration beyond the scope of this article. Suffice to say, health professionals, healthcare managers and indeed patients themselves all played a role.

Prof. Dermot Power
Dr. Dermot Power

More recently, the thrust of national and international healthcare policy has been to move services back into the community, closer to the patient. This is being driven by the closure of several smaller, local hospitals in favour of larger ‘centres of excellence or expertise’ and the realisation that non-core hospital activity can be more effectively and more cheaply delivered in smaller centres, running extended office hours. In welcoming this move, it also must be remembered that the delivery of services through the hospital had certain advantages – access to specialist advice, support and expertise on a 24 hour basis for example. It is essential therefore that the development of community-based services must be undertaken with the support of and appropriate links to general hospital services as required.

A prime example of this joined-up approach to devolving certain hospital roles to a community-based service exists in Smithfield in north central Dublin, where the Mater Misericordiae University Hospital and St. Mary’s Hospital are operating two novel clinical services. The Mater Rapid Injury Clinic is a consultant-supervised urgent care centre where patients with minor injuries and other non-emergency illnesses can present without appointment for review, diagnosis and treatment in a purpose built facility supported by high tech diagnostics as appropriate. The Clinic operates under the governance of the Mater’s Emergency department and is staffed by the same clinical staff. Already in only its first year of operation the clinic has reduced the requirement for Category 4 and 5 (minor injury/illness) attendances at the already overcrowded Mater Emergency Department.

A prime example of this joined-up approach to devolving certain hospital roles to a community-based service exists in Smithfield in north central Dublin, where the Mater Misericordiae University Hospital and St. Mary’s Hospital are operating two novel clinical services

In addition, the St. Mary’s Rapid Access Clinic, located in the same purpose-built facility, has been operating for nearly five years. This dedicated, older-persons clinic accepts GP and ED referrals of older patients (over age 70) from the Mater catchment area with urgent but stable medical conditions including weight loss, recurrent falls, TIAs (mini-strokes), acute pain syndromes etc. The clinic operates under the governance of the Medicine for the Elderly service at the Mater Misericordiae and St. Mary’s Hospitals and is staffed by consultants from those hospitals, supported by dedicated, fulltime specialist geriatric, medical and nursing staff. Since opening in 2006, the clinic has seen nearly 10,000 older patients and has become an invaluable part of medical services for older people in north Dublin. It is estimated to have prevented the admission of 1,500 to 2,000 patients over the years and has significantly reduced the length of stay of many others.

The joined up approach to the provision of services in the community is to be encouraged and welcomed. Partnerships between hospitals, community services and the private sector, where appropriate, can deliver both quality clinical services and cost-effective solutions for the over burdened health service. The potential for further expansion of existing services and the development of further initiatives should be explored.

Dr. Dermot Power is a consultant geriatrician at St. Mary’s Hospital Phoenix Park and the Charter Medical Group.