Doctors must debate the issue of hospital closures, says an article in this week's BMJ.

This issue, which has suddenly become headline news, has never been the subject of a full national debate in the profession, writes general practitioner, Richard Lehman.

Over the past 15 years there has been much talk of centralising services, and many local campaigns over individual threatened local hospitals, but little systematic collection of evidence to inform decision making, he says. Instead the process has been driven largely by financial pressures, by the European Working Time Directive and its effects on junior doctors' staffing, and recommendations from the royal colleges.

Inevitably these pressures have driven hospitals to amalgamate services, at some cost to local accessibility. Equally inevitably such moves are deeply unpopular with patients, who may have to travel considerable distances for acute care that used to be on their doorstep.

The services most likely to be cut or merged throughout Britain are paediatrics, obstetrics, and emergency services the very ones that patients particularly want to be near.

This presents a dilemma for trusts seeking to maintain a lower level of service, for example by substituting a midwife led birth unit for a consultant led obstetric service. Such units only accept "low risk" births, but emergencies inevitably occur, requiring transit to the nearest consultant led facility. If considerations of cost are allowed to predominate that may be a very long distance, he warns.

This issue is one of several that need to be debated urgently before a further wave of such changes sweeps the country, he writes. It cannot be timed or located to suit electoral convenience.

We need clearer guidance on issues such as safe transit times for paediatric and obstetric emergencies, and we need more creative thinking on shared site working and flexible training rotas.

It is time
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Contact: Emma Dickinson
edickinson@bmj.com
44-020-738-36529
BMJ-British Medical Journal
21-Sep-2006