BMJ 2014;349:g4324 doi: 10.1136/bmj.g4324 (Published 1 July 2014)
Page 1 of 1
Letters
LETTERS SERVICE REDESIGN
Rigorous science is needed to justify the centralisation of services John S Yudkin emeritus professor of medicine, University College London, London N7 0AG, UK
Simon Stevens’s address to the NHS Confederation stated the need for rigorous testing of new approaches to service delivery.1 In the same speech he also held up London’s reform of stroke services to justify the centralisation of services. His evidence was based on a before and after study showing a “12% reduction in death rates.” The study compared outcomes for patients treated for stroke before and after the introduction of eight hyperacute stroke units in London.2 The adjusted 90 day survival rates increased from 87.2% to 88.7%, an absolute increase of 1.5%. Extrapolated to the total number of 6438 stroke patients admitted across London, this corresponds to 96 people per year. Moreover, the total costs were predicted to fall, largely as a result of reduced length of stay.
There is, though, the risk of using this study to justify reconfiguration of services across London, as the royal colleges and the chair of the Academy of Medical Royal Colleges are doing. 3 They argue for concentrating emergency care in a small number of specialist centres, while downgrading other departments to urgent care centres. But what is a proper benefit-risk analysis? On one side are these estimated 96 stroke patients, and an estimated 120 of 7000 patients with acute myocardial infarction who would benefit from immediate percutaneous coronary intervention.4 But these two conditions make up only 0.5% of the 2.6 million emergency department
attendances across London,5 and there has been no assessment of the impact on the 99.5%. Indeed, patients after a stroke might want to balance benefits of about 8 months longer quality life expectancy against greater distance from their family during admission.
The royal colleges, and Simon Stevens, should be using rigorous science rather than simply claiming that change is justified on the basis of studies of single conditions with significant P values. Competing interests: None declared. Full response at: www.bmj.com/content/348/bmj.g3744/rr/701172. 1 2 3 4 5
Moberly T. Service redesign should be tested as rigorously as new treatments, NHS chief says. BMJ 2014;348:g3744. (5 June.) Hunter RM, Davie C, Rudd A, Thompson A, Walker H, Thomson N, et al. Impact on clinical and cost outcomes of a centralized approach to acute stroke care in London: a comparative effectiveness before and after model. PLoS ONE 2013;8:e70420. Douglas N, Gilmore I, Field S, Mascie-Taylor H, Arulkumaran S, Stephenson T, et al. NHS change must be driven by clinical evidence. Guardian 28 April 2010. www. theguardian.com/society/2010/apr/29/nhs-change-clinical-evidence. Cantor WJ, Fitchett D, Borgundvaag B, Ducas J, Heffernan M, Cohen EA, et al. Routine early angioplasty after fibrinolysis for acute myocardial infarction. N Engl J Med 2009;360:2705-18. Health and Social Care Information Centre. Attendance rates at major A&E departments highest in London. 28 January 2014. www.hscic.gov.uk/article/3875/Attendance-rates-atmajor-AE-departments-highest-in-London.
Cite this as: BMJ 2014;349:g4324 © BMJ Publishing Group Ltd 2014
[email protected] For personal use only: See rights and reprints http://www.bmj.com/permissions
Subscribe: http://www.bmj.com/subscribe
Copyright of BMJ: British Medical Journal is the property of BMJ Publishing Group and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
Page 1 of 1
Letters
LETTERS SERVICE REDESIGN
Rigorous science is needed to justify the centralisation of services John S Yudkin emeritus professor of medicine, University College London, London N7 0AG, UK
Simon Stevens’s address to the NHS Confederation stated the need for rigorous testing of new approaches to service delivery.1 In the same speech he also held up London’s reform of stroke services to justify the centralisation of services. His evidence was based on a before and after study showing a “12% reduction in death rates.” The study compared outcomes for patients treated for stroke before and after the introduction of eight hyperacute stroke units in London.2 The adjusted 90 day survival rates increased from 87.2% to 88.7%, an absolute increase of 1.5%. Extrapolated to the total number of 6438 stroke patients admitted across London, this corresponds to 96 people per year. Moreover, the total costs were predicted to fall, largely as a result of reduced length of stay.
There is, though, the risk of using this study to justify reconfiguration of services across London, as the royal colleges and the chair of the Academy of Medical Royal Colleges are doing. 3 They argue for concentrating emergency care in a small number of specialist centres, while downgrading other departments to urgent care centres. But what is a proper benefit-risk analysis? On one side are these estimated 96 stroke patients, and an estimated 120 of 7000 patients with acute myocardial infarction who would benefit from immediate percutaneous coronary intervention.4 But these two conditions make up only 0.5% of the 2.6 million emergency department
attendances across London,5 and there has been no assessment of the impact on the 99.5%. Indeed, patients after a stroke might want to balance benefits of about 8 months longer quality life expectancy against greater distance from their family during admission.
The royal colleges, and Simon Stevens, should be using rigorous science rather than simply claiming that change is justified on the basis of studies of single conditions with significant P values. Competing interests: None declared. Full response at: www.bmj.com/content/348/bmj.g3744/rr/701172. 1 2 3 4 5
Moberly T. Service redesign should be tested as rigorously as new treatments, NHS chief says. BMJ 2014;348:g3744. (5 June.) Hunter RM, Davie C, Rudd A, Thompson A, Walker H, Thomson N, et al. Impact on clinical and cost outcomes of a centralized approach to acute stroke care in London: a comparative effectiveness before and after model. PLoS ONE 2013;8:e70420. Douglas N, Gilmore I, Field S, Mascie-Taylor H, Arulkumaran S, Stephenson T, et al. NHS change must be driven by clinical evidence. Guardian 28 April 2010. www. theguardian.com/society/2010/apr/29/nhs-change-clinical-evidence. Cantor WJ, Fitchett D, Borgundvaag B, Ducas J, Heffernan M, Cohen EA, et al. Routine early angioplasty after fibrinolysis for acute myocardial infarction. N Engl J Med 2009;360:2705-18. Health and Social Care Information Centre. Attendance rates at major A&E departments highest in London. 28 January 2014. www.hscic.gov.uk/article/3875/Attendance-rates-atmajor-AE-departments-highest-in-London.
Cite this as: BMJ 2014;349:g4324 © BMJ Publishing Group Ltd 2014
[email protected] For personal use only: See rights and reprints http://www.bmj.com/permissions
Subscribe: http://www.bmj.com/subscribe
Copyright of BMJ: British Medical Journal is the property of BMJ Publishing Group and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
