Donaldson: how the media and politicians act against the public interest

Close analysis of Sir Liam Donaldson’s report points to a potentially catastrophic failure of authorities to effectively explain the rationale behind the reforms which are so essential to our future. As a result we may never get the changes we need to have a fit for purpose health system.

This raises profound questions not just for the authorities themselves but also for politicians and the media.

All the headlines have been dominated by what appears to be a bizarre recommendation that an international panel should be brought in to reconfigure the health system, and that politicians and the public should sign up to implementing its conclusions in advance.

Not surprisingly this was dismissed out of hand by local politicians.

But it is the rationale behind this that is so fascinating and has gone pretty much unreported. The picture that Donaldson paints of our existing system is disturbing.

A system fit for purpose?

The reason why change is imperative is not that difficult to grasp. Our ageing population which itself is a result of the success of the health service to date and of technological breakthroughs is massively increasing demand on services at a time when resources are finite. At the same time we now live in advanced consumer society and citizens, quite rightly, demand high levels of service and will complain if they don’t get them.

We are left with a system which is no longer fit for purpose. There are too many hospitals and as a result patient care is jeopardised. Going to a small, under-resourced hospital, particularly out of hours can seriously damage your health.

There is too much emphasis on acute care within the hospitals and not enough on preventing people going to hospital in the first place. Transformational change is imperative, the risk of not doing this is unthinkable.

At this critical time relations between the health authorities and the media are appallingly poor. The new chief executive of the Health and Social Care Board Valerie Watts has even gone so far as to say that if she had the resources she would fund her own TV channel to redress the balance. This may not have been a rational response but it does highlight the frustration she and her colleagues feel about media coverage.

The Donaldson Report has this to say:

“Northern Ireland’s health and social care system is subject to a high, perhaps unrivalled, level of media coverage – much of it negative. Over recent years, it has also been the subject of a series of high profile inquiries. All have highlighted numerous failings in the leadership and governance of care. Many have made extensive recommendations and the extent to which these have been implemented has itself been controversial. The pressures of increasing demand for care have meant that access has been more difficult. There has been a focus on over-crowding and delays in emergency departments, the front door of the hospital service. All of this has meant that the last five years has been a period of unprecedented scrutiny of the way that health and social care in Northern Ireland is planned, provided and funded.”

It is, of course legitimate for the media to cover these inquiries and the failings they have exposed. But Donaldson suggests that there have been too many of them here, certainly many more than there have been in other jurisdictions

“The number of recent major investigations and inquiries into shortfalls in standards of care in health and social care services in Northern Ireland is striking in relation to the size of its population. This does not necessarily mean that such occurrences are commoner than elsewhere in the United Kingdom. It may simply be that the level of public and media scrutiny is higher and the pressure from this triggers a statutory response by government ministers and officials. The end-result is that the profile of the service is more often one of failure rather than success.”

Essentially this becomes a spiral: the more hostile media attention the service gets, the more politicians and administrators respond by initiating inquiries into matters that elsewhere would be handled differently, this in turn triggers more negative coverage and within the system an atmosphere of fear and retribution within the system.

He sums up the problem thus: “When something goes wrong, many patients’ and families’ first reaction is to want to know who is to blame. The situation often escalates, with the media coverage and political pressure that the detail of the story generates. In an ideal world, leaders of the system should be able to step in to paint a proper picture of the background to these complex events, and to build public understanding that few are a simple case of incompetence and carelessness. Instead, to remove the heat from the situation, approaches are announced that may not be the most effective way to achieve learning. On top of this, day-by-day the media portrays health and social care in a mainly negative light. There has been one inquiry after another. These are conditions conducive to blame and fear, not to transparency and openness.”

And Donaldson points out that that kind of atmosphere added to the paralysis caused within an organisation when an inquiry is underway is more likely to cause deaths than prevent them.

Who is in charge?

This paranoia may also help to explain why people even within the health service don’t seem to know who is ultimately in charge of it.  Not one of the people his team consulted with named a single individual.  Their answers included: “The Minister”, “The Permanent Secretary in the Department of Health”, “ The Chief Executive of the Health and Social Care Board”, and “ The Director of Commissioning of the Health and Social Care Board.” One respondent rather colourfully told him “there are more pilots than in the RAF.”

This lack of clear accountability makes it very hard to determine where responsibility ultimately lies when things go wrong but it also means that it is very hard to bring about change and reform.

Then we come to local hospital services. Donaldson believes that there is a general lack of understanding of what modern hospitals actually do and that there has been a failure to explain clearly enough the inherent dangers of the present system.

This lack of understanding appears to extend to politicians and the media as well. He argues that campaigns to save local hospitals are examples of where both politicians, and presumably by extension the media are sometimes acting against the public interest, whilst apparently defending community interest.

It may be better, for instance, to improve the transport structure rather than keep open a hospital that is generating risk to patient care and indeed more clearly explain to people that the inconvenience of travel for better care outweighs the risk of inadequate treatment.

It’s hard to think of a more damning indictment than Donaldson’s summary of this syndrome: “In short, the services that exist are not the services that the population truly requires. Political and media pressure acts to resist change, despite the fact that change is much needed. It is not clear who is in charge of the system …”

Donaldson says that staff he talks to are extremely frustrated at the collective failings of the authorities, media and politicians to explain these simple facts. “There is deep frustration that the public are not properly informed about the higher risks of smaller hospitals and that the misapprehension that alternative forms of provision are in some way inferior to a hospital.”

He also argues that media and political pressure has depressed the salaries of managers in the health service, meaning that as there is now a considerable discrepancy in what they might get paid here as opposed to in England, Wales or Scotland, this will inevitably lead to a fall-off in quality.

“The public would be better served if their care system could compete to attract the very best managerial talent. The pressure to keep salaries down may be penny-wise and pound-foolish.”

Almost all coverage of the Donaldson report has concentrated on two aspects: the observations about the need to reduce the number of hospitals and the recommendation to bring in an international commission to sort the mess out. It’s a pity that there has not been more attention to the detail as it raises very serious questions about the effectiveness of the communications of the health authorities and of the behaviours of both politicians and media.It also goes a long way to explain why he does not believe change can be effected without external help.