Entrusting health cuts to the public

Health Reform this week reached an absurd new pitch when the public were asked what cuts they would like to make to their local services.

The need for radical structural change across Health and Social Care has been known for years and there have been several substantial reports putting forward both the case for change and also detailing what this change needs to look like.

Papers such as Transforming Your Care (TYC) in 2011, the Donaldson report in 2014, and then Bengoa – published under a year ago – not only all laid out pathways for reform, they all said pretty much the same thing.

Expert after expert has come to the same conclusions about what needs to be done. So, surely, that’s what we will be doing?

Apparently not. Health reform has gone nowhere Health reform is being left to the people.

The Department of Health has asked the trusts to make savings of £70m. Rather than deliver these cuts themselves, they are throwing it to the audience.

This is strange for a lot of reasons, not least because the cuts are to be applied for the remaining seven months of the current financial year – i.e. right now – yet any public consultation will take at least a couple of months.

In a series of meetings across Northern Ireland today, the trusts will outline their proposed method for meeting the £10m per month shortfall: significant cuts to agency staff and locums (which might lead to reductions in number of beds), with some impact on non-urgent procedures, operations and other appointments. New domiciliary care packages are also likely to be halted, with no new admissions into nursing or residential care homes. Fertility treatments are also set to be affected.

Third-sector providers, and therefore their service users, could also take a hit. The need for the cuts to be made now narrows the options to areas where outgoings can be stopped immediately.

Actually, it is unfair to say that health reform is being left to the public. This consultation refers to the next seven months only, and are solely to do with cost-saving measures and not meaningful reform. Nevertheless, it is a galling development and a worrying sign for the tough decisions to come.

What they are being asked to do is what is happening instead of health reform: increasingly desperate attempts to put fingers in growing cracks in the dam.

Sick of experts

The local health system is collapsing. The ability to cope with demand within the current structures is diminishing daily and we have got past the stage where services are being stretched and into the phase where some vital aspects are now beginning to break.

The reason why this is happening is because of huge and rapid demographic changes. People are living much longer, and many more people are living with long-term conditions that require treatment and support. Demand is increasing by around five or six percent, per year.

This is far too high to simply be fixed by throwing more money at the issue. If we increased the health budget by 6% every year it would more than double in 12 years. Clearly that is impossible, hence the necessity of TYC/Donaldson/Bengoa.

However, much of the debate with the public has not focused on those terms and instead looks at the supposedly negative aspects of proposed reform – hospital closures as a result of centralisation, and an obsession with service levels at a local level rather than the health of the service NI wide.

If the public is going to be engaged more deeply in health reform then it needs to be properly informed about the rationale for change. To date, much of the general debate has missed the point – politicians see reform as necessary but also as a tough sell, and fall back on political pointscoring that becomes an obstruction to change; the media mischaracterises loss of services on a local level; the most voluble public pressure groups are focused entirely on maintaining what they have in their town or constituency. The true reasons for change appear to go unheard rather than unheeded.

The response from public sector union Unison to the health trusts call for a consultation is instructive in this regard.

Unison

The union’s Regional Secretary, Patricia McKeown, issued a statement saying Unison would challenge all five local health trusts “to refuse to comply with a demand for a further £70m in cuts”, adding:

“The Trusts have been asked by the Department of Health to produce these cuts, despite the absence of a Commissioning Plan, and in the face of financial crisis.

“UNISON will remind all Trusts that they have both legal and moral obligations to the people of Northern Ireland and to the health service workforce.

“The people are suffering from rampant rationing of care. The workforce is suffering from pay capping and increasing casualisation. At the same time, private medicine is mushrooming as some make extraordinary profits from a growing crisis.

“We are calling on the leadership of the Trusts to fulfil their obligations and be courageous in defence of our health service.”

A lot of what Ms McKeown says is fair enough, but it creates the wrong impression.

The pressures felt by the trusts in this financial year are not a one off, they are just the latest symptom of a health service that is crumbling. Yet Unison’s response does not mention the arguments for structural change.

This makes it seem as if this is a one-variable scenario, and that the only issue is one of money, specifically how much of the public purse gets spent on Health and Social Care.

Finding an extra £70m for the period between now and next April will of course help ease some of the issues at hand, but it provides no help for the future where, on the current trajectory, there will be more frequent, and larger, shortfalls of this kind. Thankfully the problems in health are not a zero-sum game – but you wouldn’t know it from the union’s response.

Local politics

Nor would you know it from many of the responses from local politicians, where Sinn Fein is blaming Tory austerity – while the UUP is keen to lay into Sinn Fein while apparently not offering any solutions themselves.

Most of the other main parties have been just as self-serving when it comes to public discussions of health and, with summer nearly over and the Executive (or not) back at the forefront of the news, expect this to become a political football to the benefit of no-one who needs treatment or care.

The primary challenge for whoever does pursue health reform – if and when this happens – is to commit to and then achieve massive, sweeping changes to the interconnected behemoth that is HSC, while at the same time maintaining its functionality on a day-to-day basis during the transformation.

The challenges facing trust bosses today touch on both these issues: on the one hand, services as they are will increasingly fail under the pressures of demand; however, structural change will not help with immediate problems (and will likely exacerbate them) so more short-term plate spinning will be absolutely necessary.

This is such a difficult job that local politicians have been taking about what is required for years without ever actually doing it.

The Donaldson report proposed that politicians remove themselves from this pickle by mandating an agreed team of experts to make the changes they thought were necessary.

There is a certain irony, therefore, in local trusts pulling such a political move, issuing this consultation when they have been tasked with making cuts (though it is worth making clear, again, that cuts and reform are not the same thing, that the cuts essential in this financial year are in fact a result of not having made any reforms, and the changes suggested in TYC and similar reports were not about spending less money but, rather, about spending it differently and getting a much more effective service from the same financial resources).

Belfast Trust Chief Executive Martin Dillon went on Newsline this afternoon to say: “The first thing I want to say is that we are not implementing anything today, we are not doing anything today. We are inviting public comment on options that we have to save money in the second half of the year that could impact on services. So I can’t emphasise enough, we are not doing anything today, or implementing anything today. We are inviting public comment on the options.”

If you’re looking for positive suggestions, an opportunity to show leadership, or to place these cuts in their context – that being the need for structural reform – you won’t find it here.

For Donaldson’s suggestion of delegation to work, the experts would either have to be completely immune from any public anger or – better – the case for change would need to be properly explained to the people of NI.

Problems in health and social care could hardly be more prominent in Northern Ireland but the nature of the debate is misleading.

Health and social care is sick. The symptoms are clear, a correct diagnosis has been made but widely ignored – and this means the necessary treatment remains on hold.