Health reform, part two – stubborn opposition

27 Oct 2016 Ryan Miller    Last updated: 27 Oct 2016

Scope looks at media shortcomings and the spectre of a populist threat to health reform that just won’t go away.

The media’s role in driving our health services to the brink has been flagged up numerous times, most notably in the Donaldson report.

Yesterday morning the Nolan Show devoted itself to Bengoa and the proposed reforms. The fact that it did so shows an appreciation of the scale of what is at stake. The content, however, was mixed.

Michelle O’Neill was on to outline her vision and, at times, she struggled to deal with the questioning. This does represent a failure on her part but there is significant mitigation.

I’m sure Mr Nolan himself would say he is asking tough questions and the questions the public would want answered – which may be correct – but some of them not so much irrelevant but at cross purposes, missing the bigger picture.

Pressing Ms O’Neill on the effect on waiting times might sound good but the structural changes proposed are so vast that giving specific answers at this stage to a question like that is almost impossible.

Using waiting times as a measure of success has long been a flawed concept that leaves many clinicians rolling their eyes. The media has traditionally focused on it because it is easy to understand but it is not an indication of how well HSC is serving public health (although the ever-increasing nature of these times are at least a clear indicator that, over time, the current model will collapse) because it is not a measure of health.

Of course waiting lists are important – and longer waiting times do have an impact on health, albeit they are still not a basic measure of wellbeing – but the Minister did the best should could in saying she has brought forward a “direction of travel” and our unacceptable waiting lists are “symptomatic” of a service structure that is out of date.

It should also be noted that, under the new outcomes-based approach of government towards services, waiting times will be relegated in importance, replaced by indicators that directly measure health and wellbeing of the population. However, if these reforms are done correctly, waiting lists will go down, and will certainly be much lower over time than they would be if nothing changes.


By contrast, John Compton – chief author of TYC – dealt much better with Nolan, although he is an expert on these issues and has few rivals for experience in this field, whereas the minister is still finding her feet.

Nolan, in his interview with Mr Compton and follow up questions, did a good job of probing into the need behind reform and asking key questions that helped illuminate relevant rationale.

Finally, there was Robbie Butler of the UUP. He said he “absolutely” supports the Bengoa report and thinks centralisation of acute hospitals has been needed for many years - then he said he would not say whether he supported it. And then he said he does not support the centralisation of accident and emergency provision. And then he said evidence shows stroke services are too fragmented. And then he said it was not party policy to centralise them.

Altogether, maybe best written off as a Nolan debut than a true statement of position.

Elsewhere in the media, things are improving. News Letter political correspondent Sam McBride wrote this week about both the similarities in all these recent reports while also outlining some of the political toing and froing that has led to inertia.

His only error isn’t so much an error as a slightly mistaken emphasis. He correctly says that the focus of Bengoa is not on hospital closures, but says this lies in contrast to TYC and Donaldson.

In fact, none of these reports are about hospital closures. They are all about a complete restructuring of HSC to get far better value for money – meaning, vastly better health and wellbeing for people, using the same amount of funding. Hospital closures (or diminishment) are, in each report, identified as a necessary step in these changes.

A subtle shift of emphasis, perhaps an important one, but another indication that these are not straightforward matters to discuss.

The Irish News also carried a report that is, more or less, accurate about the context of Bengoa. This, generally, is better than what went before.

Pressure releases

Ahead of the May Assembly elections, Scope went through the big five parties’ manifesto promises on health. It was dispiriting. The context is here, while the assessment itself is here – and showed that pandering to public misconceptions in a bid to win votes remains a major stumbling block to reform.

News releases in recent days are not much more encouraging. The UUP’s Health Spokesperson Jo-Anne Dobson seems broadly supportive of TYC – she should have a word with Robbie Butler – but argues over costing questions that are, realistically, difficult to answer at this stage, while also suggesting there is no political mandate for reform.

Mark H Durkan, of the SDLP, also was critical of the minister’s lack of specifics – and price tags – but does not tie this in with his acknowledgement that the current model would see health taking up 90% of the Stormont budget in a decade, if left unchanged. He also raises the concern that this is “a smokescreen for the reduction of services”.

The Alliance Party best understands the rationale for change and what is at stake. Scope finds nothing to disagree with in Paula Bradshaw’s comments.

One would expect the two parties of government to be completely in line with these reforms. Both the Health Committee Chair, Paula Bradley of the DUP, and Sinn Fein’s Catherine Seeley have done so- as have the First and deputy First Ministers.

However, dangers remain. Sinn Fein’s Barry McElduff came forward with a topical question during Ministerial Question Time with the Agriculture Minister on Tuesday, and his position strongly implied a defence of the status quo.

The debate that followed the Minister’s policy announcement is also worth a closer look. (LINK TO dotw).

In conclusion

When putting together their report, Bengoa and his colleagues saw fit to quote the Donaldson report right at the top of section 1:

“A proportion of poor quality, unsafe care occurs because local hospital facilities in some parts of Northern Ireland cannot provide the level and standards of care required to meet patients’ needs 24 hours a day, 7 days a week. Proposals to close local hospitals tend to be met with public outrage, but this would be turned on its head if it were properly explained that people were trading a degree of geographical inconvenience against life and death. Finding a solution should be above political self-interest”.

This is not an easy thing to explain. In the absence of an explanation, it has been suggested that Stormont delegates these reforms to clinicians.

One of Liam Donaldson’s recommendations was to have politicians effectively hand over strategic decision making to health professionals to take politics – and populism – out of the equation.

This caused outrage among politicians, was positioned as an affront to democracy. Bengoa does not make the same suggestion in the same bold fashion, but tiptoes towards it by reiterating again and again in his reports recommendations that frontline professionals should take the lead in reshaping HSC.

The Executive Summary of Bengoa finished with a call to action:

“We should be under no illusions that transformation will be anything other than a long and difficult road. These reforms are ambitious, and they need to be ambitious. The Panel has no doubt that Northern Ireland has both the people and the energy to deliver a world class health and care system. There is no better time to start than now.”

There is a better time – but that was five years ago, and every day since.

Reforms is necessary to avoid complete systemic collapse but unfortunately the political dynamics that have kept them from any real progression still persist.

If this continues HSC as we know it will die. The current Health Minister knows this, as did her predecessor, Simon Hamilton, who commissioned Bengoa in a bid to remove the dirty aspects of politics from this vital change in policy. While we have an Executive in apparent agreement, the new shape of Stormont, with an official opposition seeking to score points off government, complicates things.

Bluffing the public into allowing the reforms seems a wild and unlikely venture. Better communication is therefore necessary.

For this, the media needs to continue its path to a real understanding of what is proposed, and why, and more importantly our politicians need to be brave and not jostle for pathetic electoral advantage.

There has been progress, but not enough. Northern Ireland cannot afford to wait another five years.

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