Health Service: the crisis deepens

2 Dec 2016 Nick Garbutt    Last updated: 2 Dec 2016

Bengoa: architect of reform

A series of news stories this week illustrate both the depths of the crisis engulfing the health service and the immense task faced by reformers. 

In October 2015, the Regulation and Quality Improvement Authority (RQIA) announced it was to carry out unannounced inspections largely focused on Emergency Services. These reports are now coming through. They are illuminating the stress being felt by our hospitals.

An unannounced inspection of the Emergency Department at Altnagelvin Hospital found that the unit was under-staffed and that those working there were tired, stressed and demoralised.  

There were delays in recruitment and difficulties in hiring “agency staff” to fill the gaps.

RQIA’s inspectors considered that at busy times, the Emergency Department was not adequately staffed to ensure appropriate patient care.

They noted that there has been a surge in visits to ED, both from those walking in from the street and GP referrals.

This mirrors a report on Antrim Hospital back in June which found a nurse shortage in its ED department. Similar issues emerged at the Ulster Hospital in a report early last month

The picture is becoming universal, and is universally alarming: pressure is mounting on Emergency Departments as visits and referrals surge. Health Trusts are finding it difficult to recruit and retain staff. Consequently staff levels are inadequate and morale is poor.

At the same time insufficient social care funding means that people who are well enough to leave hospital are marooned there, because no suitable care package is available. The resulting bed-blocking is not only expensive it has an impact that can back up right into A&E leaving newly admitted patients on corridors.

The crisis is also affecting the Ambulance Service which is falling behind response time targets. In extreme cases there have been ambulances backed up at departments unable to bring patients in because of a shortage of beds.

This is not a problem unique to Northern Ireland, the situation in the rest of the UK is just as grim.

It is safe to conclude that the crisis predicted for so long by health professionals is now upon us and that reform is now so urgently required that time has run out. And may even be too late at this stage to avoid extremely unpleasant consequences.

Tragically some of the problems were avoidable. The RCN has argued for some years that the nurse shortage is a direct consequence of inadequate workforce planning and short term thinking. It has claimed that nurses trained in Northern Ireland have migrated to Scotland and England because local trusts could only offer them temporary contracts when permanent ones were available elsewhere.

There is an answer to a nurse shortage and that is to train more but that is not a quick fix. Hiring agency staff is very expensive, adding an unnecessary financial burden to a creaking service. Overseas recruitment helps to alleviate the problems, but there is growing competition for the necessary staff.

There is probably little that management at Altnagelvin, or the Ulster or Antrim for example can do in the short term to transform its Emergency Services it is very much a case of carrying on as best they can.

So what does need to happen?

In the medium and long term care needs to be shifted from acute settings into the home and broader community-based services. Investment in such care and public health initiatives to combat conditions caused by lifestyle choices is imperative.

What will not work is for all expenditure to be thrown at the immediate symptoms: ie propping up all our struggling Emergency Departments. The key is to make sure that fewer people end up there in the first place. This involves a cultural shift, one for which the general public needs to be properly prepared.

There is clear evidence of widespread misunderstanding of what the emergency services are for. The ambulance calls broadcast by the BBC this week – of the woman who wanted her bank card replacing, and the patient who wanted to be driven back from hospital, provoked amusement.  

But they suggest that too many people still do not understand that ambulance personnel are highly trained first responders and that ambulances are sophisticated mobile clinics, not white taxis with fancy lights.

Similarly, Emergency Departments are not walk-in clinics, they are for emergencies. There are still far too many people turning up at them who should not be there.

Further to that the fundamental question we need to pose about our health service is not whether there is an Emergency Department at the end of our street, but what solution will make us most likely to recover from whatever condition or injury we have sustained.

Commonsense tells us not that there are too few Emergency Departments but there are too many and that if there are staffing issues at some institutions it might be safer to have staff concentrated in fewer sites, offering the efficiencies of scale that that brings. Northern Ireland is a relatively small place and in order to justify an ED in a location, say no more than 45 minutes in an ambulance from another one, the argument has to be around quality of care, not convenience. Sadly this is not how our politicians or the media see it. For too many of them the debate is about buildings rather than care and generalised statistics about waiting lists which, although easy to understand are not a measure of health.  

If ever Health Minister Michelle O’Neill doubted that her role would be challenging she will have been thoroughly disabused by the standard of some of the questioning when she faced the Assembly on Tuesday.

Here are a few examples together with our comments.

First up Rosemary Barton of the UUP.

“Will you give a commitment that the Bengoa reconfigurations will not merely be used as a convenient smokescreen to move stroke services from the South West Acute Hospital to Altnagelvin Hospital?”

This is a classic question about buildings. Will Mrs Barton oppose such a move if it were to be demonstrated that her constituents would get better outcomes as a result?


Michele Gildernew, Sinn Fein. “The Minister is all too aware of just how busy the South Tyrone Hospital site is. Will she expand on how she sees South Tyrone Hospital fitting in with her approach as outlined in Delivering Together?”

Another question about a building rather than patient outcomes.

Steve Aiken, UUP: “In view of the awful figures that we hear from Antrim Area Hospital, can the Minister — given the recent media reports on the lengthening of waiting list times — explain how massaging targets to match the poor performance of her Department is beneficial to the near quarter of a million cases on our waiting lists?”


Claire Hanna, SDLP: “Earlier this month, the government parties voted against our motion on waiting lists because they said that the figure referred to cases and not to people. The old figures may very well have referred to people. So, on the basis of the old targets, do we know how many humans are actually waiting?”

Waiting lists are not an indicator of health or well-being, rather they are symptoms of the overall strain on the service: reform the service and you would expect them to come down as a consequence. Calls such as these imply there is a magic wand to reduce health service overload, which, of course, does not exist.  It also suggests that growing waiting lists are a result of Departmental incompetence rather than a growing international trend driven by demographic changes.

Justin McNulty, SDLP: “The emergency department at Daisy Hill is a valuable service to the local community, and it is imperative that we retain the facility and retain acute hospital status. Will the Minister give me and the people of Newry and the surrounding area a categorical guarantee that Daisy Hill will retain its 24-hours-a-day, seven-days-a-week emergency department for many years to come?”

This mirrors the SDLP’s Election Manifesto which welcomed Health Reform and the implied necessity for the concentration of acute provision on fewer sites, and simultaneously demanded that Downe and Daisy Hill be ring-fenced. It does not address the issue of whether or not emergency patients from the Newry area might be better off if treated elsewhere given the current crisis within Daisy Hill’s emergency Department.

Looming political opposition to health reform is a serious threat to its implementation. Sadly this will not be an easy fix either: it is an inevitable consequence of our electoral system. Politicians will always defend locally provided services even when that might not be in the best interests of their constituents. Those who decide to act more responsibly risk becoming unelectable: even if that means dire consequences for us all.  

Is it any surprise that the Donaldson Report recommended taking the whole matter out of their hands? 

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