Unhealthy future - part one

13 May 2016 Ryan Miller    Last updated: 17 May 2016

Illustration by Patrick Sanders
Illustration by Patrick Sanders

The need for health reform will become even more pressing throughout the next mandate. Scope has analysed party policy alongside the unanimous view of experts who say how and why HSC should be remodelled. The conclusions are worrying.

The elections are over, Stormont will take a similar shape – albeit with many different faces – and discussions about both the Programme for Government and the Executive now move to centre stage.

The UUP, SDLP and even Alliance all have decisions to make about their presence in government but, regardless of whether they go in or out, DUP and Sinn Fein between them still hold a majority position and will provide most of the legislative direction.

But perhaps the most important issue before the Assembly currently is one that requires political consensus – health reform.

Therein, a united front is needed to implement the necessary changes identified in Transforming Your Care and the Donaldson report.

To try and bring these forward, an international expert – Prof. Rafael Bengoa – held a summit in February with all our major parties to try and achieve just that.

Scope has heard from a number of people that this could have gone better, with parties generally saying they of course supported this principle, before introducing significant (and presumably different) caveats.

More and more pressing

After at least three incumbent ministers who failed to properly address the rapidly growing demand that will eventually break Health and Social Care, without a major and specific overhaul, Simon Hamilton at least made all the right noises during his tenure at the end of the last mandate.

However, as well as noting that talking and doing are very different things, there is also no guarantee he will be in the equivalent post when the Executive is formed.

Regardless, as per above this reform requires agreement – the reason behind the Bengoa intervention. To ask whether we can achieve such, a reasonable starting point is the party manifestos.

One exemplar of the willingness to take tough decisions on health reform is hospitals. Neither TYC nor Donaldson is fundamentally about closing hospitals, but both reports deem this necessary to avoid systemic disaster.

This is not about cost cutting – no less money would be spent, it would simply be spent differently – it is about Northern Ireland having simply too many hospitals and the population as a whole getting poor value for money from the public spending that flows into them.

In the past this was an affordable luxury but with the public purse stretched, now and into the future, greater efficiency is needed.

What the papers say

To bear that out, here are some comments on the hospitals estate from Donaldson:

  1. “Northern Ireland’s health and social care system is subject to a high degree of political, as well as media, interest. This is a valid and expected feature of a publicly-funded system. Ironically, though, the way in which this interest becomes manifest often creates results that are counter to the true public interest. There have been many examples of local communities – and therefore their politicians – wanting to keep a local hospital open, contrary to the analysis of service planners. This has created a situation in which Northern Ireland has more inpatient units than is really justified for the size of population, and the expense of maintaining them impedes provision of other services that would represent better value for money and more appropriately meet the needs of the population.”
  2. “A striking feature of the provision of care in Northern Ireland is the wide distribution of hospital-type facilities outside the major city, Belfast, some serving relatively small populations by United Kingdom standards. This geographical pattern leads to specialist expertise being too thinly spread, and to the patchy availability of experienced and fully competent staff… There is therefore a two-tier service operating in Northern Ireland - in-hours and out-of-hours - that is more pronounced in some places than in others. This is one of the biggest influences on the quality and safety of care. Delivery of services is too often higher risk than it should be in a 21st Century healthcare system because of the pattern of services. Past analysts and observers have pointed to the current level and siting of provision not being in keeping with maintaining high standards of care. Some populations are just too small to warrant full-blown general hospital facilities yet they are kept in place because of public and political pressure. Amongst those who work within the system, 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.”
  3. “The pattern of ill-health in the population has changed substantially since the systems were founded, and the systems have not changed to keep up. The Transforming Your Care review set out a convincing case for change. It described inequalities in health, rising demands, and a workforce under pressure. It particularly established that Northern Ireland has too many acute hospitals – that elsewhere in the United Kingdom, a population of 1.8 million people would likely be served by four acute hospitals – not the 10 that Northern Ireland had. Transforming Your Care set out a broad new model of care, which aimed to be tailored to today’s needs and person-centered. In practical terms, its most substantial proposal was to move £83 million away from hospitals and give it to primary, community and social care services. Those interviewed by this Review Team unanimously supported the need for this initiative. The widespread feeling, though, is that Transforming Your Care is simply not being implemented.”
  4. “A proportion of poor quality, unsafe care occurs because local hospital facilities in some parts of Northern Ireland cannot provide the level and standard 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.”

There is more, if you want to read it, but the point is surely made: Northern Ireland has too many hospitals, they are spread too thinly and result in an inefficient service that also has negative impacts on other areas including primary and community care, and ultimately the whole health estate.

The entire population would be better served by a rationalisation and with money better spent elsewhere and, indeed, these changes are necessary.

The question is whether the political will and unity exists therein.

Read part two here.

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