Health reform: different places, same story

20 Apr 2018 Ryan Miller    Last updated: 20 Apr 2018

Our politicians have largely failed to progress health reform - due to problems mirrored elsewhere - but their absence does not really make things easier.

We're better off without that lot on the hill.

Sure they're only in it for themselves.

They don't care about us.

In case you missed it, the Northern Ireland Assembly isn't well. The diagnosis is chronic; cure unknown.

In the 18 months that we have carried on regardless without any government, the usual complaints that people from all across NI make about our politicians have only gathered pace. Absence has not made the heart grow fonder.

It is tempting, therefore, to not only dismiss the trouble that stems from Stormont's ongoing infirmity, but to see where the positives are.

Health reform is the most pressing issue for local public services. Provision is going to collapse without major intervention. Our politicians have known this for the guts of a decade and yet progress has been weak.

The problem has been that, while the general principles of reform have been agreed, when reconfiguration of services suddenly becomes real - in particular, when one locale risks a reduction in any particular service - there is controversy, even though it will be lead to better outcomes for everyone. All politics is local; parish pump wins the day.

Surely then, with our MLAs out of the way, we can press forward more easily.

This is an appealing idea. It was even discussed at this week's annual conference from the Northern Ireland Confederation of Health and Social Care, an excellent event with numerous great speakers and plenty of interesting topics discussed - with the need for reform the foremost of these, which is only natural given it hangs like a cloud over the entire system.

However, things are not so simple.

Same everywhere

Politicians in NI often get treated as piñatas - and this can be totally understandable - but the first thing to realise is that stuttering health transformation is a problem that is replicated elsewhere. It is certainly not the case that our representatives are causing issues unique to us.

The reasons why change needs to happen (an ageing population, a huge rise in long-term conditions, shifting both the extent and nature of the demands faced by health and social care, while increasing the tax burden on a per capita basis amongst people of working age) are common to many countries around the world. Unsurprisingly, this includes both Scotland and Wales - two places which have made similar assessments to us, and come to similar conclusions.

Hence NICON had experts from both countries deliver a joint address to the conference.

Vanessa Young, Director of the Welsh NHS Confederation, said: "If you look at a review that took place in Wales, a parliamentary review [A Revolution from Within, published in January], and the idea was that it would be used to build political support and consensus around the need to change.

"We got agreement with political parties and support about the general direction. It was published and 10 high-level recommendations were made, and the politicians all said it looked very sensible.

"Within about 10 days there was an issue in one of the health boards, in West Wales.

"The strategy recommends the closure of some services in some hospitals - and the politics locally went mad, and even people within the Labour government said 'You can't close our hospital,' so even though we had built consensus, when it came to the crunch, when it came to the changing services on the ground, politics got in the way again.

"We were very lucky that our cabinet secretary look a very robust line. That's very important, but what will really help is getting all parties to maintain that tough line."

Northern Ireland has seen similar ructions over the potential for reduced services at regional hospitals, amongst other matters.

The question of how to pay for spiralling social care costs has also proved controversial. As you can read in our other Scope article this week, potential answers have been met with panic across the UK (and a rapid collapse in political will).

Dr Brian Robson, GP and Director of Healthcare Improvement Scotland, told the NICON conference: "I don't know what it's like to live and work in Northern Ireland but a big issue in Scotland is national politics versus local politics.

"No doubt that the strength of interest in health and social care is also one of its greatest problems; politicians don't want change on their own doorstep, and they want to think about the election that is round the corner.

"But in Scotland there is a consistency of thinking among all parties and that's a great strength."

That final quotation hints at what is really needed here.

Popular opinion

Political will has wavered when confronted with some of the harder aspects of health reform, but this doesn't happen in a vacuum.

The driver is public opinion.

As Ms Young said further: "It... comes down to comparison of the overall demographic national change with specific local service change… these should be continuous decisions made in agreement with the public and if we persuade the public then the politicians will come on board."

However, more can be asked of political leadership than simply to fall into line behind whatever the public wants.

Politics is a very difficult job and the balance between representing the wishes of your constituents and providing leadership is extremely tough.

Nevertheless, that is the job. Rather than be glad that NI is adrift without political leadership, we should want stability restored and better leadership in place.

The biggest barrier to transformation (other than the inherently enormous job it is) is not the absence of political consensus - what is needed is consensus per se, from the general population.

This is not simple or straightforward. It cannot be solved by a basic public information campaign, disseminating a series of plain, if not universally known, facts.

It is information that, for many people, is counterintuitive, information some will find suspicious, and which calls for enormous overhauls to things that people hold dear, and which concern matters of life and death.

Minds need to be changed. Arguments need to be won. Time is short.

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