Politics remains a barrier to health reform

 

Northern Ireland’s health system is changing out of necessity, but this change is difficult.

Politics and policy remain at odds. Broadly speaking, Health and Social Care (HSC) needs to streamline to survive. Acute services must become more centralised.

Too many overlaps over too many hospitals mean the current model is inefficient – and this inefficiency is unaffordable.

That was one of the central messages of Transforming Your Care – way back in 2011 – and in every major health review since (along with other principles such as providing greater independence for people, using the home as the hub of care when possible, more focus on prevention, and more). Similar findings were reiterated in the recent NI Fiscal Council report on sustainability in the health service.

The unfortunate reality is that any solutions to this will be difficult and involve compromise. When it comes to acute care, a lot of that compromise will be geographical. Northern Ireland has loads of hospitals and too many of those hospitals do too many things. Services need to be streamlined.

Or, put another, way, services need to disappear from some settings and be consolidated elsewhere.

However, when that happens, there tends to be a backlash. This will remain the case unless and until everyone understands that Northern Ireland has one single health system and, for that system to maximise itself, it needs to work on a single basis.

That means specialist care that exists over several sites might have to be shifted entirely onto a single site. That means that your granny who lives in Newtownbutler and doesn’t drive might end up having to go to Coleraine’s Causeway Hospital for treatment.

Is that ideal? Absolutely not. Is it better than systemic collapse? Yes.

Politics isn’t necessarily helping.

It was announced last month that Daisy Hill Hospital in Newry is to become a hub for elective surgery, including overnight stays. That represents a specialism for the hospital and implies that other hospitals will lose some of this function.

At the same time, it looks like Daisy Hill will lose its capacity for emergency general surgery (which, of course, will be consolidated elsewhere).

SDLP MLA Justin McNulty welcomed the news that Daisy Hill would become an elective hub but said this did not make up for the loss of emergency surgery.

This is typical of the problem, which is not to pick on Mr McNulty. His response is the norm. He is an MLA for Newry & Armagh. He is elected by the people who live near this hospital. All politics is local.

However, the key point is that Mr McNulty is not necessarily protecting local interests, it just seems like he is. The entirety of Health and Social Care will live or die together. Daisy Hill cannot be an all-encompassing hospital. Such a model is unsustainable.

Fiscal Council

Early in September, the NI Fiscal Council published a report looking at the sustainability of NI’s public finances. That paper excluded the health service, because health is such a large proportion of local spending and has such significant concerns with its sustainability that it required its own individual report.

That supplementary report was published at the end of September. Its findings and conclusions cover similar ground to Transforming Your Care, Bengoa, Donaldson and all strategic analyses published by the Department of Health in the past decade.

It also warned that, despite the inefficiency of the local system, spending per head of population was now falling below per capita spending in England for the first time in recent history.

“DoH is proposing a new Integrated Care System, focused on local partnership models that will bring together health and social care professionals, the voluntary and community sector, local councils and others to plan, manage and deliver care for their local population taking a population health approach… Regional and specialised services would be planned, managed and delivered at a regional level.

“Provision of health services might be expected to be more costly than in England since NI is more rural, resulting in a greater proportion of smaller hospitals. This situation is similar to Scotland and Wales. In 2019-20, per capita health expenditure in NI was 7 per cent (£181) higher than in England, in line with the average over the past 20 years…

“The spending plans for DoH in the Draft Budget 2022-25 published by the Minister of Finance in December 2021 imply that the funding available for health spending in NI is growing at a significantly slower rate than for the Department of Health and Social Care (DHSC) in England. As a result, health spending per head of population has fallen below that in England for the first time in 2022-23 and will remain 2-3 per cent lower until at least 2024-25.

“If these estimates are accurate, this suggests that health spending in NI has previously been broadly in line with relative need. However, the slower growth in health funding more recently means that NI would not be able to afford to deliver the same standard of services as in England unless it ran its services more efficiently than they are run in England.”

The previous Fiscal Council report warned that Northern Ireland’s general spending premium – i.e. the amount spent here on public services, per person, when compared with England – was shrinking due to how Barnett consequentials are calculated.

However, that does not mean need is shrinking and, when factoring in inefficiency as well, this creates problems.

Politics

The Fiscal Council’s original report concluded that NI faces a roster of choices ranging from the difficult to the unpalatable – accept lower-quality services than in England, accept fewer services, raise revenues somehow (through extra taxes or handouts from Westminster), or to increase local efficiency.

Nobody wants lower-quality services, but it’s hard to see how anyone can sell this in health, of all sectors. At the same time, we are living that reality right now. One look at waiting times for planned care will tell you that.

Northern Ireland will, of course, seek more money from Westminster – it might even get some – and perhaps from direct revenue. That won’t be enough to repair a health service whose problems are far more systemic than financial (which is not to say health and social care will ever be cheap).

This leaves efficiency – which means transformation.

Justin McNulty got singled out earlier in this article for his effective opposition to health reform. But, and this cannot be stated enough, he is no outlier.

Back in February, when it was becoming clear that Daisy Hill could permanently lose emergency surgeries, Newry, Mourne and Down Council passed a motion which said: “This Council expresses its complete opposition to the Southern Trust’s decision to temporarily remove Emergency Surgery provision at Daisy Hill Hospital. We call on that decision to be reversed and efforts redoubled to guarantee continued and improved service provision for people in this district.”

The motion was brought by Sinn Fein, with Cllr Roisin Mulgrew saying that her party is “totally opposed to services being taken out of Daisy Hill”, adding: “Our vision for the future sees services returned and improved upon. We want to see Daisy Hill expand and offer even better healthcare to the people of this region.”

Complications

Daisy Hill is not the only hospital where change is happening.

Emergency surgery services at South West Acute Hospital (SWAH) in Fermanagh are also at risk. The service might disappear. Local politicians have raised concerns, including from the DUP, the UUP, and Sinn Fein.

However, perhaps these concerns have more substance. Some clinicians have warned against the closure of SWAH’s emergency service provisions. Consultants have warned health officials that failure of this service could lead to people (including babies) dying unnecessarily.

Retired cardiology consultant Prof Mahendra Varma also said there could be serious consequences, noting that “the longer the journey to a hospital, the greater the morbidity and the mortality.”

This illustrates the pressure on those who need to transform all of HSC. The current model is unsustainable. That means failures will happen, which only reaffirms the case for Bengoa-style transformation, including rationalisation.

That rationalisation will mean some people will need to travel further for services – but that travel does itself need to be safe (none of this is to suggest the possible failure of emergency services at SWAH is planned, in any sense – it appears to simply be happening, which is of grave concern).

But these are the terms in which we all need to discuss the future of our health service, our politicians most of all. We need to make some difficult decisions, which will lead to some geographical inconvenience, because if we don’t make those choices than services will crumble of their own accord.

That means accepting that change will happen, that all hospitals may lose some services that are valued by local people, but that when it comes to HSC we are all locals, wherever we live.

We have to do all that while simultaneously not ignoring geographical reality, and not conflating good compromises with bad planning or (accidental) failures.

This article doesn’t even touch on transport, and on how this will have to grow and adapt to ensure everyone can access the care they need, when they need it.

However, how can we expect rural communities to buy into reconfiguration unless we can both stand over the speed and reliability of ambulance response to emergencies, and also a public (or community) transport system that allows people to get from their home to their place of treatment when they need to be there, wherever that might be?

Yet, while politics remains a barrier to health transformation, this barrier might itself be weakening. Not every party has been critical of recent changes (although it’s only fair to say that Alliance has a heavily urban voter base and Belfast’s MLAs will find it easier to say these things because Belfast will be well catered for, whatever transformation occurs).

Moreover, while the substance of the grumbling remains the same, perhaps the volume of this political localism has shrunk compared with a few years ago.

We can but hope, because it really is one system and, when it comes to Health and Social Care, we all live in one constituency.