Stark choices, expensive healthcare and cheap politics

17 Feb 2015 Ryan Miller    Last updated: 18 Feb 2015

Broderick Crawford as Willie Stark in the 1949 film of classic novel All the King's Men
Broderick Crawford as Willie Stark in the 1949 film of classic novel All the King's Men

Three weeks after the Donaldson report and it appears all is forgotten. Are local political dynamics driving our health system unstoppably to the brink and beyond? Scope investigates.

“Make 'em cry, make 'em laugh, make 'em mad, even mad at you. Stir them up and they'll love it and come back for more, but, for heaven's sakes, don't try to improve their minds.”

Robert Penn Warren’s All the King’s Men is the great American political novel, but its lessons apply beyond the borders of the USA - they are about democracy.

Perhaps foremost of its themes is populism’s strength amid public ignorance and how, in that context, simple and emotional messages trump cold, complicated, rational reality.

The novel isn’t about blame, however, at least not in a simple way. Doomed governor Willie Stark begins as an idealist but his analytical gifts push him ever further down a road of pragmatism, a journey which ends with him an election-winning monster shaped by surrounding political dynamics.

With that in mind, the Donaldson report was published three weeks ago - but some of our representatives seem not to have noticed.

Following the report’s release, Scope examined how the media and Stormont have left the Northern Irish public fundamentally uninformed about the needs and pressures on Health and Social Care (HSC).

Last weekend – less than a month later - saw a great example of how the wrangles faced by those who administer HSC are cut off from the general public.

Services at Downpatrick’s Downe Hospital have been scaled back in recent months. People in the area understandably believe the future could see more of the same.

Concerned locals organised a rally for last Saturday branded “Love the Downe”, asking the community to march for retention of services – with campaigners calling it a success, and claiming 20,000 people attended.

Lead or follow?

How have local politicians responded to these worries? Have they explained the arguments behind Donaldson and, prior to that, Transforming Your Care (TYC)?

SDLP MP for South Down Margaret Ritchie joined the call to arms, calling for “solidarity” and telling people to “show that the health of rural communities is off limits to any cuts” – afterwards calling saying local people would accept nothing less than restoration of the hospital.

Sinn Fein MLA for the area Chris Hazzard delivered a similar message ahead of the demonstration, before telling Health Minister Jim Wells to “go back to the drawing board” and support the Downe.

What about the minister? His constituency is South Down, so any message he gives about the hospital is also given to the people who elect him.

In comments in a Newsletter article published online on Sunday he made no mention of TYC, the reasons behind it, or the need for a huge restructuring of health and social care, instead referring to “assurances I have received from the management team at the South Eastern Health and Social Care Trust that the Downe Hospital will continue to play a vibrant and vital role in the acute network which will deliver essential hospital services now and in the future.”

Of course, the minister is in a very difficult position, with political pressure from all directions.

Margaret Ritchie might be very surprised to hear her own party’s health spokesperson, Fearghal McKinney, not only going out to bat for TYC and Donaldson but adding that it vindicates the SDLP’s position.

Similarly, Chris Hazzard might want to speak with Sinn Fein’s Chair of the health committee, Maeve McLaughlin, who recently urged Jim Wells to “provide leadership and take tough decisions”.

Educate and inform

It is impossible to mention the political moves in isolation. Local paper the Down Recorder splashed on the march, asking its readers “Can you afford not to care?”, and calling them out to the rally.

The paper also featured testimony from a local woman who received lifesaving surgery at the Ulster Hospital, where she had to recover due to a lack of provision at the Downe, and a plea from a retired local nurse to boost services at the Downe in an article which quoted her schoolboy grandson saying it is a “local hospital for local people”.

Online outlet the Down News previously published a letter from the Down Community Health Committee which said, “Our resolve as a community has never weakened. It never will… The publication two weeks ago of the Donaldson Report, sounding like the death knell for the accident and emergency provision at local hospitals, even enhanced local hospitals, has further heightened our resolve…

“I believe that any political party that seeks to use this issue for party political advantage will pay a heavy price. If local democracy and local accountability are what the Northern Ireland Assembly has delivered, I have no doubt that our campaign will be successful. The Downe is the people’s hospital. It was built due to pressure from the ordinary people of Down District… If you care, you will be there.”

It could be said that local representatives require courage to challenge perceived ideas and speak out about what health experts are clear in saying, but what is nonetheless not common public knowledge.

However, in truth, unless politicians’ sole concern is counting votes what is called for is not courage, it is the bare minimum of public service.

The key issue here is not the Downe Hospital, it is instead the nature of public discourse on the future of HSC.

Informed choices

All things being equal, it is fully understandable that people would be very reluctant to see a hospital close to their homes shrink or close.

But all things are not equal, not by any measure, not even close – and this is what lies behind the recommendations in 2011’s Transforming Your Care and the recent Donaldson report.

Central to both is the fact that Northern Ireland does not have enough specialisation within its provision, HSC is too thinly spread, we have too much local homogeneity (including too many hospitals), and that this has a direct and significant impact on the quality of services – cold, abstract if precise language, but lacking emotional punch.

Another way to put it is: if you or a loved one is seriously ill, paying to keep your local hospital open might make you or them more likely to die rather than get better.

Does the public know this? The letter from Down Community Health Committee acknowledges the report, but provides no detail. Have our politicians highlighted its reasons to the appropriate degree?

They should be repeating the messages again and again, explaining to their constituents that this is the nature of the situation, that TYC and Donaldson are not merely agendas for cuts, and that these are the decisions that have to be made.

If instead people think they are in a straight battle to lose or save nearby provision, they will always demand its retention.

The Donaldson report itself notes: “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.”

Perhaps, when all the analysis has been completed, the Downe will be seen as a necessary part of HSC. Perhaps not. But the public will not accept the closure of local services anywhere unless they are correctly informed about the stakes.

HSC is already suffering palpitations and these will only get worse. Decisive action is required.

The current Mexican standoff cannot be ended by one politician or party – such a move would likely see those stepping forward crushed by spurious populism. Instead a common voice is required, explaining the difficult rationale to the Northern Irish public.

Independent expertise

Sir Liam Donaldson himself has said he fears one of his ten recommendations will not be accepted by the Assembly.

He proposed the establishment of an impartial, international panel of experts to deliver the model for HSC “commensurate with ensuring world-class standards of care” and – the controversial bit – “that all political parties and the public accept in advance the recommendations [it puts forward]”.

The report itself received a muted response and the call for the international panel was called “the most totalitarian, undemocratic recommendation ever seen”.

Without claiming to be inside Sir Liam’s mind, it appears that the call for this panel whose recommendations would be binding was suggested as a political get out for Stormont, a way for them to implement the changes needed for the health and wellbeing of NI by deferring to independent expertise and hoping the public would accept that.

However, it is clear to see how such a move would be vulnerable to a populist approach which could still find a way to punish those who would implement the reforms needed, meaning things are unlikely to change.

This is not a case of who to blame - indeed there is no one person or group of people at fault. Many have taken mis-steps but the failures are systemic. It should also be remembered that blame is not the same thing as a solution.

The choice here is stark: mature, co-operative politics or the collapse of our health system.

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