Unhealthy future - part two

In part one of our look at Northern Ireland’s need for health reform, we identified the issue of hospitals as an exemplar of any party’s or politician’s willingness to be straight with the electorate.

Looking at the manifestos for the main five parties in Stormont, Scope found varying degrees of honesty or understanding of the issues at hand.

Altogether the picture is disconcerting. Clinicians and the public alike should be very worried.

Pre-election promises - DUP

As well as their main document, the DUP also published Our Plan for a World Class Health Service, itself an expansion of health in the manifesto, and which mentions both Transforming Your Care and the Donaldson Report – the key documents in for reform – and the party’s fundamental support for these papers and also the work of Bengoa.

“Northern Ireland’s Health and Social Care system faces a range of challenges now, and in the years and decades ahead. Some flow from the fact that we have a growing and ageing population. Others as a result of a related rise in the number of chronic conditions people are experiencing. More stem from the impact of many of us leading unhealthy lifestyles. Demand for Health and Social Care services is rising by around 5% each year. And all at a time when there is unprecedented pressure on public finances. It is evident that seeking to address the Health and Social Care needs of our citizens inside the present system is simply unsustainable. Radical reform is required.”

However, as above, a willingness to talk openly about the need to close hospitals is a great indicator about whether an individual or a party is willing to be frank about reform.

The DUP’s document does not mention shutting hospitals, and instead hints at the opposite.

It cites the new Emergency Department at Antrim Area as an achievement from the previous mandate, while enhancements at several hospitals including Craigavon Area and Daisy Hill are promised for the next five years.

However, it is explicit about offering support to primary care and also clear about how a major overhaul of health will go hand in hand with increases in spending to try and manage growing demand.

Sinn Fein

Martin McGuinness said this week that discussions on the Programme for Government had been ongoing “for some months”. On this basis, it is likely both DUP and Sinn Fein will have had one eye on their promises when drafting their manifestos.

It is a short paper; one of its 10 key promises is for “£1 billion additional health spending” and the rest of its health proposals can be replicated here in full:

• Remove the ‘internal market’ within our health structures, specifically the commissioning/provider split;
• Involve all health workers, professional and clinicians, in decisions regarding the design of a health care system that best meets people’s needs;
• Implement recommendations by the Older Person’s Commissioner on the culture of care provision, dealing with regulation and inspection, standards of care, protecting whistle blowers and training and value of workforce;
• Increase first year training intake for G.P. specialism.

More concerning was a pre-election appearance by John O’Dowd on Radio Ulster where the outgoing member of the Executive – albeit with the educational brief – said he did not believe that Donaldson really recommended closing any hospitals, or that any such measures would be necessary.

If that reflects the party line it is unlikely NI will see the reform it needs, given Sinn Fein’s continuing power within Stormont.

UUP

The party acknowledges there is a crisis, saying HSC is in the midst of huge challenges, and that it has the best interests of patients at heart.

Scope always tries to be polite, but what comes next requires firm commentary:

“Decisions about the future of the health service must be made on the sole consideration of what is best for patient outcomes and wellbeing, rather than focus inflexibly on buildings and organisational charts. Besides, too much time has been given to the flawed assumption that if hospital sites close it would free up endless resources to use elsewhere. It won’t, the savings would be negligible given that the single biggest cost is staff salaries and everyone agrees we need more, not less of them. Rather we want to shift the focus to providing the best quality of care and we believe hospitals across the network are best placed to respond, such as through the regionalisation of services, whilst also being there to respond to the emergency needs of local people.”

It is difficult to know whether the UUP are seeking to be mendacious here, presumably in a bid for public favour, or whether they are just stupid.

The idea that spending the same money in different staff settings might produce different results – with one more efficient, i.e. better value for money, and therefore resulting in better overall provision for the same financial support - is not difficult to comprehend.

Yet the above paragraph seems unaware that this is possible, as if all money spent brings the same result, with the only variable the amount put down.

Despite unanimity amongst the independent experts about the remodelling that is required to get the best value out of HSC, the UUP “believes” it knows better. This is extremely worrying.

Now, experts are not always right – even when unanimous – but, frankly, it seems whoever drafted this section of the UUP manifesto has not taken the time to even read TYC or Donaldson, let alone grasp it.

Their blithe dismissal of one of its important recommendations, using a feeble straw-man argument, indicates a failure to even understand, never mind argue against, the core principles behind the experts’ proposals.

SDLP

Here we go further down the rabbit hole.

“The SDLP wants to create a modern, financially sustainable Health and Social Care system that delivers universal, high quality and safe services that are free at the point of delivery. The Transforming Your Care reforms were to deliver a strategically planned, sustainable and financially viable model of healthcare for Northern Ireland. While the SDLP supports the intentions behind Transforming Your Care, the implementation of its recommendations have been hindered due to a lack of funding from successive Health Ministers.”

So far, so sensible. The document then goes on to say that there has been a lack of investment in community care, that this has led to pressures elsewhere, and that the party “will campaign for the full implementation of Transforming Your Care.”

Greater support for Primary Care, as per TYC, is also stated as a key aim, before talking up the potential of cross-border cooperation on certain health services where better outcomes can be achieved.

However, the paper goes on to say:

“We remain committed to the protection and retention of full A&E and stroke services at Daisy Hill hospital in Newry and the full A&E and cardiology services at the Downe Hospital. We want to sustain all other services there and plan for the provision of new services where capacity exists.”

Bear in mind that, as well as Donaldson, TYC itself has as one of its summarised recommendations:

“Over time, move to a likely position of five to seven major acute hospital networks in Northern Ireland.”

So, the SDLP wants to fully implement TYC, including its recommendations for hospitals – but, don’t worry, they want to not just protect but enhance services at the two (relatively nearby) hospitals where the party’s voting bloc just happens to be strong.

Now, when the particulars are analysed it might be the case that one or both of the Downe and Daisy Hill have a place in NI healthcare into the future – but anyone serious has to move forward with an open mind.

Instead, the SDLP talks about making all the difficult decisions, except in its own heartland. It is hard to believe the party could be so brazen.

Alliance

Again, this manifesto begins by making all the right noises – the current model is “unsustainable” and, moreover, that “it must be clearly understood that health is more than just hospitals but involves a wide range of interventions that are focused around promoting well-being.”

The different here is that there are no mad caveats, no doublespeak, no naked dissonance; in fact, if there is a qualification upon anything it is the importance of local access:

“Alliance recognises that a significant imbalance lies in the proportion of the health budget that is spent on facilities at the expense of patients. Alliance recognises the importance of providing local access, where practical, to the widest range of services, and preserving local facilities for current or alternative use as far as possible. However, this must be balanced with the need to achieve economies of scale in relation to access to the very best equipment and technologies, and to allow clinicians to maximise their skills in some specialism through having a critical mass of relevant patients.”

The party explicitly supports the creation of independent panel which, in liaison with a cross-party working group, would “discuss and recommend a major package of reforms, including the future institutional infrastructure and further investments in transport for patients and visitors.”

Northern Ireland is no stranger to reviews, or independent advice, but Alliance also suggests the clever, fudge-avoiding mechanism whereby the recommendations of the panel would be subject to nothing more than a yes/no vote in the Assembly.

Conclusions

Of course, manifestos are about winning elections. It might be the case that no-one wanted to say anything unpopular ahead of the polls but are willing to make tough decisions now.

Unfortunately, that is an unlikely optimism spun unconvincingly from an assumed starting point of wilful political deceit. So, no consolation at all.

And it cannot be stated enough that neither TYC nor Donaldson are primarily about closing hospitals and are certainly not about cuts.

In the course of one article it is very difficult to fully summarise all aspects of a report as substantial as Transforming Your Care. However, to put it succinctly (and to risk repetition, Scope does feel like it is banging its head against a wall), closing hospitals is identified as a necessary aspect of a fundamental restructuring of services.

This restructuring is, broadly, about more preventative measures, and a much greater focus on community and primary care (and therefore less on acute). Another aspect is better value for money: it is not that NI is looking to spend less money, however demand is already not being met and spending is already close to the limit – for provision to be adequate into the future the model must change.

The likelihood is some fudge, at best, will be made upon our health system and it will continue its lurching path towards some kind of catastrophe.

Unfortunately HSC does not have the money to waste on political failures.