It is time to take politics out of the day to day running of the health service. A guest post by Dr George O’Neill.

 

All of the party leaders, before the recent election, committed themselves to taking politics out of health. Is that realistic? I would suggest not. But what we can do is we can take politics out of the day to day running of Health and Social Care. That is an entirely different prospect.

Bevan’s original idea of the Health Service was that it would dramatically improve the health of the population. Demand would decrease and cost would be reduced. This has not happened and we now have an infinite demand with finite resources.

We spend almost half the block grant on Health and Social Care: the equivalent of over ten million pounds a day. That delivers only eighteen per cent of the health and well-being of each of us.

We need to work with and support the other social determinants which are responsible for the other eighty two per cent of our health and well-being.

So with budgets short and political will scarce: how do we go about this?

We had difficulties with policing, a very contentious issue. One of the ways of addressing some of the problems, not all, was to set up the Policing Board. It is composed of politicians, as well as the good and the great, who can challenge, question and demand explanations from the Chief Constable.

The Chief Constable is directly responsible for day to day operational matters of policing and cannot be over ruled by the Policing Board. If they do not like what the individual is doing the only recourse is dismissal.

Therefore I would suggest we need to have a situation where there is a Chief Executive with absolute authority over operational matters. The Chief Executive would be answerable to a board that has the right to question, has the right to demand explanations, and if necessary sack the individual but cannot overrule any decision.

This board would consist of politicians and some of the good and the great and it would be assembled according to the dHondt formulary set out in the Northern Ireland Act 1998. The Department and the Minister could develop policy in strategy. But they could not nor could the Board if set up overrule the Chief Operating Officer.

My hope is that the report by Professor Raphael Bengora will suggest a similar scenario and will help drive forward the necessary changes. Also in the background is the long delayed O’Hara report of the Hyponatraemia Inquiry which when released will certainly have significant implications for the governance and accountability of those who operate in our Health and Social Care system.

What should an ideal health care system look like?

It should be universal, it should be free at the point of need not want, its focus should be in preventing illness and health promotion and in fact it should run a wellness service not an illness service. Our priorities should be given to self-management and we should be supporting carers. This is also the self-management of minor illness, which was the case when I started my career, but now appears to have disappeared. Everyone wants an instant response and instant solution to trivial, not life threatening, episodes of illness.

The focus should be on Primary Care. By that I mean in a broader sense including District Nurses, General Practitioners, Pharmacists, Dentists: the whole team that delivers most of our health and well-being outside of hospital.

There needs to be a greater emphasis on identifying people who need extra support. The gold standard is to have proper integrated care not the present service which lacks evidence of integration at the coal face. Ideally all involved in Health and Social Care should work for a single organisation, but that is probably a step too far at present. Greater efforts are needed to improve information technology and develop co-ordinated care.

We also need a different model of delivery. When I first qualified I was trained in acute episodic curative illness. All of my patients with chronic diseases attended the medical outpatients at hospital and now the medical outpatients have disappeared. My hospital colleagues are super specialists for the most part and chronic disease management is in the hands of general practice. Yet we are using the same acute episodic curative model for conditions which we will never cure, and will eventually result in the death of the individual. There has been no increase in funding or numbers of health care professionals in Primary Care to deal with these significant and increasing demands.

In summary, whilst it is not possible to take politics out of health, politics can be removed from the day to day running of health.  A body similar to the Policing Board with the equivalent of a Chief Constable in charge of operational matters needs to be agreed by our elected representatives with a consensus ten year vision based on the Bengora Expert Group report for Health and Social Care.

The Health Board would consist of politicians based on the dHondt principles and the good and the great. They would be able to hold the Chief Executive to account and question operational decisions. But they could not change or overrule and if they were not happy they could sack the individual. Change is needed urgently as time is running out.

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  • Brian O’Neill

    George will be talking about this topic on Talkback today. Tune in.

  • chrisjones2

    I admire the sentiment but if we did this what then would the role of the politicians be? If they could not interfere and grandstand who would they get access to the pork that secures votes. Imagine the row if for example Downpatrick Hospital was culled (as rationally it should be) or the Donaldson plans were fully implemented

    The reality is that if we adopted this rational model we wouldn’t need another Assembly Minister and for that reason alone (with a multitude of others) no matter much this might benefit society , it will never happen

  • Dai Dobbs

    Read this from George before. Trouble we have is with the costing model. We don’t fine poor performance we don’t even measure poor performance. Also regional medical models won’t happen untill we get 1 trust delivering our care.

    We have a Chief Executive of the Health and Social Care service his name is Richard Pengelly a partner of DUP MLA Emma Little-Pengelly and he answers to the Health Committe all the time.

    Ultimately as a society until we decide to either fund social care better we have to rely on acute care to look after our frail elderly.

    The other solution is prevention…. something we currently spend less than 5% of the budget on….

  • Skibo

    The one issue I see is we have to address the acute care as that is where the crisis is. It is eating up the funds. Money spent at the other ends with education will be more cost effective but as there is no crisis there the funds will not be released.

  • Teddybear

    Let’s take politics out of education, agriculture, economic planning etc

    Sorry but despite this being a nice sentiment, it makes little sense. Politics is not a negative thing but it’s made out to be. Politics is the debate over how to spend limited resources in response to changing needs within any given timeframe.

    Therefore it’s impossible to take politics out of healthcare provision. Treatments change, demographics change, technologies change, medicine changes, public health concerns change etc. Health is a v fluid matter and all these things I’ve mentioned involve making decisions to allocate funds and resources appropriately

    And that is politics

  • chrisjones2

    There is no magic money tree. Rational decision have to be made on cutting some services to pay for what we really need. That way we can create the space for change within the budget . but that requires rationality and decisions …two words not often found at Stormont

    Anyway we will know soon enough …if they dont commit to do it in the first year it will never be done as it will then be too close top the next election

  • notimetoshine

    The problem is politics is riven with petty party political and parochial demands which inhibit “making decisions to allocate funds and resources appropriately”.

    Take the whole issue of closing hospitals and centralising services. An eminently sensible policy, one which has been mooted fr years in NI by people as diverse as Maurice Hayes and Sir Liam Donaldson. Yet the politicians would never countenance the idea, too unpopular with knee jerk populists and those with parochial mindsets. Newry is a good example, where the argument against any change of service in Daisy Hill seems to be “we are a city we need a hospital”.

    It really is time to take the experts seriously and not the politicians, who haven’t exactly shone with competence on these and other ‘operational’ matters.

  • Skibo

    I didn’t say to shake the magic money tree. I merely pointed out why it is politically pragmatic to make sure the vast majority of money is spent at the acute end where it is actually less effective. Health should be removed from direct political on-the-cuff decisions and run by a medically minded executive. Run as a business but with an advisory role only by politicians.

    One board is enough to cover the whole of NI. Probably enough to cover Ireland as a whole when you think about it.
    The decision on the number of hospitals and their locations should be relatively simple once we have one board.

    The GP system needs to be resolved also. GPs should be available 24/7 to treat all minor injuries and take the pressure off the A&E and the hospitals.
    Social care has gone backwards in the last ten years. This has resulted in bed blocking and people capable of going home, not able to as the care is just not there.
    The cost of hospital care starts somewhere round £400/ day while care homes cost between £80 and £100/ day.
    15 minutes morning and evening would be minuscule compared to that.

  • Dai Dobbs

    There’s no crsis NI ED attendance has only increased by 5% in last 5-6 years. Problem has been the pay rises the increasing amount of consultants and the fact that everything has to be done by a specialist as Dr O’Neill explains. So more expensive secondary care = more money needed to keep pace. In a perverse way the fact that our NHS needs more resources is testimony to us living longer and now presenting with more complicated comorbidities. Alas we can’t have our cake and eat it.

    We now need a 2 tier health service. Free care for those needing emergency treatment and a levy for all non essential care. Good luck selling that to the electorite who still want a 1950s model for 2016!!!

  • Skibo

    “In a perverse way the fact that our NHS needs more resources is testimony to us living longer” a sign of just how effective the NHS has been.
    If we do not decide what we can afford for a health service and stick to it, we will have a monster on our hands that we cannot control.
    Sounds sadistic but will we actually be able to afford to pay for health care in the future.
    It was interesting in GB when the Junior doctors went on strike, the waiting lists in the hospitals were gone. The percentage of consultants to junior doctors must be an issue with the normal day to day running of hospitals.
    Wonder what happened to the waiting lists for private patients during that time?

  • Teddybear

    Centralising hospitals is as sensible as centralising street lighting. Speed to hospital is what matters. I bet people who have to travel from Omagh to Altmagelvin or Enniskillen have slower
    To heal injuries as a result.

    Not to mention relatives having to make epic journeys to visit loved ones. Ever try to go to altnagelvin by bus?

  • notimetoshine

    Well Sir Liam Donaldson isn’t exactly a novice in these matters and he would disagree I should imagine. Case in point really where politicians and politics trumps expert advice in favour of political expidency and ego stoking.

    The health service would be in far better hands if it were left to the experts.

  • Vince

    Despite the propaganda that we spend too much on healthcare in this country, the opposite is in fact the case. There are indeed inefficiencies – too many patients attend ED who should not be there, money is wasted on antibiotics when they are not needed (increasing the risk of antibiotic resistance), too little resource is directed to effective mental health care which has consequences for physical health, employment etc, not enough patients are seen in the right place, at the right time by the correct doctor, too many NHS consultants can be found working 9-5 Mon-Fri in the Ulster Independent Clinic and other private Healthcare facilities, there are too many acute hospitals, not all of which have the services required to provide truly comprehensive care, and having 5 regional healthcare Trusts in a population of 1.8 million is just absurd. However, despite all of this (and much more), we spend a significantly smaller proportion of our GDP on health than the Republic, US, Australia, France, Germany, Italy – and we manage to keep it, largely, “free”.

    It is actually quite remarkable. Improving it requires some extra spending and some reorganisation, with some smarter deployment of existing resources. It can be done. Rather than taking politics out of health, we need politicians with the guts and vision to take it on.

  • chrisjones2

    Why do we need a Board when we have a department with a Minister or Vice Versa?

  • chrisjones2

    Sorry speed isn’t what matters outside very small numbers of major trauma cases Volume of procedures is the key and that applies even in trauma cases so best with perhaps 2 centres at most in NI plus an air ambulance

  • Nimn

    George O’Neill’s frustration at the inability of a small health service consuming over £4.6bn to cover the health needs of 1.8m people, (many of whom infrequently use health services) is palpable. Many of us share that frustration. On 26 May Michelle O’Neill’s issued a statement which began.

    “The north’s health and social care sector is the envy of many countries across the globe and there is much we should be proud of and thankful for. We are pioneering, innovative and patient focussed, while remaining free at the point of delivery.”

    If you remove Michelle O’Neill’s name from the statement (and leaving aside the usual semantics of where we live) every minister since 1998 could have signed this. Anyone who has come into sustained contact with our much lauded integrated healthcare system will know that for the majority of care it is not “innovative pioneering or patient focused”. It is in the main a service which is working at full capacity and failing to answer demand. In may instances what we have is a type of ‘displacement care’ where people are moved on as quickly as possible from one part of the system to another. This is particularly noticeable with social and community care, where the support for re-ablament and all that is good in Transforming Your Care is simply not there.

    We also need to be brave enough and honest enough to recognise that all front line care is not stellar, as we are asked to believe. Most front line staff are working to capacity, but quality of care and dignity are suffering as there is not enough time to provide for patient needs. Equally we have patients and clients in the system who need not be there and treat the system and its staff with contempt.

    We are probably now beyond the point where our Healthcare system can heal from within.

    The new shiny Department of Health only need look at its own website to see the catalogue of political spinelessness which is the biggest drag anchor on our healthcare system. Under the topics and health policy tabs:
    https://www.health-ni.gov.uk/topics/health-policy you will find references to the Hayes Report 1999, recommending a new configuration of hospital services Developing Better Services, 2002 which set out that new configuration and the Donaldson Report, twelve years later where he voiced his obvious frustration at the lack of progress by suggesting an independent panel come to decisions on hospital configuration and politicians endorse it. Almost 17 years of inaction since 1998, despite the same conclusions on reform. That is leaving aside Transforming Your Care, also languishing on a dusty shelf.

    Rather than proclaim a utopia of a a ‘world class health service’ we need to ask a series of different questions. Have we reached a tipping point where reform is required in every corner of our health care service and where it may be impossible to reform itself? Why in a world of diminishing resources and attendant diminishing outcomes do we cling to the same delivery models when we know the patterns of care are changing? If we are really serious about increasing health outcomes are we not sufficiently mature as a political class and a society to discuss a full range of provider care, public, private and the VCS under the cornerstone principles of universal coverage and free at the point of need? Far too often we degenerate into the public/ private healthcare debate without discussing how the strengths of both systems can deliver the quality healthcare we need.
    As an example on highly effective vertical integration (aligning the clinical and business models) – the Alzira Model – in the Spanish public healthcare system read this:
    http://nhsconfed.org/~/media/Confederation/Files/Publications/Documents/Integrated_healthcare_141211.pdf
    Professor Bengoa, the latest in our merry go round of reviews will be very familiar with this model, but I don’t expect his report this summer to say anything we don’t already know for years past.

    Also George O’Neill and the BMA as champions of general practice need to have a heart to heart with themselves. Our Out of Hours system is a shambles. General Practice is a huge part of our integrated system, but are they not also a significant part of the problem?

    Our political class and our TUs are so ideologically wed to a fully public healthcare system that the only solution is to pump ever more money into a broken system. Throwing cash at waiting lists is a short term solution and talking about £1bn headline cash injections into healthcare here is a political conceit. It is merely around the average annual uplift in healthcare spend across the next five years and does not address the full demand cost. It is certainly not new money for new things.

    Rather than platitudes from Ministers we should be discussing whether our Healthcare system has reached a ‘Gordian Knot’ moment where we can continue to try and unravel the systemic issues in healthcare here and continue to fail, or take a sharp sword of reform to it and have the hard edged discussions that will genuinely change our system. That will take imagination, magnanimity and real leadership from our political class – three attributes sorely lacking this far.

    What is clear is that tinkering at the margins of structures and structural reform is a further example of the ‘displacement activity’, which avoids any meaningful change, and while George’s frustration is palpable and his idea sincere I think it would be largely a waste of time.

  • Skibo

    Why not?
    There is now one board for Education where there used to be numerous boards. The Minister cannot manage the whole thing. I guess these things will be left in each department until there is a SF Minister to sort it out!
    Even in a large company there is a board of directors with a Managing Director pulling the strings.

  • Theelk11

    Most nurses and doctors in emergency care wish they were working somewhere else, there is a vicious circle of not being able to meet demand because the job is highly stressful leading to a lack of staff to meet the demand.
    They see elderly people coming with an ” emergency ” with conditions which are anything but and which any sensible system would have the forsight to treat before it became not a medical but a social crises leading to the GP attending defaulting to emergency care by ringing an ambulance and landing frail elderly patients with ill thought out or non existent care plans into an utterly inappropriate environment. Primary care lets these patients down.
    Centralised emergency care in fewer sites will not solve this. The people who work in emergency care know that what will happen is that resources will be rationalised on fewer sites leading to exactly the same pressures except on a much larger scale. If the general public are sold that they will be seen quicker if we have fewer emergency departments they will be buying a pup.
    We have the lowest bed capacity of any first world country coupled with the lowest funded social care budget , perfect storm..

  • Nimn

    “Primary care lets these patients down”.
    I was talking to a nurse recently who works in a geriatric ward in the City Hospital. Her view was that the City is now a dumping ground for everyone Royal staff don’t want – a lot of whom are inappropriate GP referrals. The example she gave for a GP referral to hospital was the elderly patient was “off her feet”.
    For many GPs hospital is an easy option.

  • Nimn

    I agree with you and the language around the hospitals debate isn’t helpful either. The media constantly talks about ‘closing’ hospitals when what they mean is removing acute services. These hospitals won’t close but will be ‘reconfigured’ for diagnostics, smaller non acute procedures, outpatient appointments and step down bed facilities for those preparing to go home, all receiving pressure on the main acutes.

  • Theelk11

    Hi Nimn
    I hope this posts beneath you I can’t work this posting system
    its not about GPs , they are starved of choices because they are starved of options and resources they have no alternative to calling an ambulance and overloading emergency care.
    Knock on is that emergency care is crowded with patients to to which they can unfortunately add little value to their journey through the health care system and they lie on trolleys till someone calls Nolan
    audits show the emergency departments and acute hospitals in this jurisdiction excel at their core function of identifying and treating the very sick . That is the core function. Everything else is political.

  • Theelk11

    Emergency medicine is not a specialty that lends itself to private practice. So that’s a non starter in acute care.
    Emergency attendances have indeed increased but the proportion of older people with multiple complex medical problems has grown enormously these patients are complex to treat. The medical aspect of their care is often a sideshow to complex social issues.
    There is also a huge tension between acute and elective care which hospitals fight to balance between emergency admissions and keeping the flow of elective beds free to operate on non emergency conditions.
    as the baby boomers age and continue to demand the best for themselves sequentially by age (dope, music,lying to girls about sex ,unemployment benefits, houses, pensions ..health care…) they want everything and they want it now and they want it free .. Man…

  • Dai Dobbs

    We let the Department run it ….. Lolololol civil servants being accountable….. Lolololol…..

  • Nimn

    I quite believe the audits when it comes to aggregated numbers and measures, but my personal experience with A&E – I have attended in support of a close family member around 9 times since early March – has been very mixed. On the first occasion 16 hours on a trolly, where my relative got a lot worse and ended up in ICU the following day; conflicting diagnosis by different doctors in the space of an hour; lack of equipment and a general air of chaos management at times. Patient dignity and privacy was low.

    Most of all the bed management in the hospital was struggling. In one temporary stop in a ward there were people lying down the centre of bays and screened off in corridors. How can this be safe dignified care?

    As for GPs being starved of choices – they are I believe too quick to take the hospital referral route.

    As I said in my original post, it feels like we have a healthcare system which is operating on a principle of displacement, where moving patients on to another stage or level gets the immediate problem off someone’s hands.

    I know my way around the healthcare system and at times it was a battle a day to get things done. That leads me to wonder what level of care those people who cannot speak up for themselves or have someone advocate for them, receive.

  • John Collins

    CJ
    Correct. And crucially for specialists to maintain, and indeed enhance, their skills they need a certain level of cases passing through.

  • articles

    Credit where credit is due. Was this not Conall McDevitt’s bid idea?

  • articles

    Credit where credit is due. Was this not Conall McDevitt’s big idea?