The Real Politick of Health

Michael McGimpsey has been one of the leading complainers regarding the recent PfG spending plans. He has requested (at least £300 million) extra funding with some significant backing.

This brought opprobrium from both Robinsons (Iris and Peter) at one stage resulting in Iris’s ejection from the chamber. Now, however, the SDLP seem to be asking the department to make efficiency savings. Efficiency savings, like anything else involving decisions may be unpopular with McGimpsey.
One of the many elephants in this particular room is the number of hospitals in Northern Ireland. The Hayes report (links no longer available) recommended reducing acute hospital numbers and a previous report to the old Stormont Parliament in 1966 recommended six acute hospitals (no online link).

A good parallel to draw is with Wales. Apart from along the M4 corridor; there are considerably fewer acute hospitals per capita frequently with larger distances between them and road links at least as problematic. Prior to the last Welsh assembly elections, Labour proposed merging hospitals and reducing their numbers. This proposal became an important issue in the election campaign there and following Labour’s poor showing these proposals were put on hold.

As medical practice moves inexorably towards increasing specialisation and larger individual units it is not just Wales where mergers and closures seen as medically and practically desirable then become politically unacceptable. Dr. Kieran Deeney’s two election victories in West Tyrone on a ticket of saving Omagh Hospital are paralleled in England by Dr. Richard Taylor’s victories in Kidderminster in another save our local hospital election. Even within the Westminster government itself there have been divisions with Hazel Blears being accused of hypocrisy for protesting against the closure of a maternity unit in her constituency.

Whilst an argument can be made for having as few as six hospitals in Northern Ireland; a good compromise would probably be to have the “Gold six”: Royal, City, Ulster, Craigavon, Antrim, Altnagelvin and a “Silver Three”: (my term) Enniskillen, Causeway, Newry. Clearly this would require the expansion of the remaining hospitals prior to the closure of the other units. However, the chances of persuading the politicians let alone the Northern Ireland population?

So the question is: Whatever the efficiency improvements and the medical arguments in favour of a rationalisation of the number of hospitals here; have hospital closures become politically impossible and to what extent do the medical and nursing professions support them?

  • Dewi

    Well Done Turgon. That’s your first yes?
    Very interesting observations – you are right – here Plaid were unashamedly parochial in defending local hospitals – to the extent of modifying Party description on ballot paper eg “Plaid Cymru – Party of Wales – Save Withybush Hospital” in Preseli Pembrokeshire.
    Not particularly proud of that.

  • George

    I find it extremely odd that if we are talking about the realpolitik of health on this island that no mention is made of the potential benefits of an all-Ireland health strategy.

    After all, we already have a situation where those with private health care enjoy the benefits of access to facilities north and south of the border so why not everyone?

    The larger population count would lead to better more economically viable specialist supra-regional services.

    The nearest hospital might be in the other jurisdiction. Why travel further than necessary for emergency treatment?

    It would help alleviate the disadvantages experienced by those living in border areas. The mortality rates of those living in border areas in Northern Ireland are higher than the average.

  • The problem is that hospitals aren’t chessboard pieces. They are major pieces of civic infrastructure not to mention substantial employers – and they rarely leave large centres for small ones, more the other way round.

    Therefore you combine the fear of not having ready access to service (you can wait four hours to be seen near home or travel two hours to wait four hours) with the usual uproar that would follow the loss of a private sector employer of equivalent size.

    The fear is that specialisation is a nicer way of saying cost-cutting, that while quality of care might improve once you get to the head of the queue that the queue will get longer because the centres of excellence will not expand sufficiently to absorb the former hospitals’ caseload and so on.

    In my view these kinds of changes can only be sold rarely, and then only if there is a commitment to expand the current services the local facility provides so there is not an obvious death by a thousand cuts as the hospital is demoted to a clinic and eventually closed.

  • Michael Shilliday

    George. We can have a taxpayer funded all island healthcare system. Just as soon as the Republic re-joins the Union. Until then, the south will have to make do with their shambles.

  • red branch

    Interesting take. The key unanswered question is – what is and acute hospital? What services do they provide and does any of out golden or silver hospitals make the grade?

    If radical change is to be made then services and not buildings shouldbe consdered. Clearly we have too many buildings, located inthe wrong places, failing to provide an adequate service. Just think – the Royal, the City and the Ulster. while Belfast is the greatest centre of population the resources of these three could better serve the public/patient bymoving at least one of these out of Belfast.

    Yet the question remains what services are needed and how accessible should these serviices be to the public?

  • interested

    Closure of hospitals is always going to be a political hot-potato. Its like school closures only on a much bigger scale. Everyone but everyone talks of the thousands of empty desks and our erstwhile Minister for Education even uses it as an excuse for her ‘plans’ regarding post-primary transfer. Yet there is never any talk of actually closing a few schools, which is one thing which would get rid of a few of those empty desks. No-one wants to hear of their school or their hospital being closed, but we’re all very happy to talk about the generalities of the issue.

    Leave hospital closures aside for a Minute – if Micky McGimpskey wants to save a few quid then he could get on with replacing the Health Boards here with the Single Authority promised. FFS its in his own election manfiesto and in the Ulster Unionist Party’s response to the Review of Public Administration but he seems paralysed by fear, preventing him from actually doing something which could drive some money back into the front-line of health care.

    Its good that the SDLP have finally started to wake up on this issue. No Minister can just keep asking for more and more money without being questioned about how they’re managing the money they already have.

  • George

    Michael,
    you seem quite happy to have a billion euros of Irish taxpayers’ money to help bring your Northern Irish roads up to standard without any mention of potential political unification.

    Something tells me you won’t be demanding this Republican money be handed back any time soon.

    And last time I looked the waiting lists for surgical procedures north of the border were a hell of a lot longer than those south of it.

    There seems not enough reality and too much politik in the realpolitik being discussed here.

  • wild turkey

    Turgon

    A very clear, pithy and provocative piece. Do I have the answers, no. But I do have some questions.

    1. Is anyone aware of any efficacious methodologies that, within a given catchment area, take into account varying population densities, demographics (ie age, incidence of disability, income) and road traveling times when attempting to identify potential sites for major infrastructure projects such as acute hospitals

    2. In this and other juridictions, what is the stance professional bodies (BMA, Royal College of Nurses, etc) and unions (Unison) regarding the rationalisation of acute hospital services.

    3. What appears to work best elsewhere in the world?

  • Michael Shilliday

    You’re seriously going to try to argue that the South’s health system is better than Northern Irelands? Really?

  • George

    Michael,
    are you seriously going to argue that waiting lists are not longer north of the border?

    And are you seriously going to argue that when looking at how to improve health services in Northern Ireland, taking into account potential benefits of co-operation with the Republic shouldn’t even be considered? That was my original point which you have singularly ignored.

    Just like on infrastructure projects, there are a number of health issues where it makes sense for the two jurisdictions to co-operate.

    And I see you aren’t advocating handing back the billion euros of Republican money that will improve your infrastructure and our access to the Northwest.

    Mutual benefit is not a dirty phrase.

  • Michael Shilliday

    The billions of Euro’s that the South has handed over for foreign investment is neither here nor there, Northern Ireland is a part of the 5th largest economy in the world, we can live without investment from the south, that same cannot be said about the east. The South’s health system is a mess. A total, stunted mess. Ours isn’t perfect, but its a clear shot better than what the south have.

  • George

    Once again Michael you have failed to address the point.

  • Michael Shilliday

    If the Republic wants to take advantage of the superior system in Northern Ireland, they’d better be prepared to pay for it. If there are instances where the opposite is true, there should be a costing done and the most cost effective use of UK taxpayers money arrived at.

  • steve48

    “Significant investment is required to improve
    efficiency In Northern Ireland.We advocate increased funding in excess of the Barnett formula to ensure those in the province receive a standard of care that matches the best found elsewhere in the United Kingdom.Northern Ireland has suffered from relative underfunding compared with the rest of the UnitedKingdom for decades. It is estimated that more than 20% extra spending per capita on health care is required to achieve the same level of service as in England.Yet the Barnett Formula does not consider differential need.The extra costs of treatment as a
    result of the last 35 years of violence total around £300 million.” DUP Priorities For Health

    Interestingly Iris has asked the Minister to outline why the Mater Hospital has not been closed. Perhaps she should ask her colleage Nigel Dodds who took the campaign to save the mater to westminster.

  • Truth & Justice

    Its interesting to see that the Health budjet has got 51% of all new money 460 million pounds of new money for a budget for Health of 7 Billion thats nearly half a billion more for Health and it was interesting to note the Health Miniter stated he could get 500 million pounds of efficiency savings over time i think he is playing games with the health money?

  • George,
    I find it extremely odd that if we are talking about the realpolitik of health on this island that no mention is made of the potential benefits of an all-Ireland health strategy.

    In these modern times, no need to be so parochial; why stop at an “all-Ireland” health strategy, make it an “all-EU” one and then we’ll see the real benefits:

    http://news.bbc.co.uk/1/hi/world/europe/7150879.stm

    If that comes off, then there’ll be no need for your real-politiking, the sick punters either side of the border will be able to vote for the best service with their crutches.

  • Dewi

    Same debate in Scotland – it’s funny that everyone says says take language out of politics – might be an idea to take Health out of politics. Interesting debate.

  • Comrade Stalin

    Congrats Turgon, nice to see you aboard as a blogger.

  • Danny O’Connor

    I have been totally unimpressed by McGimpsey as health minister-he almost makes me wish that we had bairbre de brun back-and that is saying something.He is being led by the nose by civil servants in trying to close the only hospital beds that are left in Larne.He has not responded to a number of letters from the council on the issue-the first one sent by myself and the chief executive during my term as mayor,he has also not responded to the current mayor,despite giving him an assurance-which he has since reneged on to come to the council and discuss the issue.So much for devolved government uup style.We have had a DUP minister visit the council ,a Sinn Fein minister visit and the SDLP minister visit twice.

    I have to say also that the performance of the MLAs on this has been woeful.

  • lamh dearg

    North v South, not a lot too choose between them, both middle ranking in international terms, both have strengths, both have weaknesses, both have too many small peripheral hospitals, both locked into their inefficiencies by political inertia.

    There is scope for joint working, CAWT http://www.cawt.com/site/default.asp is running some cross border Out of Hours primary care schemes, there is obvious potential for (just examples) people from Belleek to go to Sligo rather than Erne and people of Inishowen to go to Altnagelvin rather than Letterkenny. There is real potential for joint working in Cancer Centres where more patients mean more expertise and better results and possibly less travel for patients. But to a large extent that misses the point of too many hospitals.

    Omagh Hospital is not sustainable as a modern acute hospital despite what Ciaran Deeney might claim to believe, likewise Larne.

    There is now proof that for some of what used to be the core business of these smaller hospitals size does matter. A woman with breast cancer has a greater chance of survival if she is operated on by a surgeon who does at least one hundred breast cancer operations per year, likewise bowel cancer patients, likewise paediatric surgery. If you take these out of hospitals like Omagh there is no longer enough work to allow the surgeons and anaesthetists to maintain their skills.

    I often wonder if the campaigners protesting about closures would accept a lower standard of care for their families in order to keep these small hospitals open, because in effect that is what they are asking the community to accept.

    But no-one will ever win extra votes by suggesting closing a local hospital, even the local professionals who really do know better will rally behind the Save Our Hospital banner and the waste, the duplication and the second rate services continue.

    Perhaps if the NHS was handed over to a non-political Agency with a mandate to run the service free of political interference things might change but the politicians are too scared to do that. Locally our best chance was Sean Woodward, arrogant enough and free from seeking Northern Irish votes to be able to actually do something. None of our local “leaders” will ever have the guts to close a hospital, our current one cannot even allow the demise of the Boards and our last one was famous for telling her Civil servants “I don’t take decisions”

  • Danny O’Connor

    lamh dearg
    the beds in Larne are mot acute beds.They are for patients requiring rehabilitation following strokes etc.there is also a paliative care facility.The acute hospital at Antrim is already at over capacity .there is no attempt by anyone to close the beds in Masserene hospital despite it being less than 2 miles from the acute hospital.The beds in Braid valley or the community hospital in Ballymoney (1st ministers constituency)or the Mid Ulster (deputy 1st ministers constituency) are not under any immediate pressure, I wonder why.Larne was promised a community hospital & minor injuries unit 10 years ago.when the Moyle closed the future of Inver House was guaranteed by the board.All the people of Larne have had is broken promises. s

  • lámh dearg

    Danny

    Larne, Masserene, Braid Valley, Ballymoney, none of these should be called hospitals.

    Have step down beds or intermediate Care beds in these areas in Nursing homes, for patients who have recovered from an acute illness or an operation or as you say for palliative care (although even in this case a dedicated hospice offers a far superior service where home care is no longer viable), with access to a proper hospital if a patient’s clinical situation deteriorates but we should not try to pass them off as hospitals in some attempt to fool the local communities.

  • Danny O’Connor

    are you suggesting the privatisation of the NHS.The required changes to proide home care is not available.If someone needs their home adapted to enable them to return there ,there is a lengthy planning, building control and grants process,even then try getting a registered builder to do the work for the grant money.As for Hospice it is a charity ,as is MacMillan ,as is Marie Curie Best Practice elsewhere alows for community hospitals led by a nurse practitioner supported by GPs.There certainly is a suspicion that that is exactly what is happening.ie indirect privatisation.

  • lámh dearg

    I am talking about short term convalescence, not long term adaptions.

    If, for example, an elderly resident from Larne developed pneumonia requiring hospitalisation he/she should be admitted to a properly staffed equipped District General Hospital, in Belfast or Antrim, when on road to recovery but still perhaps on injection treatment or still needing oxygen or just too frail to return to own home, then transfer him/her to an intermediate care bed in Larne, most economically provided by nursing home be it private or local authority or NHS owned. Good for patient, good for friends and relatives and frees bed in acute DGH for another patient.

    What is a “community hospital”, what type of patient gets what kind of care there, from whom? GPs no longer work 24/7 so who is medically responsible at night? Basically a commub=nity hospital is a nursing home and that’s fine but let’s not pretend it is a hospital.

  • Danny O’Connor

    I have visited community hospitals in Devon with representatives of the board,they are managed on a day to day basis by a nurse practitioner with a minor injuries unit dealing with minor accidents ,these are linked to the county hospital in Exeter.One has a maternity unit,another deals in day surgery,another deals with opthalmic surgery.fractures can be set,x-rays are viewed via computer ,tele- medicine as it was called then.peoplle also convalesce thus avoiding bedblocking in the county hospital.The point is that it works.This was going to be implemented in the northern board area-10 years ago.More empty promises.