Waiting for Godot: Northern Ireland’s health care

Waiting for Godot, one of Samuel Beckett’s greatest works, documents Vladimir and Estragon’s fruitless wait for the eponymous Godot. At times waiting for health reform in Northern Ireland has been rather like Beckett’s play: lots of promises that it is about to happen but nothing ever does.

In 1966 there was apparently a plan to have six main hospitals for Northern Ireland and most of the reviews subsequently have suggested that as the optimal number of acute hospitals. Throughout Direct Rule few decisions were made: at one level this might seem surprising. Direct Rule ministers were largely conscientious about their work and one might have thought, having no local constituency backlash to fear, that they would have been willing to make medically necessary though politically unpopular decisions. Part of the problem may have been that Direct Rule ministers did not want to make politically contentious decisions. There was already enough political controversy in Northern Ireland without adding hospital reorganisations to the mix. There was often the hope that a devolved administration was just around the corner and as such the NIO ministers may have felt that such decisions could soon be taken by locally appointed politicians. Finally and more cynically the Northern Ireland Health Minister was not an especially important post in the scheme of Westminster government appointments and creating waves as a local minister might have damaged the upward rise of the minister’s career.

Since the resumption of devolution we have had little more in the way of action. DeBrun made a virtue of doing nothing and seemed unable to comprehend that radical changes were required. McGimpsey was apparently aware that there were major problems but was incapable of taking major decisions. Rather like a rabbit in the headlights he seemed paralysed when the need to rationalise the acute hospital sector was mentioned.

The case for reform of medical care in Northern Ireland is fairly overwhelming. Even with the recent closures there are 12 acute hospitals admitting patients. This is per capita significantly more than any other region in the UK (or Ireland). We are not a particularly large region and contrary to popular belief compared to many parts of rural England, Scotland and Wales we have good transport links. What Northern Ireland needs is less acute hospitals and more community care to keep people especially the elderly and frail (disproportionally the major users of hospital services) in their homes. Added to that we need a smaller number of acute hospitals each of which with a larger range of services: fewer hospitals but the ones we have being centres of excellence. The idea of admission, stabilisation and onward transfer is out dated, expensive and leads to poorer outcomes and longer in patient stays than transfer even over longer distances to definitive care. The much vaunted “Golden Hour” is the hour to definitive care which can often only be offered in larger hospitals: a factor ignored by those defending the need for a hospital in every medium sized Ulster town.

Closing hospitals is of course one of the causes guaranteed to unite politicians across Northern Ireland’s divide. One need only look at the downgrading of Tyrone County to see Pat Doherty and Thomas Buchanan united as one. Furthermore, frequently the closure or downgrading of one hospital as opposed to another is regarded as a sectarian decision: a position viewed with bemusement by almost all health care staff, but common in the community. As an example the Royal is a “nationalist” hospital whereas the City is a “unionist” one: a concept recognised yet simultaneously regarded as incomprehensible by almost all their employees.

The need for reform of the Northern Ireland’s acute hospital estate is overwhelming and often privately acknowledged by politicians: however, for the reasons mentioned above we have been waiting for Godot forever. Now, the combination of two factors may bring the waiting to an end. The reality is that as well as being inefficient and old fashioned the excess number of small units costs a great deal of money. In the current financial climate if Northern Ireland is to maintain its current position in health let alone close the gap in the many areas where it has fallen behind the mainland GB health service, it needs to rationalise and nowhere more so than in the provision of acute hospital services.

The second factor is that we now have a Health Minister who might be willing to make the difficult decisions. The Comtpon Review was announced in June and was due to report last week. It has now been delayed until next week. This is hopefully merely procedural. Poots has so far stated that he will take decisions even if they are difficult ones and has been willing to agree to a reduction in hours in the A+E department in Lagan Valley in his own constituency. As such the signs are hopeful. However, there will no doubt be shroud waving by various groups in the localities where the hospitals are to be downgraded along with the sight of politicians leaping onto assorted bandwagons and attempts to get the courts to overturn medical decisions or to get the judiciary magically to create appropriately qualified doctors.

We are still waiting for Godot: maybe Compton or Poots will bottle it and fluff the review though it looks as though both men are made of sterner stuff than that. However, even if the review is as radical as it needs to be, no doubt the guerilla campaign against the necessary changes will go on. If they carry it off, however, Compton and Poots will go down as men who made a massive contribution to healthcare in Northern Ireland. If there is any justice in politics such an epitaph will not also be the end of Edwin Poots’s career.

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  • Drumlins Rock

    Turgon, was looking the The Royal & City on Google earth today and they are extremely close together, surely they could be treated as one Super Hospital for the entire province, even if some special transport link were needed to achieve that. In essence that is how things work, it is one regional hospital but awakardly split in two, whereas the rest are local hospitals of various degrees. If that was the case the Mater could become the local hospital for North and west belfasf and Dundonald for the south and east.

    Could you give us the list of current acute Hospitals? and to put you on the spot, which 6 would you retain?

  • Turgon,

    You have blogged this issue a number of times with little response. It seems like a no-brainer but there you go.

  • Turgon

    Joe,
    I agree it is a bit depressing. People would prefer I lauch attacks on someone or other and denounce me as a bigot: such is life.

    DR,
    To an extent that seems to be the idea: to have the City as cancer and some elective stuff and the Royal for other things. That will probably work well: the only problem is that sometimes the elective people “go off” and that means one needs some duplication of services on the City site. Not an insumountable problem.

    Turning to numbers and positions of hospitals.

    Currently we have:
    Royal (Belfast)
    City (Belfast)
    Mater (Belfast)
    Ulster (Belfast)
    Lagan Valley (Lisburn)
    Downe (Downpatrick)
    Daisy Hill (Newry)
    Altnagelvin (Londonderry)
    Antrim (Antrim)
    Craigavon (Craigavon)
    Erne (Enniskillen)
    Causeway (Coleraine)

    I would have thought instead we should have:

    Royal / City (I am adding them together)
    Ulster
    Craigavon
    Altnagelvin
    Anrim
    Erne

    The other smaller hospitals may have useful roles in rehab, out patients etc. but not as acute hospitals i.e. admitting new sick patients. They might also usefully have minor injuries units as that could keep waits in the main A+E departments down. The larger hospitals should have many of the complex services the Belfast hospitals have apart maybe from nueurosurgery and some cancer services.

    The above is a practical option. Had we bitten the bullet when there was money as the English, Scottish and Welsh did (the Welsh still have a bit of a way to go) we should have gone for

    One Royal / City possibly on the Musgrave Park site where there is government land available and then downgrade maybe even sell off the RVH and BCH sites
    Ulster
    Altnagelvin
    Ballymena (to replace both Causeway and Antrim as well obviously as the Mid Ulster etc.)
    Dunganon (to replace Craigavon, Erne and Omagh and Daisy Hill)

    You could have run with five but where the hospitals are now and in the current financial climate building new units would be difficult. As such the first suggestion above is probably the best compromise.

  • Drumlins Rock

    Turgon, you missed Causeway on your original list, and what exactly will the position of Omagh be if developed as planned.

    And to what extent should cross border care be taken into consideration? Without that element Daisy Hill does not look viable, the Erne will struggle and Altnagelvin will not hit its full potential, but completely different healthcare systems make it a very complex system to manage.

  • quality

    Drumlins Rock

    From what I’ve heard from Poots, he is particularly keen on cross-border services and selling services to the south. Particularly in Fermanagh, not so sure Daisy Hill will be maintained at current levels.

  • Turgon

    DR,
    Have updated it. I am unsure re Omagh but I think it will be outpatients a bit of rehab and stuff like that along maybe with minor injuries. All of that is excellent and appropriate.

    Cross border is always tricky. In European countries (ie ones with a land border) is it rarely standard to cross the border for most / all health care. Secondly we do not have efficient systems to bill RoI patients for care (actually the system is non existent).

    Then there are practical political objections (not orange ones).

    It would be impossible for the RoI health minister to make decisions on NI hospitals. As such s/he could not decide for a given treatment and against another. Hence, the post code lottery could be profound with some patients in say Newry entitled to one thing (because they were from NI) and others to something different (being RoI).

    If that did not happen and every patient in an NI hospital got exactly the same then RoI patients might get better / worse care in one part of their state (the bit served by an NI hospital) than another (served by an RoI hospital).

    Next there is the problem of the scandal. Imagine a doctor in a border hospital is useless or whatever. How can a TD for say North Louth or North Letrim stand up in the Dail and demand something be done. That would be outwith the RoI health minister’s control.

    Then we have the economy. The largest single share of health budget is staffing. If one has a hospital in NI serving lots of RoI patients realistically most of the staff will live near the hospital (in NI). They will spend their money in NI much more than the RoI. As such if the RoI are purchasing health for whole swathes of their population in NI they are throwing money away as it is not recycled into their economy. This is unlikely to be popular.

    Then there is the “save the hospital” issue. We have campaigns to save local hospitals. Do we think that in the RoI the citizens will meekly accept their hospitals closing to ensure that NI ones stay open?

    These problems can be overcome for some things. Furthermore the RoI is willing to purchase some elective treatments (it does so now) but that is a small minority. They might also be willing to purchase some complex stuff (even emergency stuff) like modern heart attack treatment. However, those can only be offered in larger centres and so are unlikely to benefit the small NI units. Overall although cross border work is not irrelevant it is not a basis to make decisions about long term sustainability of the smaller NI hospitals.

  • Turgon

    quality,
    Posts crossed. I agree. I suspect cross border work might keep the Erne going and strengthen Altnagelvin further but that is probably about it. Also remember that Craigavon is not that far from the border. Indeed if one thought sensibly re health the Royal is not far from the border in time terms. It is only an hour on the M1 / A1.

  • quality

    Turgon

    As you’ve noted, thinking sensibly is difficult in the face of rampant populism.

    I’ll be honest – I can’t say I thought much of Poots before he took this ministry, particularly given the creationism and all that. But he’s proving (along with Michelle O’Neill) to be a very competent Minister (or at least making the right noises).

    Hopefully he has the courage of his convictions – though the Compton Review may take a bit of heat off difficult decisions he’ll have to take (“not my idea guv, its in the review”)

  • Johnny Boy

    You forgot to mention Union opposition to change on top of all the others that would be opposed. Basically common sense has no chance.

  • tinman

    I fear you may be disappointed, Turgon. Firstly, you’ll have to wait a wee while longer – according to evidence given to the Health Committee the Minister gets to spend a couple of weeks reading the report before any of it is made public. According to the original schedule that was through a statement to the Assembly on 12 Dec – I’m not clear whether the whole thing has now slipped a week.

    Secondly, John Compton explicitly says: I do not think that it is helpful simply to enumerate a list of facilities in Northern Ireland and specify this facility here or that facility there. That is not what the review is about. So a list of hospitals to become non-acute looks unlikely.

    Thirdly, if you read your way through the Health Committee discussion, most of it focuses very narrowly on saving Daisy Hill, and this from the MLAs who are supposedly the best informed about health care and best placed to see the big picture. It does not bode well for a mature, responsible assessment of our acute hospital configuration.

    I predict: a bit of fudge from Compton, a huge amount of noise from Trade Unions and MLAs, and then more of the same – the gradual collapse of 24/7 services in smaller hospitals, with none of the advantages of strategic planning.

    Or perhaps Godot will turn up after all.

  • quality

    tinman

    I think its coming to the Assembly on Tuesday. Could be wrong.