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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