Does Northern Ireland have too many hospitals?

A recent report into health services in N Ireland has said that there are ‘too many hospitals’. The report also has a lot to say about the organisational structure of the NHS here.

This isn’t the first time that hospital provision here has been questioned; decades ago, an MP in the old Stormont described N Ireland as having a hospital at every bus stop. So how many acute district hospitals (DGH) would be appropriate? It’s easy enough to calculate a number if you accept that a DGH should have a population base of between 250,000 and 500,000. Many such observations have been based on experience in England.

However, what works there may not be appropriate here. In England about 80% of the population live in urban areas, the long term legacy of the industrial revolution there. Beforehand, about 80% of people lived in the country. In N Ireland about 64% of us live in urban areas. The population density of England is 406 per square kilometre, here it’s 130 people per square kilometre.

So, we have a much more rural population than England, and there are many less of us. Should this affect hospital provision? Think about Scotland for a minute; there are small populations in the Outer Hebrides (26,000), Orkney (21,000) and Shetland (23,000). On a purely rational, economic basis, none of these places would have any hospital provision.

In N Ireland a little less than half the population live in the greater Belfast area; the remainder live in smaller towns or in the country; rural population is more like that in the Scottish islands than that in the English countryside.

Hospital provision can’t simply be an economic or mathematical concept; it must take patients’ needs into account. While large hospitals can offer ‘better’ treatment and a greater range of services, they may also be remote and impersonal.

Maternity provision is a useful proxy for studying hospital ‘activity’. If it was once recommended that a maternity unit should have 1,000 delivers per year, this has increased to 3,000 and there are calls, in England, for units of 5,500 to 6,000 births per year. The idea behind these numbers is that doctors and midwives in large units would have, between then, have greater experience, and this should translate as better and safer maternity care. In N Ireland only about 0.2% of deliveries are home births; there are around 25,000 births in hospital here. Only the Royal Maternity hospital has more than 5,500 births per year; and it, and the Ulster and Craigavon hospitals are the only ones with more than 3,000 per year. (In Shetland, there are about 130 births a year in the local hospital.)

If the 3,000 figure is taken as a baseline, then there should only be 8 maternity units in N Ireland; if the 5,000 figure is used, then there should be 5 units. There are 11 hospitals here offering consultant-led and/or midwife-led maternity units.

If there really are ’too many hospitals’ here, there is another, associated problem. The location of many hospitals in historical, and may have been initially appropriate. Is this still true today?

Perhaps N Ireland should develop a model of provision somewhere between the English mega-hospitals and the very rural ones of remote Scottish islands. Such a model will almost certainly be more expensive than a few very large hospitals.

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  • Holby18

    It seems to me from reading information that NI has too many of everything. Too many hospitals (I have to travel some 20 miles in England to attend an A&E Department and some 100 miles if I require specialised treatment), too many schools, too many community centres etc etc. We on the mainland are having to make huge cutbacks. It is time the same happened in NI.

  • Kevin Breslin

    Such a model will almost certainly be more expensive than a few very large hospitals.

    Large hospitals aren’t always the be all and end all, I do take the case of radiotherapy where building up massive radiation doses on a single site to cope with a growing population would kill doctors at their desks. Nothing is more economically inefficient than that.

  • Starviking

    Are you suggesting doctors at large radiotherapy departments would either ingest radioactive material, or deliberately overexpose themselves to radiation? That’s what it would take to kill doctors at their desks.

  • chrisjones2

    Listened to the Unions on BBC this morning and it was shockingly narrow insular and verging almost on racist. I am sure they didn’t mean it that way but it was so instructive:

    How dare this ENGLISH man recommend this.

    Hes ENGLISH and not aware of our Rural communities (yeah like hes never heard of Cornwall, Hampshire, Yorkshire, etc).

    Best of all – the ENGLISH HNS isn’t a good model for anyone to follow.

    Its not perfect but we need to get rid of all the management and monitoring what we do and just give us millions more. One said we could reform but only after a complete shift to a proactive public health funded by a huge injection of cash

    Utterly divorced from reality in terms of the current quality of care and the money available

  • Kevin Breslin

    You know I mean doctors dying from cancer not radiation poisoning.

  • the rich get richer

    Maybe the don’t have enough sick people.

    You know how the NHS has ways of making you soldier on because you don’t want to clog up the system, cost tho much, put too much strain on the overworked health professionals .

    The NHS has to get bolder and actually encourage sick people to go to the doctor or even the hospital.

    I actually wish that I were joking. We all know(used to know) people that are dead from not looking after themselves. Heroes to the NHS but sadly dead.

  • Metro

    Keep building decent roads infrastructure and bigger – and fewer hospitals. It is that simple. You can’t take a “Shetland” model for here because rural areas are always within 45-60 minutes of an urban area, whereas Shetland needs a boat or a helicopter to leave. The reality is that the labour market within health is such that well qualified doctors etc want to work where there is a high volume of cases, giving them better experience (and potential private work) – and if it can be attached to a university all the better for their research potential.

    We aren’t that big, we aren’t that dispersed, we aren’t that different.

  • Starviking

    Still does not make much sense to me. People working in radiotherapy departments limit their exposure to radiation in line with regulations – the size of the facility has nothing to do with that.

  • hugh mccloy

    To begin with to give this argument any validity the question just be answered:

    Are the current acute units in the correct locations to serve the population.

    if we are to start with a blank sheet where would the 4 hospitals go, unless that is answered then the model shown by Donaldson is null and void as it will only be building on broken foundations.

    Since developing Better services right up to now that question has never been answered.

  • hugh mccloy

    Issue is from meetings I have been part of N Ireland is compared to Birmingham not the rural counties

  • hugh mccloy

    There are 11 hospitals here offering consultant-led and/or midwife-led maternity units.

    it would be better to break these down into what delivers what service rather than bunch them.

    Mid Wife led are used to take away people from consultant led, this is forward planning and not regressive and should be promoted.

    Look at still births here, plus issues on actual birth type, N ire has the lowest % or normal births and this is very worrying.

    Other issues such as neo natal care, new Antrim’s ward is below RQIA infection standards but gets the go ahead regardless, its a prime example of centralising services at any cost

  • Korhomme

    Where would you put them?

    And, would you discuss health provision with the Republic?—there are several hospitals close to the border.

  • hugh mccloy

    There is a reason why SW got where it did, at the expense of the NI tax payer and patient.

    There is need for cross boarder and why CAWT was set up however we can only commission on the basis of needs of residents. If you look from Mid Ulster right down to Monaghan there is a corridor of several hundred miles that is devoid of any acute care and reliant on dwindling ambulance cover

  • chrisjones2

    it would be better to break these down into what delivers what service rather than bunch them.

    By bunching them you get fewer dead mothers and disabled babies. that is what counts …same with surgery etc etc etc

  • chrisjones2

    On that argument every county town needs its own hospital. Thats nonsense.

  • chrisjones2

    Absolutely and vice versa

  • chrisjones2

    Scientific nonsense

  • chrisjones2

    Seems to me that as long as we have a waiting list for surgery, then we dont have too many hospitals.

    That depends what the % utilization of theaters and surgeons and staff is Thats what affects it

  • hugh mccloy

    If it was ever to do with safety why shut a maternity that won awards for safety a year after in N Ireland ?

  • hugh mccloy

    figures have show a the the moment the bunching of services to Antrim has led to more still births, more non normal deliveries,

  • Tacapall

    Anyone who believes there are too many hospitals here needs to visit the Cancer units at the City Hospital, overcrowded, understaffed and increasingly becoming unable to cope with the sheer amount of people needing treatment. Its like a cattle market everyday and people wait months on life saving treatment only to be told there is no beds the follow up treatment is even worse, vital check ups that need to be done every two or three months after the first stage is completed are simply not available, people have been erased off the lists, doctors retire and their patients are forgotten about, no-one seems to give a flying fk.

  • Tochais Siorai

    Not to mention the cross border duplication….. Sligo, Letterkenny, Monaghan & Drogheda are all within a half hour of the border and an hour or less from a similar size hospital in NI.

  • Korhomme

    Look at the DHSS statistics on p40 of this:

    http://www.dhsspsni.gov.uk/hospital_statistics_-_inpatient_and_day_case_activity_2012-13.pdf

    It lists the consultant and midwife services here by hospital.

  • Korhomme

    One problem is that such journey times eat into the “golden hour” of trauma resuscitation—and how long do you wait for the ambulance?

    Surprisingly, perhaps, there are some people who actually prefer living and working in more isolated communities. The most isolated community in the world is on Tristan da Cunha, population less than 300. All the inhabitants were transported to safety after volcanic activity. But many of them didn’t like the UK, and went back. And yes, Tristan has a “hospital”, a doctor and a few nurses. Isolation isn’t just absolute, it’s also relative; and NI does have some very isolated areas. Don’t the people who live there deserve the same level of care as those in greater Belfast?

  • Dan

    Quite a lot of patients don’t give a flying fk either.
    I was at my local surgery this morning to see the nurse. After that I went to get my blood pressure checked on their machine. The girl who runs the bp clinic stopped to speak to me and said that she could review my bp history immediately in her office as the first five patients booked in hadn’t turned up…nor had any of them had the courtesy to ring her. That’s a disgrace, and it’s time that a fine was imposed on such selfish bastids.
    That’s just one professional in one surgery…how many appointments are missed throughout NI day and daily, causing delays and backlogs in the system. There has to be a penalty.

  • Ian James Parsley

    Great piece. Makes a refreshing change to hear the straightforward figures presented with fair arguments!

    Another issue, of course, is infrastructure (which ties in with your point about historic location). If, for example, you actually did build the A5, things in the West would change.

    Joined-up government? Sorry, enough of the fantasy stuff…

  • Korhomme

    Thank you! *blushes*

  • Kevin Breslin

    Yes it does, when you start packing in new Radiotherapy machines into the one centralized area, the background radiation levels will increase. You are also assuming there is adequate space to place the larger number of linear accelerators on the grounds and the capacity for sheilded rooms.

    How can a doctor limit their dosage when there are more patients, more machines and more work, probably less professionals working in that environment?

  • AndyB

    I’m going to take a look at the Donaldson report later on, but I’ll happily drop a wee note in on the subject of acute hospitals here. Keep my post on the rest of the report focussed 😀

    The problem with reducing the hospitals in number is that they’re in the wrong places.

    For example, Altnagelvin, Erne, Causeway and Daisy Hill are all on the periphery of Northern Ireland.

    If you close Causeway, that would leave the likes of Ballycastle and even Coleraine unacceptably far from Antrim or Altnagelvin. Erne should arguably have been built in Ballygawley in the first place, or even Omagh.

    To make do with four hospitals would require them to be in Belfast, Banbridge (which is a bit far from South Down really), Ballymena, somewhere near Ballygawley, and Dungiven to cover the country adequately.

    You could make do with six or seven of the existing sites, I think, but that requires something I will talk about later on, and that is enough beds to admit people with a clinical need to, which in turn requires a mixture of more hospital staff and sufficient community care to effectively reduce demand on in-patient beds.

  • Zeno

    Comparing anything on the UK Mainland, 60 million population, with Northern Ireland 1.8 million population is like comparing sausages with the Hadron Collider.

  • Yes there are too many hospitals and many of them are located in city centre locations that prohibit low cost expansion.

    Northern Ireland needs one HUGE major hospital that performs major surgery, houses the top consultants and is also a teaching and research hospital. Other spins offs then occur from it.

    Take Addenbrookes in Cambridge, in 1976 it started off relatively small and over time it grew into a world famous teaching and research hospital.

    I have always maintained that such a “super” hospital for Northern Ireland should be built on the Maze site. That location can be easily connected to the motorway and rail network, it is within an hours drive of a large part of N. Ireland’s population. More importantly it has room for expansion and accommodation can built upon the site for staff, students even for relatives of patients staying in the hospital.

    Remember quite a few people from Northern Ireland end up going to the mainland for specialist treatment. If the expertise and equipment was located in one hospital, it would attract the top professionals.

    Then 3 other hospitals located in Omagh (serving the west) Londonderry (serving the north) and one in Ballymena area.

    These 3 hospitals deal with routine operations, cancer treatment and also have major trauma centres / A&E.

    If the Enniskillen and Newry critical care units remain these should serve cross border health care (these two hospitals should be partly funded by the Irish government).

    All other hospitals are closed down and the sites turned into much needed low cost housing or even care homes / retirement villages for the elderly.

    To make this feasible, the road network and rail infrastructure need to be improved.

    An orbital motorway (similar to the M25) needs to be built around Lough Neagh. Then the roads off this orbital motorway link into the major trunk roads, like the A26, A29, A32, A4, A29 etc which all should be upgraded to dual carriageway status. This orbital motorway needs to be such that no town in Northern Ireland is more than 20 minutes from it

    A dual carriageway needs to be built from Dundonald directly to the M1 at the Super hospital, skirting to the north of Carryduff, thus avoiding belfast.

    This road network would allow faster travelling times to the three major hospitals.

    Another crucial benefit of this network would be faster travelling times between various parts of Northern Ireland, encouraging businesses to locate in areas which are currently not suitable, making it easier for tourists to visit various locations and allowing people to live in areas that are currently too far to commute.

    Finally two air ambulances should be deployed, one located at Aldergrove and the other situated at Enniskillen airport.

    The above should be considered a 20 year blue print.

    In the first 10 years start with the teaching hospital at the maze and the orbital motorway and dual carriageway up grades. Then in the next 10 years concentrate on developing the district sites and then slowly close down the other hospitals.

    It will be expensive in the short turn, but in the longterm it will save money and promote economic stimulation across all areas of the country.

    Political differences between ALL parties should be set to one side to ensure that Northern Ireland is developed into a country that can stand on its own.

  • On the mainland people travel many miles for appointments – when I lived in England I regularly traveled 45 miles to a hospital for treatment – people just accept it and get on with it.

  • puffen

    Ballymena lost its Hospital, because Paisley needed manners put on him, now we have one in Antrim, to close to Belfast and one in Coleraine which is too far away from anywhere

  • Zeno

    em, well done you.

  • I fully agree – I am from England and when I moved here I couldn’t believe how much was on ones doorstep.

    The other noticeable thing is that many people in Northern Ireland are not use to travelling very far.

    Geographically, Northern Ireland is probably comparable to the peak district or the lake district – i.e. it has large towns with swathes of sparsely populated areas in between the towns and the odd major conurbation.

  • Geographically, Northern Ireland is probably comparable to the peak district or the lake district – i.e. it has large towns with swathes of sparsely populated areas in between the towns and the odd major conurbation.

    I often compare N. Ireland to that of Manchester in terms of population – more people live in Greater Manchester than the whole of Northern Ireland.

    My other comparison figure is that EVERY day nearly twice the population of Northern Ireland are transported around the London Tube network.

  • Korhomme

    The locations you suggest for four hospitals are based on their being at the centre of their hinterland, more or less. Dungiven and Ballygawley are, I’m sure, delightful places, but they are both small. They don’t have enough local facilities to support a hospital, at least not at present. I’m thinking of housing, schools and shops. Not only would patients have to travel some distance, but so would the staff. Ballygawley, for example being sort of equidistant from Enniskillen, Omagh and Craigavon could be seen as disadvantaging all three places.

  • AndyB

    It would also require a ridiculous amount of money to be spent building three brand new major acute hospitals (and arguably flattening most of the Royal site and starting over!)

    On the whole and with the arguable exception of Enniskillen, the existing acute hospitals have been placed rationally with regard to other pre-existing provision – for example, the existence of the Causeway justified building a new acute hospital in Antrim rather than in Ballymena. For that reason, I don’t think we’ll ever reach four – there would be too many gaps.

    Craigavon would fall under Banbridge in my theoretical model, which would be a lot less unacceptable if that makes any sense!

  • Tacapall

    “There has to be a penalty”

    Indeed Dan for both sides and and what would the quid quo pro be for all those uncaring bastids who leave seriously ill pensioners on trolleys to die, should they be sacked or imprisoned or those alcoholic porters who take almost a day to walk a few hundred yards to bring patients to wards. I used to go regulary to a cancer outpatient dept in the royal and it was like a cattle market every time but since the appointment system was taken over by Musgrave the cattle market has disappeared the place is almost empty every day, is everyone cured or simply erased from the system.

  • Korhomme

    Your use of the term ‘top consultants’ is understandable but unfortunate. It would be more accurate talk of super-specialists, people who only treat a very limited number of conditions, and who need an ‘adequate supply’ of patients to maintain and improve their skills, often only possible in a very large centre.

    The skills needed outside a ‘mega-centre’ are quite different, an ability to manage a much larger range of problems. A ‘top consultant’ would be quite out of their depth there, as much as would a ‘peripheral’ consultant be in the mega-centre.

  • I agree with what you are saying.

    I was thinking about surgery more, surgeons who already practice in Northern Ireland and are specialists in their field. The “top” ones will reside at the super hospital.

    The super hospital would undertake more serious major surgery; e.g. heart surgery, transplants, tumor removals etc.

    The other two hospitals cater for more minor surgery and consultations.

  • It is not a ridiculous amount of money if spread over a number of years.

    The recent Enniskillen hospital cost around £280 million and took a couple of years to build. That cost was not helped by amount of round stablisation works that were required even before work could start building the hospital.

    If the NI Executive could show the UK government that by spending say 1.5 billion pounds over a 10-15 year period on building state of the art hospital facilities at 3 locations and that the running costs for the NHS in Northern Ireland would be reduced. Over 10 years that is only 150 million per year.

    The existing sites can be sold off for redevelopment.

    All political parties in Northern Ireland have to wake up to the fact they can’t please everybody. They also need to understand that their position within Northern Ireland politics is quite safe as they can not be “kicked” out of power.

  • Korhomme

    An interesting concept; would your ‘mega-hospital’ also do the more routine stuff?

    Some procedures you mention are at least as dependent on the pre-op and post-op care, and there’s a difference in difficulty between a renal and a liver transplant—would there be ‘enough’ of such cases here?

    Somehow, I wonder if there is the political will to drive things forward; and I’m concerned that they could be swayed more by ‘belief’ than by ‘evidence’. Or will it just come down to ££?

  • Catcher in the Rye

    answer “yes”. We have four large hospitals (Royal, City, Mater, Belvoir) which are close to good motorway connections. We could easily make do with two.

  • barnshee

    “10 years that is only 150 million per year.”
    A few 150 million here and there and soon you will be talking real money LOL

  • The one thing I hope doesn’t happen with this, is that political parties start to try and score “points” against each other.

    The people who each party represent ALL have access to the health service, so all parties should be able to work together to create a health system that works for Northern Ireland now and in the future.

  • I am not from a medical background (mine is in property and construction) so I am not familiar with the ins and outs of medical procedures.

    However my experience tells me If you concentrate the majority of your services in a few sites your overall running costs and ability to expand will be cheaper than if you had buildings spread out in numerous locations.

    Better infrastructure can be created to serve these few sites. Anybody who has tried to visit the Royal for an appointment in the morning will have experienced the traffic congestion on the Westlink and in trying to get parked at the Royal.

    In addition to the main 3 hospitals one could introduce larger health centres in key locations. These could undertake minor day operations, house x-ray equipment for routine x-rays requested by a GP and other screening services.

    Politics needs to be swept to one side here – Each party’s electorate all access the NHS, so each party should be aiming for a health service that works for Northern Ireland, one that is efficient to run and has the ability to last into the future.

  • Korhomme

    Economies of scale; but these can bring their pwn problems. In small working groups, people feel that they ‘own’ processes, and also that ‘we’ are responsible. In large groups, ‘they’ are responsible, and this may fuel a sense of alienation.

  • Eugene Doherty

    Belvoir? Do you mean Dundonald or perhaps Musgrave?

  • Metro

    Yes they do, but they aren’t getting it at the minute. Good Doctors don’t want to work in the middle of nowhere with small populations, they want to extend their knowledge and skills – which is good for patients. Also, A&E is just one element to medicine, the more important parts of the health service system involved planned admissions. If I needed a heart operation, I would rather have it done in a bigger hospital than Tristan da Cunha…