Donaldson in review

It is a pity that coverage of the Donaldson review has focussed on his comments on the number of hospitals in Northern Ireland relative to its population.  It is true that he remarks on this, but his report is a lot broader than considering whether skills are being spread too thinly across too many hospitals – something korhomme discusses here, and I comment on briefly with regard to locations.

What stands out is that Sir Liam considers the Northern Ireland Health Service to be no more dangerous than GB, even after consideration of issues such as c. difficile, the 2011 review of a senior dental consultant, delays in reporting x-rays, pseudonomas, governance in Northern Trust, hypnotraemia, and of course the ongoing issues with Belfast’s Accident and Emergency Departments.  He is however concerned that the focus of inquiries tends to be on the behaviour of individuals rather than also on the impact of the systems of which they are part, and the impact on quality of care and patient safety of not taking a more holistic approach.  This comes up again later in the report when discussing incident reports and investigations.

This is indeed where the number of acute hospitals comes into the equation, but again it is in the context of a holistic approach to the correct form of care that will tackle dysfunction and offer better and more efficient care (bearing in mind that for an ill patient, efficient means being treated as quickly and conveniently as possible!), and improve morale among overstretched staff in hospitals, in the community, and in ambulances.

Transforming your care is demolished as not being properly implemented or funded, and structures are identified as a serious problem; on commissioning, the process by which the Health and Social Care Board procures patient services through its local commissioning groups, Sir Liam remarks that:

The problem for Northern Ireland is that it has gone just partially down the commissioning path. It does not have the benefits of a sophisticated commissioning system, yet has the downside of increased complexity and overhead costs. The worst of both worlds.

Sir Liam presents this as a challenge beyond the scope of his review – the tenor is not necessarily that we should move to a “proper” form of commissioning as per NHS in GB, but rather he presents a few options to look at in finding a solution correct for Northern Ireland – something that pervades his recommendations.

Recommendations

Recommendation 1 is that a binding review be carried out by experts to determine what the overall structural solution for Health and Social care in Northern Ireland might be, although it is reported that this one might not be adopted.

Of the remaining recommendations, recommendation 2 advocates a redesigned and simplified commissioning process,  and recommendation 3 carries an imperative to fund and implement Transforming your care properly, including enhanced roles for pharmacists and paramedics.

Recommendation 4 seeks to enable patients who could administer their own treatments in the community, much as diabetics do now, to do so.

Recommendation 5 advocates developing the regulatory functions further, including applying them to the NHS trusts (The Regulation and Quality Improvement Authority currently regulates neither NHS hospitals nor General Practices.)

Recommendations 6 to 9 deal with incident reporting and investigations; general clinical benchmarking; and the use of technology.  Recommendation 10 proposes a much strengthened place and voice for patients.

Conclusion

So what to make of it?  I think that the review is asking the right questions.

In the end, however, only one thing matters.  A&E relies on having beds in other parts of the hospital into which to admit patients who have been stabilised but need further treatment as an in-patient, in order that new patients can be treated and given the time that not only do they deserve but that doctors and nurses ought to be able to offer rather than being overstretched.

Unless those beds are available, either because money has been invested in community patient care so that more people can safely live at home with adequate care from carers, community nurses, pharmacists, GPs etc, or because more beds have physically been opened, with sufficient clinical staff, no amount of reviews can possibly hope to successfully tackle the long waits in A&E – or indeed, the other issues in Sir Liam’s report.

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  • Korhomme

    Indeed, the Donaldson report is about much more than ‘too many hospitals’, though this problem is one than many are interested in and have a ‘stake’ in.

    He considers the Trusts in NI, the organisation of the Health and Social Services here. Surprisingly, perhaps, ‘general’ management only entered the NHS in the 1980s, after the Griffith report. (IIRC, Griffith was the deputy CEO of Sainsburys.) It’s quite possible that we now have too much management, or the ‘wrong’ sort of management. It could be said that much of the report is in ‘management-speak’, which isn’t perhaps surprising.

    There are always new ideas in management; often they seem to be dreamed up by self-styled ‘gurus’, stylishly presented and ‘sold’ to managers. Whether these new ideas are simply theories, or whether they are ‘evidence-based’ is unclear.

    As you say, and quote, NI hasn’t gone far down the commissioning route. But is it the right route to go down? Previous organisational changes in the NHS have been undone at a later stage—think of ‘Cogwheel’, which though intended to bring clinicians into decision making, ended up grossly bloated with committees, and any progress was very slow.

  • AndyB

    I agree completely, and also with what you said in your own article. The growth of bureaucracy, whether good or bad (you can guess what I think about this particular example!) also takes funds away from direct care, so that even if you index-link NHS funds to “protect” them, clinicians still end up with less to spend on treating patients.

  • Ian James Parsley

    Another excellent Health post on Slugger, Andy. A pity not more have read it – it’s actually relevant to real life!

  • AndyB

    Thanks very much Ian! The best of it is that Mick, korhomme and I had three different but complementary things to say about it.

    What I forgot to mention in the article was a discussion I had elsewhere, which was along these lines:

    Another person had suggested that allowing persons with certain problems to be admitted through outpatients departments rather than A&E. I pointed out that as outpatients services tend for the most part to operate during office hours only, this would have a limited impact as most A&E delays happen in the evenings and at weekends.

    It doesn’t mean that the idea of enabling specialist admissions via Outpatients when available rather than via GPs and A&E doesn’t have merit, it just wouldn’t address the capacity problems in A&E when it matters.