Korhomme asks some good questions in the wake of what is something like the seventh review to suggest that Northern Ireland has too many acute hospitals.
Liam Donaldson’s report usefully points up some key reasons for the delay in action not least the pressure from a public wary of losing health provision and its local economic impact, and lack of leadership (the CMO in NI double jobs as the boss of the Belfast Trust).
But his focus on hospital re-organisation probably reflects his view of what has already been achieved in England. It is a line long re-iterated in previous reports and is usually willfully ignored.
The NHS was in a pretty parlous state in 1997 when Labour took power. Over the intervening years they pumped in vast amounts of money and also changed much of the management culture not always for the better. However, in England they introduced significant structural changes.
The smallest hospitals were downgraded to cottage type hospitals whilst the medium sized District Generals (large hospitals in NI terms) were upgraded with more scanners, equipment etc. and tasked with performing many of the relatively complex procedures which once had been the preserve of the teaching hospitals.
In Northern Ireland large amounts of money were pumped in but there was far less structural reform. So in terms of hospitals we should only have 4 or 5 hospitals but we still have at least 12.
Furthermore the larger NI hospitals have not been developed as much as their counterparts in GB. This is especially relevant as people are very often admitted to say Antrim or Altnagelvin and subsequently have to be transferred to the Royal or BCH for something.
This makes the system sticky and less efficient. It exacerbates delays in the patient getting treatment and means that patient’s bed is not available for the next patient. This lack of bed turn over is the single central cause of the A+E crisis as the patients in A+E cannot be moved into the ward beds.
It’s a point hammered home with some force and guile by Brunel Professor Terry Young when he compares supermarkets to hospitals:
Supermarkets didn’t just hope for the best. They designed ways to flow groceries into their stores with extreme care, setting up advanced signalling systems to tell them exactly what was needed where and when. To do this, they’ve moved well beyond checklists, using simulation and modelling to design their logistics and advanced computing to predict what will happen next. In the same way, we need to focus on the flow of patients into and around our centres of service.
Our intuition to meet demand by creating more posts, or more beds – or to run for longer hours – is simply likely to delay the point at which demand inevitably overwhelms our ability to provide a service. We need to design and implement much deeper solutions. Just as getting rid of supermarket storage was a measure that ran counter to normal intuition, so our intuition and experience in health are unlikely to help us find the best interventions for healthcare.
Of course, there is a crisis throughout the NHS. However, in GB more than 90% of patients are still being seen within 4 hours. In NI it is nowhere near that and has not been throughout the summer let alone now.
In addition the reduction in social care money in the community (File on 4) has had a major effect. This is one of the reasons why the current Transforming Your Care programme is only moving at a deadly slow pace.
Further structural problems occur because of the way in which the NHS is funded in NI versus GB. In England especially money follows the patient. Hence, hospitals want to set up new services and attract patients from elsewhere.
Although this creates a more anarchic system it means that hospitals are always striving to do more stuff. In NI hospitals largely get a block grant of money and told to provide a service. This opposes innovation.
It also reduces interest in expanding their services to other Trust’s patients as treating an extra number of patients does not attract an extra sum of money.
The politicians have also been part of the problem. Perhaps when there was money in NI was to build new hospitals, the smaller ones could have been closed. But in the 1990s / 2000s only SWAH was built and it is relatively small and has few services, so that any patients are still sent to Altnagelvin or Belfast.
For instance, closing Antrim and Coleraine could have been offset by a new build in Ballymena. Craigavon Newry and Enniskillen could have been replaced by one in Dungannon.
When the topic of closure was mentioned in Northern Ireland it is fought tooth and nail by local campaigners and various politicians. That tended to mean that services were kept staggering on until they fell apart.
Rather than admit they were going to close a given hospital in say two years and build capacity at another hospital no one was willing to make such longer term plans and if they did they were shot down.
So today the Minister is both facing criticisms from opponents like Sinn Fein’s Foyle based Health spokeswoman Maeve McLoughlin for being too slow on Transforming Your Care, and protests from his own MLAs like Alex Easton.
Donaldson’s solution is a rigidly top down one, no doubt because of the lack of political agency in health in Northern Ireland: he wants the recommendations of a working group to be binding on the minister.
But on Tuesday Jim Wells was almost pleading for some kind pax or truce on the matter in order to clear the space for a rational debate on the matter.
This makes it an interesting moment. One perhaps in which to consider the alternative, ie a more open approach to policy making in the manner outlined by Matilda Murday in our Open Gov late DigitalLunch…
The risk we face is that policy makers will only put up for consultation those things that they already know are popular. But this is a tool for them, and if they can be open and be transparent there is a certain amount of credibility there that on occasions they’ve lost. What they need to do is to make sure they put forward what are unpopular conversations to have.
In classic policy making, even the most progressive design based projects, the planning and execution generally takes up 80% and usually less, with the consultation almost invariably happening at the very end.
The primary cause of consultation fatigue is a strong sense in members of the public that the big decisions have already been made, and someone just needs their input to get it past the minimum legal requirements.
Not talking about it has resulted at best in inertia, and at worst money spent on the wrong assets.
Talking about it, through a more creative open policy making approach might help to develop a more broadly shared understanding of the problems and begin to get a sense of the desirability, feasibility and sustainability of the possible solutions.
In a space where politicians are fond of waving their mandates in their local areas, but struggle for any kind of popular agency, it might help provide sufficient public will to actually get something done.
And, perhaps, opening out Health might be a practical issue for the Northern Ireland Open Government Network (actively seeking new members) to consider, and a possible early objective?