Is it time for more ‘Open Government’ in NI’s sluggish healthcare reform?

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?

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  • The wariness is not necessarily in change itself, but a lack of confidence in the competence of the great and good to make improvements. The wariness is in change heralding things going from bad to worse – e.g. closure of City A&E didn’t ‘solve’ A&E provision and there is a sense that it is worse now even though probably at least only just as bad.

  • Kevin Breslin

    Not often I agree with the Shinners, but I agree with Maeve … we need action and decisions not more debate. You seem to think if we talk until the cows come home reform will happen. This culture of naivity shows at heart there’s very little difference between the Middle English Fabian Society idealist and the drunken bar-stool professor down in Longford.

  • mickfealty

    I hear those thoughts guys, and I think you are both right. There is some value in the ‘just get on with it’ approach, but then again, as the Newsline piece points out, Ms McLaughlin’s party colleagues are also leading some of the local resistances.

    And yet I don’t want to put too much on the STV system (which actively encourages local defection from broader policy) because this problem of poor agency in government is much broader than just Northern Ireland.

    As Jean-Claude Juncker famously said, “We all know what to do, we just don’t know how to get re-elected after we’ve done it.” It’s compounded somewhat in the case of the DUP who barely showed their predecessors the least compassion.

    “Decision making by procrastination” is the time honoured British/Irish approach to government par excellence, but we now have speeded up timeframes in which change happens regardless of whether or not government chooses to keep up.

    And there’s a cost to that. Without some reaching out to ‘the village’ the mistrust will continue, and the queues A&E will get worse, Nolan will get more and more apoplectic, and the rest of us bystanders will be none the wiser.

  • mickfealty

    PS as an aside, you have to wonder too, who cares about this stuff? Margaret Wheatley comes to mind…

    “We need to replace the questions ‘what’s wrong?’ and ‘how can we fix it?’ with two better ones – ‘What’s possible here?’ and ‘who cares?’”

    This, I think, is a good place to start:

  • salmonofdata

    I think Health is probably the most glaringly obvious area where the local prediliction for nonsense politics (e.g. debates about tiny flags on driving licences) over meat-and-potatoes retail politics is having the biggest impact. The political class know that issues such as A&E waiting times aren’t front of mind for voters, which means that there are no consequences for failure, especially if there is no mechanism for “kicking out the bums”. And as you say, much civic engagement in health tends to be of the knee-jerk populist “no hospital closures” sort, which can often be spun along tribal lines anyway.

    I think that the biggest achievement open government could bring would be if there was agreement across society that all data and information held by government and public sector bodies should be available to all. Any information available to the Health Minister, or the Chief Executive of Belfast HSC Trust, should be available to everyone. There should be no “secret” public data, excluding matters of national security.

    I don’t agree that we should all be quiet and let our elders and betters make decisions without consulting the public. It should be the job of the public to ask awkward questions. Public data provides citizens with the tools to ask awkward questions that need to be asked. No more deference, it’s partly what got us in to this mess in the first place.

  • Nevin

    “For instance, closing Antrim and Coleraine could have been offset by a new build in Ballymena.” .. Mick

    I was told recently that a decision to build a new hospital in Ballymena was turned down – on political grounds. It’s alleged that a former Secretary of State vetoed such a proposal as Ballymena was at the heart of Dr Paisley’s constituency. So, we ended up with two new acute hospitals instead of one!

  • D99

    Good analysis of the A&E crisis and of the main reasons for government lack of action on such matters. Even when they deign to focus on important soci-economic issues and come to understand the problems and acknowledge the solutions, local politicians procrastinate for reasons of personal or party interest. They generally ignore the common good, in order to appease their voter base.

    Problem is: in the world of cuts and austerity that they’ve signed up to, this approach is unsustainable. They’ve little money to throw at problems and will struggle with new budget cut related crises that are coming our way. So they’ll need the intelligence and expertise to come up with real solutions and the will to implement them, even if the solutions are not in their short term self-interest.

    Yes, this is an opportunity for Open Government advocates to encourage local representatives to create space for wider engagement, collaboration and input on a practical issue that effects everyone. You could think about it as a way of testing how open, receptive and engaging the local decision makers are prepared to be. And, of course, if the engagement was successful in providing new perspectives, ideas and solutions, it would almost inevitably lead to further collaboration.

    Problem is: most people are skeptical when it comes to consultations, which pay lip service to wider public opinion, or are carried out for legal box ticking reasons. So politicians must find a way to prove they are serious about openness, transparency and engagement. And as Salmonofdata suggests, Open Government advocates must be less deferential, more demanding when it comes to the availability of information, the desire for citizen engagement and the need for accountability on the part of decision makers. And they must press for a process for engagement on a range of issues, not just ones politicians are keen to talk about.

  • mickfealty

    I agree with that, and I’d add that an open approach would proactively try to address the problems in the system by trying to expand the number and type people involved in the debate beyond those stakeholders with the resources and direct interests who are often the only ones with the resources to scope the landscape and ‘engage with power’…

    The political pay off for such collaborative sensemaking lies in their pursuit of focused actions capable of bridging the needs of those at the edge (where most of the real people in society actually live) and the centre where strategic decisions are made.

    Thus enabling to match a democratic mandate with actual agency… A pretty useful prize within a system that privileges stability over almost everything else…

  • AndyB

    Part of the problem is that sometimes what passes for consultation is a bald statement that “We are doing X. Is this a fair way of doing it?” rather than a meaningful “What do you think about our proposal to do X in the first place?” – classic example was public sector pensions where the “consultations” were how to implement a pre-determined outcome.

  • hugh mccloy

    I met several times with Ian Jr over Antrim hospital, h have not forgotten his words, Antrim was built to spite his dad and is one of the few things I really believe

  • hugh mccloy

    Comparing Hospitals to supermarkets is not a useful thing, consider the year after they shut Mid uslter Hospital Tescos opened a store in Magherafelt.

    Many moons ago there was some talk of planning that would have seen large acute Hospitals in Cookstown & Ballymena, this feeds into Nevins point about Antrim & Coleraine.

    Had that went ahead when the royal colleges was backing it: Mid Ulster, Dungannon, Omagh, Coleraine, Whiteabbey and Antrim hospitals may not have existed today in any format other than health hubs and the general public most likely would be very acceptable of that.

    To build for the future in health in northern Ireland we do need to look at at a map and say here is where acute centres should be, that will cost £100’s of million so is never going to be a option, so the best we will get is a sticking plaster until a government is elected strong enough to make that change domestically.

  • hugh mccloy

    You should read SF’s developing Better Services, it was not forward planning it was her partys plan that caused all this

  • hugh mccloy

    Northern Ireland needs a review akin to the Francis Report, no nonsense straight to the point, in all the talk here it is the one review that no one is touching with a barge poll. Some in higher positions will know exactly what a Francis type review would find out in terms of deaths and care issues.

    To start with and make our trusts comparable to England we need to removes social care for the Trusts to local councils, part of the reasons our trusts are admin heavy in comparison is because they commission more services than their English counterpart.

    For one I would not want our super councils in charges of social care: child protection, elderly services, mental health …. So we do need to look at other ways to commission health here.

    One of the main problems is our hospitals are in the wrong place, as far back as 2010 in meetings I had with Colm Donaghy, and there is no love lost between us we agreed and was agreed by other managers and doctors that hospitals were in the wrong place, the question was why did nothing change? It was simply because right up until 2011 we were implementing SF’s Developing Better Services, the assembly and exe backed strategy to create the golden 6 hospitals. TYC did not address this in any form

    What we got from Maeve and from Donaldson were token gestures as per usual when reports like this come about. I spent 2 years constantly meeting and getting involved with TYC, the real issues that needed tackled were not addressed and politicians done their upmost to not get involved in case it would come back to bite them.

  • D99

    Yes, they consult around the edges of policy decisions, assure everyone that their proposals are not written in stone, that other ideas will be seriously considered, and then proceed to implement their original plans with very minor tweaks.
    And, you’re correct to say that it’s about how they frame the questions and about the fact that the limited scope of the consultation very often renders it meaningless.
    (Let’s consult about going to war; we’re open to ideas about whether we commence our offensive tomorrow or the day after. What do you think?)
    This lack of authenticity fails even to create the illusion of democratic participation and departmental accountability, and it seriously undermines the integrity of the process and those carrying out the consultation.
    But this is where this Open Government idea has the potential to be more authentic: in theory at least, it’s more about collaboration than consultation, more about people deciding what matters most and determining the best solution in the first place, not after plans have already been made and decisions done and dusted.

  • Chris McCracken

    Great article Mick. Private sector business thinking and practices have evolved significantly in recent decades, with huge efficiencies from good leadership, empowerment of staff, and process improvements. There are many good public officials in N Ireland, but there are also serious systemic problems. Inertia and tolerance of poor productivity are embedded in the culture. This will not change until we have political leadership that demands, and actively drives, reform.

  • Korhomme

    Indeed. There was a consultation some years ago, though many people felt that the decision had already been made. The consultation was a way of giving credence to this decision.

    There was a questionnaire, one of the questions reading—I paraphrase slightly: “If you had xyz disease, would you prefer to be treated by a generalist at your local hospital, or would you prefer to travel to Belfast, to be treated by a proper specialist?”

  • mickfealty

    I was wary of phrasing it like that Hugh, when I wrote it, but it’s hard to describe in any other way because that’s what he does in the piece.

    I always think when I hear people discussing health that it’s a bit like that story of the eight blind men discussing what an elephant must look like to a sighted person (it was in our reading books in P4 I think at school).

    Each one feels a part and takes their primary description from that bit closest to them. So consultants tend to look at it from the point of view of overall stats and high quality acute interventions.

    This is Donaldson’s view. New builds like the Downe, are frowned upon, even as they are loved by the locals (and by us when my youngest slipped and fell on rocks at Ballyhornan a few years back.

    I know from talking to hospital campaigners in Roscommon, it’s clear that the fear from the local one is driven by a lack of trust in experts, poor road infrastructure (the golden hour) problem, and lack of engagement.

    But I do think it is helpful to think of how a system which is expect to deliver universal health to every citizen/resident of NI can learn from other systems which also have to deliver on scale.

    There are other issues which affect care rather just volume.

    The quality and retention of good care and nursing staff is also key, and a fault in the system of nearly 30 years standing still largely unaddressed, perhaps through inertia and a general attitude of ‘it’s too bloody difficult’…

  • Kevin Breslin

    All back when Bairbe De Brún was minister?