Is Healthcare reform an unsquareable circle?

Two News Letter articles at the end of last week demonstrated the nigh on impossibility of solving the health services problems in Northern Ireland. 

On the 14th February the new chief executive of the Health and Social Care Board Valerie Watts in response to the question “if people could expect to see smaller hospitals closing, with fewer but bigger hospitals remaining”. Ms. Watts replied:

“That is my vision, yes, because that is the safest thing for Northern Ireland to have.”

The same day there was a rally attended by 15,000 people to protest against the loss of any services at the Downe Hospital and indeed demanding an increase in the hours of it’s A+E department. In response to this rally the Health Minister (and significantly a local MLA to the Downe) Jim Wells stated:

“I am sure you are aware of the recent debate in the Assembly when the future of both the Downe and Daisy Hill Hospitals were discussed.

“During that debate I referred to the assurances I have received from the management team at the South Eastern Health and Social Care Trust that the Downe Hospital will continue to play a vibrant and vital role in the acute network which will deliver essential hospital services now and in the future.”

The problem for health is crystalised in the contradiction between the statements of the most senior NHS administrator in Northern Ireland and the minister to whom she is responsible.

Most in health especially hospital based doctors believe by far the safest and most efficient way to deliver health care (and so prevent unnecessary deaths and prolonged waits for care) is to enhance community and GP services whilst simultaneously upgrading larger hospitals and down grading smaller ones.

This has been the model followed in the rest of the UK especially England which now has much superior waiting times as well as better access to specialized care like cancer drugs despite a lower per head health spend.

The message about needing fewer hospitals was rammed home fairly directly by Sir Liam Donaldson last month to the Assembly. The problem is that the politicians may well agree with these experts but it is almost politically impossible to action these changes.

Local people simply do not believe that anything good will come from closing their local hospital. They may frequently disparage it amongst themselves but if any outsider be they doctor, health bureaucrat or other expert tell the local populace that closing the institution is in their best interests they will react ferociously.

The mistrust of outsiders on this issue seems almost total along with a fanatical belief expressed to outsiders that their local hospital (which they may decry to one another) “punches well above its weight” etc. Should any local politician dare to suggest that the experts might be correct their political tenure is likely to become much shakier.

It is interesting to ask what basis people use to confirm to themselves the superiority of keeping their local hospital. Some of it can be dismissed as simple parochial-ness but other factors stand out.

The potential loss of jobs for people they know. This may not be stated but in reality there is a fear that job would go or that people would move impoverishing the whole community and preventing future economic growth.

Common sense also seems to dictate that it is better to live nearer than further away from a hospital. Furthermore even Sir Liam was not willing to point to any hospital in NI and state that because a patient is in the catchment of it and not another larger hospital further away hospital they are more likely to suffer worse outcomes.

The idea that a politician would state that the people of Newry, Lisburn or Downpatrick are less safe than they would be if their respective local hospitals were closed is inconceivable.

Furthermore most people do not really believe they are going to become life threateningly sick. They perceive the likely reason for hospital attendance to be a minor accident etc.

That they reason can easily be treated locally and hence, avoid a long trip to a centre of excellence which for the minor ailment would be no better. As they get older they imagine things like chest infections which again can probably be sorted out in the local hospital perfectly adequately.

There is also frequently a competing set of experts telling people that the local hospital is just fine. Local GPs almost always fight tooth and nail to keep the smaller hospitals which they have much more control over and easier access to admitting patients who are not that sick and might be refused admission in a larger hospital.

The consultants and senior nurses (and administrators) in the local hospitals are often trusted local authority figures and again usually subscribe to the local hospital “punching above its weight” and being vital to stabilise patients prior to transfer. The local senior figures may well believe this or at least not want to admit that potentially for years they have been running a sub standard service.

Also a move to a bigger centre would dilute their power. The few small hospital doctors who call for change are often labeled as trouble makers wanting a move to further their own careers and are usually forced to leave or keep silent.

These competing sources of authority combined with a mistrust of distant powerful authority figures seems endemic in Northern Ireland society most especially on the topic of health. As such it is unclear if local politicians who are very rarely health experts truly believe that NI medicine is behind the rest of the UKs and whether they truly believe closing local hospitals is a good idea.

Even if they did believe the experts it is highly unclear if they would feel able to act in their constituents best interests very clearly against those same constituents expressed views. It is also unclear no matter how much leadership politicians gave whether the local people would actually believe them or accuse them of ulterior motives.

Finally even though there is significant movement of people between NI and GB few of the people who move between them attend hospitals in both parts of the UK and so few see any significant superiority in the English system.

As such the appeals from health experts to centralize services appear to have no basis in logic, no experiential evidence and look potentially detrimental to local people’s health, well being, sense of community and the vibrancy of their local area.

They also appear to be the views of outsiders parachuted in to pronounce from a position of little knowledge of the local area. Against such arguments as these the experts pronouncement seem hollow indeed.

Faced with such overwhelming counter arguments one can understand why local politicians are so unlikely to support local services being closed.

That leaves, however, the almost complete non-sequitur of the most senior health service manager in Northern Ireland saying something only to be directly contradicted by her political boss the next day. The lack of agency for change seems almost complete.

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  • chrisjones2

    This is what happens when we elect numptys of all colours.

    They are simply incapable of managing the whelk cart and taking the hard decisions on welfare heath justice or anything that matters. It then degenerates into a sectarian fracas, petitions of concern and duplicated facilities – remember last week and Teacher Training Colleges?

    The welfare issue is a case in point – and a distraction from the reality that the real issue is the whole budget not just welfare. We are spending and planning to spend money we will not have and we are wasting millions every day – just look at the shambles around the creation of the super councils where we have ended up with far too many (with gerrymandered boundaries for political reasons) and some building rival HQs in the run up to merger to enhance their towns claim to the HQs (over themuns down the road). And of course we now have to pay them all twice as much for enhanced responsibilities in turning down planning applications from anyone who digs with the wrong foot or whose business might compete with that of a mate, lodge member, party supporter.

    The Treasury is now right. The only way to sort out this mess is to squeeze and squeeze them financially until they change or we change them

  • T.E.Lawrence

    Agree with the headline “Unsquareable Circle” No NI political party could go down the line of Centralize Health Services, the only political party who might think about it with only having a vote base in Belfast and Suburbia would be Alliance

  • chrisjones2

    Then in relaity they are allowing patients to die through maintaining a system not fit for purpose

  • mickfealty

    Chris, I notice your rep on Disqus is described as very low. You might look again at that first comment and ask yourself if you are doing yourself any favours by going in so frequently into the tackle with studs up…

    Democratic politics is the art of the possible. IT’S not possible to hand everything over to technocrats (as Sir Liam has advocated), not least because leadership needs to motivate not just drive people on through the exercise of central power and money (a core issue with the current and ongoing financial crisis..)

  • Practically_Family

    The problem as I see it is that were I to travel more than three streets distant in any direction from my home, I would enter an area where there be dragons and soon thereafter I’d fall off the edge of the world.

  • Brian O’Neill

    Good post Mick. What is interesting is how many of these local supporters vote with their feet once they need medical treatment.

    For example the Downe Maternity Unit is midwife only. This means there is no doctors around if something goes wrong. Many mothers weight up the odds and decide it is better to go to the Royal etc where you get the best of both worlds. The Royal is midwife led but there are doctors and surgeons on standby if something goes wrong.

    The Royal delivers over 6,000 babies a year. The Downe delivers a 100. http://www.thedownrecorder.co.uk/pages/index.asp?title=100th_baby_born_at_maternity_unit

    If would be good to look into how many locals bypass the local hospital and prefer to go to Belfast for treatment.

    Almost two thirds of the Northern Ireland population live within 40 minutes travel of the Royal. http://www.belfasttrust.hscni.net/RoyalMaternity.htm

    In my view it is better to spend the money improving the transport links from regional towns to Belfast. Downpatrick is only 22miles from Belfast. Have a GP lead minor injuries unit at the Downe but all serious cases go direct to Belfast by ambulance.

  • Nimn

    Mick
    “democratic politics is the art of the possible”…well in NI that’s a new one on me.
    Whatever Chris’ descriptive style, he is broadly right. This is not a new problem. We have been having the same debate about the acute hospital network since around 2000 when Maurice Hayes published his report into the matter.
    The message from health professionals has been the same throughout that period, but there has been a fundamental absence of leadership by a political class either unwilling or unable to act. After 15 years of doing nothing, the majority of that time under the watch of a devolved government we have a right to know why this stultifying inability to take decisions by our political class is continuing. If you do not manage change you get unmanaged decline. The campaigners to keep acute services at Mid-Ulster Hospital didn’t succeed not because services were deliberately run down, but because they reached a natural tipping point that no clinician was willing to work in an unsustainable acute hospital putting peoples’ lives at risk.
    However the hospital didn’t close. Its still open providing a full range of sub-acute services and continues to take the pressure of the acute hospitals in the same network
    Far from Sir Liam Donaldson wishing to hand “everything over to technocrats” (a sweeping statement in its own right) he was merely signalling his and others frustration that our politicians of whatever hue are simply incapable of providing the leadership where hard decisions need to be taken.
    If the timing had been better and Liam Donaldson’s report had come out in the latter part of last year and had been put into the SHA mix of ‘must-do’ actions in order for the institutions to survive I suspect we would be well on the way to rationalising our hospital network without a peep about it.

  • chrisjones2

    I will look at that but Slugger is rarely a popularity contest.

    I genuinely believe what I said and am simply so frustrated at the utter uselessness of our political leaders (whom we elect).. I agree completely with all you say but then leadership accepts the need to lead…not just take the populist course

  • chrisjones2

    How do I see my rep on DIsqus and how is it calculated.

  • chrisjones2

    Mick

    I looked this Disqus issue up and find it very odd. In the last 6 months i have had perhaps 6 posts deleted.

    One by you because it was man playing – I disagree but wont argue

    Another was when I posted 4 video clips

    The other was one by a mod when I honestly have no idea at all why.

    I am getting hundreds of up votes and have a +9 – is that good or bad?

    I wonder am i getting lots of down votes from someone on here?

  • hugh mccloy

    That’s a very poor indicator, during pregnancy mums are scanned and signposted to appropriate unit for birth. Correct and educated signposting could lead to increased activity in Downe site.

    A good indicator for the state of maternity is still births,2013 stillbirth BHSCT 27/ NHSCT 23 / SEHSCT 23

    I think the general public is being pounded that much in the media about having a all sing and dancing hospital at the end of the road, I am sure this level of thinking occurred in any place where local hospitals were close:

    Dad: You grandmother is is hospital
    Son: Where is she?
    Dad: Mid Ulster
    Son: I will go and visit here she most likely will be out in a few days

    Or

    Dad: You grandmother is is hospital
    Son: Where is she?
    Dad: She was taken to the Mid Ulster and transferred to the Royal . OR The ambulance took her straight to the Royal
    Son: She must be very ill, is someone with her I don’t want to crowd her while she is in there, maybe will wait until she is discharged back to Mid Ulster or get home.

    Moral of the story the vast majority of critically sick and trauma patients where always taken to one of the major acute hospitals, we even had major hospital bypass protocols to ensure this, if not then we had good clinicians in the local hospitals who were able to stabilize the patient until getting transferred.

    What has changed since these days? and that’s your answer to one of the critical ails of the health service

  • hugh mccloy

    Ohh didnt know you could do that, mine cant be that good, how do i check , more than one mla have said I am like a shot gun going off in a board room 🙂

  • Brian O’Neill

    Hugh is it clear from the stats that people are voting with their feet. No matter how normal a pregnancy is things can go wrong and people want the reassurance of doctors on standby.

  • Brian O’Neill

    The reputation thing is a new one on me also. Only we can see it, it is designed to help us moderate comments better. Some more info here: https://help.disqus.com/customer/portal/articles/745511-why-am-i-marked-as-low-reputation-

    To be honest there is no way for us to see a rankings of commentators good or bad. The disqus system is a bit of a black box.

  • hugh mccloy

    People are not voting with their feet, they are appointed to a destination which they follow for pregnancy .

    if you followed TYC you will know that more home births are required to support the model they want to bring in, and it circles the debate, does every residential home have a full neo natal unit in the spare room? Simple answer is no as the way forward via TYC is to signpost more difficult births to acute units while others stay at home.

    Which then asks the question why is it so dangerous to have a straightforward birth overseen by mid wife in a mid wife led unit when TYC is promoting straightforwards births in your home under the guidance of midwives or other trained community maternity staff.

    Health promotion at the minute is like a NLP programme

  • jimjam

    Agree with this, but it is just about possible to reconcile the statements by V Watts and J Wells. For example the Downe could conceivably lose its inpatient acute services but still have a vibrant role in an acute network, ie by having day surgery and/or outpatient services. I’m not saying that that would satisfy the locals, merely pointing out that the
    two statements are not entirely contradictory.

  • Starviking

    “A good indicator for the state of maternity is still births,2013 stillbirth BHSCT 27/ NHSCT 23 / SEHSCT 23”

    Is that just the raw figures? If so, they would need to be expressed as a percentage of deliveries.

  • chrisjones2

    Thanks. I have just realised what those little arrows at bottom right are for!!

  • chrisjones2

    I understand the politics but for me the issue is patient safety. That should be the real driver here. The case isn’t about money – its about the fact that acute services delivered in bigger units are more effective in saving lives.

    Penny packet services that are attractive in political terms actually (accidentally) kill patients or lead to worse outcomes for them. Thats the ultimate outcome and we need political leadership to say it – but they wont.

  • chrisjones2

    So they are voting for more patients to die?

  • chrisjones2

    ….and risk being put in a ward with themuns who dont wash, play The Sash / Soldiers Song all day on their ipod and keep coal under the bed

  • Nimn

    jimjam – exactly right. Far too often we write off hospitals because acute services have been removed. Both Developing Better Services in 2002 and Transforming your Care in 2011 (all those years ago) both used the same statistic that 70% of people attending an acute hospital don’t need to be seen there. I would far rather have a vibrant local hospital where timely diagnostics take place, day surgery, outpatient appointments and step down beds were available than an unsustainable acute hospital struggling to meet staffing levels any day. As an aside to all of this its about time that NI had its own air ambulance service and we should look to the private sector for sponsorship here.

  • Croiteir

    This is not so – we had 6 children all in the Mater or in the Royal. We by passed Antrim as I would not put a dog in Antrim. They tried to bully us into accepting Antrim but we refused. You can choose. Do not allow anyone to tell you different.

  • hugh mccloy

    The context I am speaking about here is the Downe mid wife led unit which offers delivery at its mid wife led unit.

    I am not sure what part of the country you are form but it is advisable to bypass Antrim, this article however is promoting the use of a few major units that would include Antrim.

    There are no mid wife led delivery units in the Northern Trust, Mid Ulster only offers limited mid wife services pre and post birth, compared to what it used to be before being closed. Which was one of the safest maternity’s in Europe, a multiple award winner the year before it closed.

    At the time it closed like the A&E it was because Antrim was in danger and it needed the staff from Mid Ulster, what happened though was most staff stayed to work in the community or retired.

    At the start they tried to force mothers who used mid uslter mid wife unit to have their birth in Antrim, I was the person who discovered this and led the lobby changing this to ensure mothers in that area could use the service and have no issues having birth in what ever hospital they wanted

    With all Mid wife led delivery units mothers are signposted in the Downe area, and if they want to shut a unti and they need to get the numbers attending lower to do so they will sign post more away from it.