Until we deal with the REAL reasons for our long hospital waiting lists we are just throwing good money after bad…

The problems in Northern Ireland’s health service (and in particular our constantly lengthening waiting lists) have been a recurrent topic on Slugger. Reference has been made to successive reports recommending transformation and hospital rationalization and the absence of any effective resulting action. As many of those reports have pointed out, the service here gets much more money per head than our adjacent jurisdiction England; we have more hospital beds, more doctors and more nurses. A 2014 study by the National Audit Office found that we have 42% non-clinical staff per capita than England. Remarkably the number of Admin and Clerical staff in Northern Ireland has fallen by only 0.4% since then. NI has a younger age structure than England and as health service demand increases with age, overall per capita demand should be less and our waiting lists should be shorter rather than longer.  Clearly, something is seriously wrong.

My contention is that not enough attention is paid to how well we use our existing hospitals and bed stock. It goes without saying that an expensive capital resource such as this needs to be utilized to the maximum extent possible commensurate with providing a quality service. Five specialities (General Surgery, Trauma and Orthopaedic Surgery, ENT Surgery, Urology and Gynaecology) account for almost 80% of those waiting over 52 weeks for hospital admission in Northern Ireland.  Using routinely available statistics I have compared Northern Ireland and England in terms of length of stay for inpatient admissions. Depending on the speciality patients remain in hospital on average between 7% and 43% longer in NI than in England (weighted average across specialities 24%). Paradoxically bed occupancy in Northern Ireland is considerably lower than in England. Were it not for these disparities it would be theoretically possible to treat at least 30% more inpatients (over 20,000) in those five specialities than at present. Bearing in mind that our clinical staffing levels are relatively good if annual inpatient admissions could be increased by only 15% (10,500) that would be more than enough to reverse the current apparently inexorable rise in inpatient waiting lists and eliminate long waits before the end of this decade.

Unfortunately, no-one in the system has any incentive to achieve this. There is no effective pressure on bureaucrats, managers or clinicians so the collective refrain is “we need more money”. In 2010 the universally respected historian of the NHS, Rudolf Klein, wrote about “the inbuilt incentives of doctors, nurses and other providers … to advertise their own claims for extra resources by drawing attention to the service’s shortcomings.” He added: “The professional cries of pain and outrage … increase the political price of successful financial cost containment.”  (This was nicely exemplified locally by the howls of outrage and shroud-waving from what some might describe as the usual suspects in response to the recent announcement of planned cuts of £70m in an overall budget of almost £5bn.)

Successive reports over the last 10 to 15 years by Professor Jon Appleby, arguably the foremost health economist in these islands, have demonstrated that we make much less productive use of our resources than elsewhere in the UK.  One of his reports indicated that our hospitals operate the equivalent of a four-day week. Cynics might say that this leaves time for the consultants concerned to spend even more time in private practice or on the golf course. And the longer the lists are, the more demand there is in the Ulster Clinic and elsewhere.

In the 1980s and 1990s, statisticians in the Department of Health undertook forensic comparative analyses of health service demand, activity and performance levels here and in Great Britain. In almost all of the 30 or more specialities, it was found that we were keeping patients longer in hospital than they needed to be and treating fewer patients per bed than elsewhere. That meant that, as now, although we had more beds than anywhere else our waiting lists kept increasing. Although there were some outstanding exceptions, our surgeons were also on average much less productive than their counterparts across the water.

The Department arranged for a small group of officials, including the then Chief Medical Officer, to present these data to over 60 medical and other groups throughout Northern Ireland. This initiative had some success in changing attitudes and was followed by measurable improvements in efficiency. However once the pressure was taken off, the picture reverted to the status quo ante.

As a mere interested observer (and periodic consumer) these days it seems to me that no-one now has the stomach to address the performance issue, either analytically or otherwise. Although it is urgently necessary in order to improve clinical quality, there is no reason to think that, on its own, hospital rationalization as recommended most recently by the Bengoa Report will improve productivity sufficiently. So nothing ever changes until another tranche of money arrives from DFP, to the delight of the private hospitals on the Lisburn and Stranmillis Roads.  The strategy from the Department and the failed HSC Board seems to be that the worse things get, the stronger the case that can be made for more funding. When new money does materialize it is used to bail out the present system rather than to transform it. Meanwhile, patients are arguably being used as pawns, they continue to suffer, and the impact falls disproportionately on older people needing operations such as joint replacements and cataract surgery with clear knock on implications for the primary and social care services that are already cracking under pressure.

Jimjam is a retired senior civil servant and health researcher.

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  • Smyth Harper

    One of the more illuminating views on our seriously flawed Hospital system, unfortunately common sense seems outwith the grasp of our “decision-makers”, with too many vested interests from local politicians, our FIVE Health Boards and yes the Health Administrators (they are the hidden fifth column)… they hold their hands up and shout, NOT MY PROBLEM, whilst we, the “voice-less”, suffer with more lengthy waiting times! In any other democracy it would NOT be tolerated!

  • Brian O’Neill

    Interesting story from Seanín Graham in todays irish news:

    “A LEADING doctor has called for the axing of the north’s five health trusts and creation of one ‘super trust’ to cut down on bureaucracy as the sector struggles to find £70 million in savings.

    Dr George O’Neill also hit out at the large NHS quangos that exist for a population the size of 1.8 million, saying only one Department of Health is required – given its current workforce of 460 staff in Castle Buildings on salaries of £22m.

    In addition to the department, there are more than 500 administrative staff at the Health and Social Care Board who were paid £26.6m last year, and almost 300 staff at the Public Health Agency, with annual wages of £16m.

    The Board was due to be scrapped in March but will continue until 2019 as it requires ministerial sign-off.”

    The public might ask the obvious. If we need cuts can we start with the bureaucracy first?

  • Muiris

    Unfortunately it is tolerated in this democracy as well, & I suspect many others. The clinicians (that includes me) are of course a vested interest, but only one of many, whether the XS numbers of managers floating around, or the front line admin. via their trade unions, apparently. (The HSE employs almost 100,000, while there are c. 2,500 GPs).

    As our American cousins say: do the math.

  • Smyth Harper

    I presume you are referring to the Republic of Ireland’s healthcare system which has it’s own not dissimilar problems. My comments were directed at the Northern Ireland Hospitals provision of service. I do recognise that Hosp. doctors and nurses are a vested interesting group, but they are labouring under top heavy administration and unwieldy employment procedures making their jobs all the more difficult to “streamline” healthcare provision.

  • How much bed blocking is there in NI? Are the social services able to quickly move patients out of hospital beds into respite centres then into homes with facilities needed to cope with their conditions?

  • Muiris

    Yes indeed. I know that the NHS spends about 8-9% of its budget on primary
    care, I don’t know if that applies in Norn Ireland, but it’s about 2% in the South, which we think is a lot of the problem ( in the South)

    I know that a common theme to RoI & UK is experienced as well as newly qualified (medical & nursing) staff leaving for better T&C in Oz, New Zealand & Canada. This is affecting ‘peripheral’ areas now, but coming to a town near you shortly. Sneem, in Kerry, is only the latest not to get a replacement GP because no one is interested. Fermanagh is being similarly affected.

    I certainly don’t have all the answers, but it seems no one asking the questions.

  • Theelk11

    George thinks the answer to everything is give all the money to GP’s.
    No conflict of interest there at all.

  • John

    The concept of giving more money to GPs is interesting. Given that it takes up to 16 days to see a GP I am unsure how or if this would help.

  • Sloan Harper

    Agree that efficiency could improve, as for all complex systems. Industry’s successful deployment of process control has never been fully exploited by the (more hierarchical) health service. Some great examples of improved productivity here: https://www.improvementscience.co.uk/jois/

  • puffen

    Having spent 38 years working at the coal face, I was grateful for a rewarding career for which i was paid, but I was conscious as watched the Administration staff leave the hospital, on a Friday, that’s it, the Core staff, the committed ones are left running the show, If for say we where to have an apocalypse, Nuclear War perhaps, where would the administrators be, we would then find who or what would be essential? The Suits ran the NHS for their own benefit, I seen this over the years, time and time again.

  • puffen

    It would be a good start

  • hugh mccloy

    dont blame bed blocking , that is a term coined up by health admin chiefs to blame patients rather than themselves

  • hugh mccloy

    No harm to Dr George O’Neill but he changes his mind like the wind, he is not the first either to say this, this was talked about years ago. Dr George O’Neill held a high profile position in health planning and ended up part of the problem instead of being part of the solution. He was happily part of the quango generation, popped up during TYC on both sides of the fence in the media but pure TYC man in the meetings, Bengoa is the same.

  • hugh mccloy

    Lean manufacturing techniques are being applied to health, it might work in manufacturing but health is a different ball game

  • hugh mccloy

    at arms length so that government nor them are accountable, nice set up

  • Georgie Best

    Health is a sector much prone to false economy. You “save” money in one place and ignore the tripling of cost elsewhere because of this. For instance, you economise on the diagnostic tests and people then have to spend an extra day in hospital because of test delays, costing far far more than having an extra radiographer or lab technician.
    There needs to be proper measurement of the effects of changes, and not jut the effect in one department. There also needs to be an investment resource to facilitate savings across the system.