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 14^th 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.