Time for tough decisions: Northern Ireland’s great health challenge

Hugh McCaughey, Chief Executive of the South Eastern Health and Social Care Trust in Northern Ireland blogs about the great health challenges facing the country, and examines the options.

Blog post

Published: 23/06/2015

Northern Ireland’s Health and Social Care system after the General Election

There might be a few new faces on the Northern Ireland benches at Westminster, but there is little change to the challenges facing our Health and Social Care system.

We also face a local Assembly election in 12 months’ time, to select those who actually control and govern our health system. With that election looming, will our political system and public leaders (including people like myself) be able to make difficult and unpopular decisions in response to these challenges?

What are the issues?

I have recently come back from the BMJ/IHI Quality Forum and it is evident the challenges facing Northern Ireland are similar to those seen elsewhere internationally — a need for financial investment of five to six per cent, just to stand still, made up of:

  • Demand rising at three to four per cent
  • Inflation at one to two per cent
  • New developments at one per cent.

So what can we do and what choices are there?

1. Increase funding

There are few economies that believe they can afford this injection of funding at five to six per cent. What would Northern Ireland stop spending money on to find this funding? Would other public services or indeed investment in the private sector suffer?

2. Address the parity issue with the rest of the UK

Currently we provide both health and social care free at the point of need. In Northern Ireland, this means some significant differences compared to the rest of the UK, for example prescriptions and domiciliary care are not subject to means testing. There are very justifiable reasons for both in terms of managing chronic conditions and avoiding nursing home care. Critically in Northern Ireland, we currently cannot reach political agreement on social welfare reform, with the risk of a consequent political crisis and potentially crippling cost to the public purse.

In essence, things we provide 'free' are not … they are paid from the public purse. They are a choice on how to spend your money; if you choose one option, it is at the expense of some alternative.

3. Implement hospital reconfiguration

Since the 1980s we have had a series of 'visions', plans and reports promoting a reduction in the number of Acute Hospitals/District General Hospitals, the most recent being Sir Liam Donaldson’s report, 'The Right Time, The Right Place'.

All of these reports promoted an acute hospital model based on four to seven hospitals. Whilst there has been some change to smaller hospitals, this has largely been driven by crisis or service collapse arising from operational problems or failing to meet standards; removal of medical training recognition or trainees; or workforce shortages.

In essence the plans have not been implemented in full and we retain 12-13 hospitals for a population of 1.8m people. In addition there are a further 11 facilities with the term 'hospital' in their title offering a range of ambulatory, rehabilitation and in-patient services. It is not necessarily that we need to close our smaller hospitals but we need to recognise our acute hospital services suffer from being spread thinly across too many sites. Smaller sites have a vital role providing services to older people, in the areas of chronic disease, rehabilitation, diagnostic and ambulatory services.

Donaldson argues that Northern Ireland’s system is subject to intense political and media scrutiny and "those who resist change or campaign for the status quo are perpetuating an ossified model of care that acts against the interests of patients and denies many 21st century standards of care". Supporting hospital reforms or closures is seen as unpopular and politically unattractive.

Indeed, my own organisation has recently completed a survey of staff with over 300 respondents. 85 per cent of these staff feel our political system and media act to resist change. This survey was conducted across all Trusts with similar results. There is a strong sense of frustration and concern amongst staff that change is not happening quickly enough and concern about the rising pressure and demand, with its potential consequences.

4. OR muddle through

Perhaps the prevailing, and yet I would argue, most dangerous solution. To provide our health and social care services with a small percentage increase in funding and ask those delivering services, particularly our staff, to absorb the balance through 'efficiency' and 'productivity'.

Whilst we should always strive to grab the opportunities for efficiency and productivity, as a long term solution, without structural and service reform, this approach is doomed to failure. Surely in Northern Ireland, and quite probably in many other health systems, we are seeing the consequences of 'muddling through'. Staff and services straining to cope with increasing demand (the dangerously spinning hamster wheel); the consequent impact on morale; rising waiting times and reduced access to services and growing public disquiet.

So what is the solution?

In Northern Ireland we need a rapid decision on what we can afford in funding and some tough decisions on 'parity issues' and hospital reconfiguration. These things would offer some much needed relief and respite but will not alone offer the long-term solution.

To do this we must reform our health and social care system from one that is reactive, focused on treatment, rescue and recovery, to one which is much more proactive and measures success in outcomes and the public health status of the population; truly a National HEALTH Service.

In essence we must manage both short and long. We have to deal with today’s pressures and problems, but also reform our service so it is better able to meet the challenges of the future.

In the meantime, our political and public leaders must face the stark choice: muddle through, or make those tough decisions. The future of our publicly funded Health and Social care system may well depend on it.

This blog is part of an ongoing series exploring the devolution of healthcare systems across the countries and regions of the UK. 

Suggested citation

McCaughey H (2015) ‘Time for tough decisions: Northern Ireland’s great health challenge’. Nuffield Trust comment, 23 June 2015. https://www.nuffieldtrust.org.uk/news-item/time-for-tough-decisions-northern-ireland-s-great-health-challenge