A Healthy Future: The SP Replies to the Hayes Report

A Healthy Future: The SP Replies to the Hayes Report

 

In late February 2003 Health Minister Des Browne announced the closure of a number of hospitals across Northern Ireland. He was essentially adopting the proposals contained in what has become known as the “Hayes Report”. This pamphlet is being published by the Socialist Party as a comprehensive reply to the arguments of Hayes’.

 

Browne’s announcement does not mean that the struggle to save the local hospitals is over. The hospitals will not all close immediately but over a period of up to ten years as new hospitals are built or existing ones extended. Any new units will probably be built under the ludicrously expensive Private Finance Initiative. This

 means that there is a real possibility of building a mass opposition campaign and stopping this process in its tracks.

 

This pamphlet will provide ammunition for activists making the case for a decent health service. It is required reading not just for local hospital campaigners in the areas where closures are planned but also for trade union and community activists in other areas. The on-going privatisation of the NHS, and the rapid decrease in the total number of hospital beds, will be key issues across the North over the next few years.

Activists elsewhere in the British Isles, and indeed on continental Europe, will find this publication useful precisely because the issues concerned-the over-centralisation and privatisation of health services-are issues everywhere.

 

The author

Ciaran Mulholland is a consultant hospital doctor working in Whiteabbey Hospital, Newtownabbey, one of the facilities under threat. He also works as Senior Lecturer at Queen’s University Belfast.

 

He is a member of the Medical Practitioners Union (a section of AMICUS), the doctors’

  trade union, which is affiliated to the Irish Congress of Trade Unions, is wholeheartedly committed to the NHS and is opposed to private medicine.

 

He is also a member of the campaigning groups the NHS Consultants Association and the Socialist Health Association.

 

He joined the Ballymena Young Socialists in January 1980 and has been an active socialist ever since. He is currently a National Committee member of the Socialist Party.

 

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PREFACE

 Northern Ireland’s health service is in crisis.  We have the longest waiting lists in the NHS with over 60,000 now waiting for treatment (a rise of 20% over the last year) and perhaps the longest waiting lists in Europe.  The number waiting for over a year for heart operations, or over 18 months for other operations, has risen by 2100 over the last year.  The Sunday Times has also revealed that another 10,000 people are on undeclared and unofficial waiting lists (24th May 2002).   Casualty departments are in chaos on a nightly basis with dozens of patients lying on trolleys waiting for admission to hospital.  Northern Ireland is short of 3,000 doctors and over 10,000 nurses.  We have fewer heart surgeons and brain surgeons than anywhere else in the NHS. 

 

This crisis has a clear cause.  The NHS has been under-funded for decades.  The Thatcher and Major years pared spending to the bone.   When Tony Blair came to power in 1997, he continued with the Tories’ spending plans for the first two years of his government.  Since 2000, spending has risen but no real improvements have been seen as the increased finance is being soaked up by the accumulated deficits of the Trusts, or is being diverted into the coffers of the private sector. 

 

The needs of the North’s health service are great.  Craigavon Area Hospital alone needs £90 million over the next ten years merely to bring its services up to scratch.  The Northern Ireland Confederation for Health and Social Services, representing the Boards and Trusts, estimates that the local health service requires an extra £100 million a year for the next ten years to “bring the service up to an acceptable level”.  Total health spending in 2002-2003 will be £2520 million, an increase of £224 million over 2001-2002.  Most of this money will be required just to maintain existing services however, leaving only £46 million for new developments.

 

Over the last period the situation in Northern Ireland has deteriorated relative to the rest of the NHS.  The cutbacks of the late 1980s and 1990s were sharper her and NI’s health service is now receiving £200 million less annually than it should receive.  We need proportionally more spending in the North because we have greater levels of poverty.  Ill-health is more common amongst the unemployed and the poor.  Poverty both causes ill-health and acts as a barrier to receiving good health care.

 

NI people need 1850 heart operations a year, but only 800 are provided at the Royal Victoria Hospital.  If you have a few thousand pounds to spare, however, you can pay for your operation privately and jump the queue.  If you cannot come up with the necessary cash you enter a daily lottery.  If you are lucky, you will survive until your operation.  If you are unlucky, you die on the waiting list.  This is the toll of class.  Money buys life.  Poverty kills.

 

This is an extreme example, though a very real one.  More mundane illnesses carry off many more working-class people prematurely every day.  If you are working-class, you are more likely to die of heart or lung disease, in accidents at work, or of almost any sort of cancer, than the middle-class.  The estimates vary, but perhaps 22,000 to 100,000 people die prematurely because of their class each year in Britain.

 

Despite these problems the NHS has been an historic success story.  It has delivered a high-quality, free service to everyone.  That it has its failings cannot be denied  and it is badly in need of resuscitation.  Unfortunately the main political parties, the main doctors organisations and health service managers all agree on the solution to the problems in Northern Ireland’s health service:  implement the Hayes Report.  The Hayes Report was drawn up at the request of Health Minister Bairbre de Brun.  It recommends the closure of six acute hospitals and the widespread implementation of the Private Finance Initiative (PFI).   De Brun has endorsed the Hayes Report in a follow-up document, “Developing Better Services”, published in June 2002.

 

This pamphlet takes up the arguments of the Hayes Report in detail.  It is necessary to do so because the assumptions made by Hayes are so widely accepted and are seldom challenged. 

 

Even trade union and community activist, whilst they are uneasy with the message of Hayes, find it difficult to answer the arguments of those who would decimate our health service.  To challenge Hayes, it is necessary to go into considerable detail on a number of points and to take up complex argument.  This means that this pamphlet is, of necessity, difficult reading in places, although every attempt has been made to present its ideas as clearly as possible.  It is hoped that community, health and trade union activists will persevere and study its arguments and conclusions.

 

If we cannot counter the ideas contained in the Hayes Report, we will ultimately be forced to adopt the position of the main parties, who can only conceive of defending one hospital by effectively calling for the closure of another.

 

This pamphlet focuses on our acute hospital services.  This does not meant that primary care (services provided by General Practitioners, District Nurses and associated staff) or community care is not important.  Rather, the pamphlet focuses on the acute sector because this is the area which the Hayes Report has reviewed.  Of course, it is not possible to consider the hospital sector in isolation from other services.  A genuine national health service must be comprehensive and all-embracing.  It must endeavour to keep people out of hospital, not just treat them well when they are admitted.

 

To seriously challenge the Hayes Report, we must pick apart its conclusions but we must also question the whole basis of a society that forces us to struggle to maintain such basic services as a decent local hospital.  And, ultimately, any serious consideration of the future of our health service forces us to ask the question: is this a sick society?  Why can we not provide a quality health service for all?  Is the way that society is organised causing ill-health?  And ultimately should we not seek a fairer way to distribute wealth, and to ensure better health for all? 

 

 INTRODUCTION

 

In August 2000 Bairbre de Brun announced the establishment of the Acute Hospitals Review Group.  It reported in June 2001. Its remit was to plan a way forward for NI’s hospital service.  The unspoken assumption was that it would once and for all decide on the future of the North’s smaller, rural hospitals.

 

This pamphlet is not an attempt to dissect every line and paragraph of what has become known as the Hayes Report (after the chairman of the Group, Maurice Hayes).  Rather it is a reply to the key ideas that underlie the approach of Hayes.  It is an argument against unnecessary centralisation of services and against the on-going privatisation of the NHS.  It is an argument in favour of democratic accountability in our health service, of increased funding, of adequate resources for both hospital and community services, of a fair deal for all NHS staff and of a real attempt to tackle health inequalities.   The pamphlet borrows freely from the work of others, in particular the arguments of Professor Allyson Pollock who has written extensively in opposition to the Private Finance Initiative, from Julian Tudor Hart, a veteran GP and socialist activist from South Wales and from the publications of the Socialist Health Association.

 

Hayes argues that the Acute Services Review is all about improving services.  Throughout the Report however, there is an acknowledgement of the financial background to the Group’s work.  There are many examples:

 

 “there continues to be significant pressure on the resources available” (page 19).

 

“our proposals for the future…. must be affordable within the resources likely to be available.  While undoubtedly there is a need for a substantial injection of funding, it is of even greater importance that existing resources are used as effectively as possible” (page 25).

 

“It would be … unwise to ignore the extent to which problems of under-funding            may be compounded by not making best use of existing resources” (page 29).

 

“to plan solely on the basis of a substantial increase in funding….. would not in our view be prudent” (page 34).

 

The bottom line is that the Hayes Report is finance driven.  The question of “limited resources” is primary, from it flows all else.  The “solution” is constructed to fit predetermined financial constraints.  Maurice Hayes and his co-thinkers argue that change is inevitable, as indeed it is, but then falsely claim that the way forward they propose is based on good evidence and is the only real alternative.   This is simply not the case.

 

Certain assumptions underlie the arguments of the Hayes Report, assumptions that are leading in the direction of hospital centralisation and privatisation across the NHS and across Europe.  These assumptions can be summarised as follows:

 

 1.Demand for health services is infinite and can never be met.

 

2. Resources are limited and will never suffice.

 

3. As a result of the above change is inevitable.

 

4. Change means increased centralisation (with the closure of smaller hospitals) as larger hospitals are both safer and more cost effective.

 

5. Change means increased privatisation as the private sector is more efficient and cost effective, and can inject resources which are not available to the public sector.

 

These are assumptions and they can be challenged.  An editorial in the British Medical Journal, written to accompany a series of articles on the future of acute hospital services, makes the point succinctly: “Distressingly little evidence is available on the best way to configure services” (British Medical Journal (BMJ) 1999:319:798).

 

And as for the argument that larger hospitals with greater numbers of cases allow doctors to become more adept at certain procedures, the same editorial states: “quantity and quality do seem to go together for some surgical operations, but not all – and evidence is much thinner on medical care”.

 

The case for larger hospitals isn’t even watertight when cost is considered. “There is virtually no evidence on costs, but nobody should assume that hospital mergers mean reduced costs. Indeed, bigger hospitals may mean higher costs for medical patients”. 

 

We will consider these issues in detail through the rest of this pamphlet.  Chapter One outlines and counters some of the main conclusions of Hayes.  Chapter Two examines specifically the widely held view that bigger hospitals are “better” than smaller hospitals.  Chapter Three considers the implications of New Labour’s decision to implement the PFI throughout the NHS.  Chapter Four looks at the economic and social background to attacks on the NHS and the entire Welfare State.  In Chapter Five we explore New Labour’s record to date and in Chapter Six, we outline the way forward and propose alternatives to Hayes.

 

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The Socialist response to the Hayes Report: Chapter One

 

THE HAYES REPORT DISSECTED

 

Introduction

The situation Hayes found when he toured the North speaks for itself.  “Many buildings were in poor condition and badly maintained.  Morale was universally low – people felt isolated, under stress and undervalued.  We were told repeatedly that hospital services had been cut to the bone, and that successive cuts had resulted in a lack of elasticity.  Hospitals which operated to nearly full capacity were unable to cope with sudden surges in demand, pressures which had previously only been experienced in the winter months were now apparent throughout the year, and patients, especially elderly patients, were waiting unreasonably, in some cases impossibly long times for elective treatments which would transform the quality of their lives”.  Despite these finding the Hayes Report proposes further cutbacks.

If the Report is implemented Northern Ireland’s health service will look very different ten years from now.  Services will be concentrated in only nine acute units adding to the distress and inconvenience of patients and relatives as travel times increase.  At least 500 more acute beds will have disappeared – Hayes recommends a cut of 500 but allows for a cut of up to 1200 if certain requirements are met.  In addition the widespread implementation of the Private Finance Initiative in a new hospital building programme will put further downward pressure on bed numbers.

In 1981 there were 24 acute hospitals in Northern Ireland.  Nine have since closed, and now there are fifteen.  A number of the closures have occurred since 1995 – Ards (services switched to the Ulster at Dundonald), the Route (services switched to the new Coleraine hospital), and Banbridge and the South Tyrone (services now based in Craigavon).  Of the very smallest hospitals (less than 125 beds) only three are left – Lagan Valley, the Downe and Whiteabbey.  New hospitals have replaced some of those that closed but the overall effect has been a reduction in total acute bed numbers of 1400 (or 21% of the total) since 1990/1991.

The Hayes Report proposes the closure of six of the fifteen remaining acute hospitals.  There will no longer be emergency care or maternity services available in the Tyrone County in Omagh, the Mid-Ulster in Magherafelt, the Downe in Downpatrick, or in Whiteabbey, the Lagan Valley and the Mater in the greater Belfast area.  The South Tyrone in Dungannon was recently “temporarily” closed in salami slices, but according to Hayes has now gone forever.  New hospitals are proposed, to be financed through PFI, and with fewer beds.    

Hayes also proposes a new organisational structure.  Reducing unnecessary “bureaucracy” is of course necessary but it is probable that the result will actually be the loss of 1000 low paid and very necessary administrative jobs and an increased burden on those who are left.  Senior managers are likely to be redeployed or to receive handsome payoffs.  Importantly the new structures will not be any more democratic. 

 

Inadequate Funding

The health service in NI has been severely financially strapped in recent years.  The combined deficit of all the Trusts in 1998/99 was £6.8 million and in 1999/00 it was £15.6 million.  In early 2001 the Assembly cleared the accumulated deficits and a stringent austerity programme was implemented by Bairbre de Brun’s department.  In one Trust area, for example, one hour of home help service could only be arranged if three hours were first  stopped.  Many Trusts stopped filling vacancies.  Despite these cutbacks deficits began to rapidly accumulate again. 

Over the three years to 2005 NHS funding in the North will increase by approximately £225  million but this will have little impact on the delivery of front-line services.  It will be eaten up by accumulated deficits in day to day funding and by the need for essential investment in our crumbling infrastructure.  An estimated £200 – £250 million is required just to carry out essential maintenance across the North. 

Hayes admits that planned increases “will not be enough to keep pace with the higher demands for services from an increasingly elderly population, and increases in costs in areas such as staff salaries, drugs, goods and services, let alone any improvement to service provision”.  The expected savings from the proposed organisational changes in the Hayes Report amount to only £10-£15 million per year.

The NHS as a whole has been under-funded for decades.  According to one authority, the NHS has lost out to the tune of an incredible £267 billion since the early 1970s, when compared to the European average.  Historically, Northern Ireland has had a higher level of NHS funding than England but the gap has been closing now for many years.  Between 1970 and 1984 for example, real expenditure increased by 7.5% in NI compared to a 11% increase in England.  In contrast “productivity” or throughput  increased by 30% in NI, significantly more than the 22% rise in England. 

In the late 1970s a Treasury Committee examined the need for health care expenditure across the NHS.  A majority of the committee concluded that Scotland required 7% more funding than England, Wales 6% more and NI 7% more. A minority felt that  these calculations were too conservative and expressed an alternative view.  They argued that Scotland actually required 18% more funding than England, Wales 12% more and NI a whopping 22% more.  In the late 1990’s Scotland actually received 25% more per head of the population than England, Wales 18% more but Northern Ireland only 5% more. 

The arguments of the late 1970s still hold.  NI requires greater funding for a number of reasons.  Our population is more sparsely distributed, with higher mortality rates and morbidity (or sickness rate) and a higher birth rate.  (Northern Ireland’s place in mortality and morbidity tables has changed a little in recent years.  There is more premature death and ill-health than in most English regions but less now than there is in Scotland and Northern England.)  There is a greater level of economic deprivation (as assessed by the level of income, total and long-term unemployment, household size and condition) than in most of England, Scotland and Wales.  Our population profile is also different with more young children.  And of course the threat of shootings, bombings or riots has not gone away.  This does not mean, of course, that NHS funding in England is adequate; rather, funding is even more inadequate in Northern Ireland. 

The Hayes Report compares current funding levels locally with other NHS regions and with
the South.  (No attempt is made to compare with other European countries where funding is at a much higher level.)  The figures demonstrate that the situation continues to deteriorate.  In 1996/97 expenditure per head of the population in NI was similar to the level in the North East of England but 8% lower than in Scotland.  By 1999/00 a gap of 5% had opened up with the North East and the gap with Scotland had widened to 13%. 

In the year 2003/04 NI will be spending £141 million less than would be the case if spending was set at the levels of  North East of England and £214 million less than the comparable  Scottish figure.  By then spending will be £737 per head of the population in NI, £819 per head in the North East of England and £861 per head in Scotland.

By 2009/10 expenditure will be £1052 per head of population in the North, £1207 per head in the North East and £1260 per head in Scotland.  NI would then need an extra £273 million to reach the North East’s levels of expenditure and £366 million to match Scotland.  Increasing our health service funding to the average EU level now would give us an immediate boost of £200 million.  As can be seen from Table 1 the NHS as a whole is presently far below the average EU level of healthcare spending and has many fewer beds.  The bottom line is that our health service is grossly under-funded.  The Hayes Report can only be analysed within this context.  It is an attempt to fit a service into pre-determined financial constraints.

Table 1

                                    Britain France             Holland           Germany         Italy        

Health Spending as      

% of GDP                    6.8                   9.4                   8.7                   10.3                 8.2          

Hospital Beds per        

1000 of population       4.7                   8.9                   11.3                 9.7                   6.4

 

How Many Maternity Hospitals?

For five years fierce arguments have raged over the future of maternity services in Belfast and across the North.  In Belfast the pendulum has swung alternately in favour of the Royal Maternity and then the Jubilee.  Now Bairbre de Brun has come down in favour of the Royal and the Jubilee has been closed and demolished.

Everyone who took a side in this fractious debate gave the impression that they had considered the medical evidence with great care.  Confusingly this included the senior medical staff from each site, who of course drew opposite conclusions.  Given this which side was right?  The answer is that the Royal is probably the best place to site a regional (covering all of Northern Ireland) unit for very ill babies.  However, it does not follow that the Jubilee should have closed.  We should not accept sterile arguments that one unit can only remain open if another closes.

The Hayes Report is suggesting the closure of several more maternity units.  It is now time to call a halt to this process.  As well as the Jubilee a dozen other maternity units have closed across the North in recent years.  The trend towards larger units has some justification in terms of safety, but it tends to take obstetric care further and further away from local communities.  In addition there is evidence that larger units become more heavily reliant on technology and medical intervention such as caesarean sections.  Already the North has a higher rate of medical intervention, such as caesarean sections, during childbirth than any other NHS region (the Ulster Hospital in Dundonald has a higher rate than any other hospital in the NHS).  Dissenting voices have been raised, including from a minority of consultant obstetricians (mostly women) and it is about time we had a full and open debate on the extent to which we wish to medicalise childbirth.

Both the Royal Maternity Hospital and the Jubilee could have remained open, the Royal as a regional centre for very sick babies and the Jubilee as a maternity hospital for the area it traditionally serves in Belfast who are not ill.  All our existing maternity hospitals should remain open, with increased priority given to the wishes of mothers and with an increased role for midwives.

Are There Enough Beds?

Northern Ireland’s health service has already seen a huge amount  of change over the last two decades.  To illustrate this point it is worth considering the area covered by the Northern Board (most of County Antrim, much of County Derry and some of East Tyrone), in detail.  The Moyle in Larne, the Waveney in Ballymena and the Masserene in Antrim closed when the new Antrim Area Hospital opened in the early 1990s.  Similarly the Route Hospital in Ballymoney and the old Coleraine Hospital were replaced by the new Coleraine Hospital in 2001.  Other smaller units, which once provided extensive services, such as the Ballycastle Hospital, have long since closed. 

New hospitals were certainly required but unfortunately each time an old hospital closed and a new one opened the total number of in-patient beds was reduced.  It is now widely acknowledged that the Antrim Area and Coleraine Hospitals are under severe pressure and often cannot find beds for those who need them.  If the Hayes Report is implemented Whiteabbey Hospital and the Mid-Ulster Hospital in Magherafelt will close as acute hospitals and the Antrim Area Hospital will expand its capacity.  The number of new beds in Antrim will not equal the number that close and total capacity in the area will fall.  Health economists and planners argue that centralisation and new technology increase “efficiency” and fewer beds are thus required.  There are simply too few beds now however, and the implementation of the Hayes Report will place even greater pressure on beds.   The fine words and carefully honed arguments of economists are of little comfort to those who lie on trolleys for hours awaiting admission or whose operations are cancelled because a bed is not available.    

The savage cutbacks of the last two decades have lead to increasing problems for the health service with every year.  Every doctor and nurse feels under pressure every day of the year.  Seldom do they feel that they have enough beds at their disposal.  Admissions are postponed and patients spend hours in pain and distress waiting for a bed (this is also distressing for staff, of course).  What used to be an annual winter crisis in the NHS is now a year round phenomenon.

Over the years bed occupancy rates (the percentage of beds with someone in them at any one time) have risen steadily.  Rates at or near 100% are now the norm.  To a particular type of manager an empty bed is an abomination, an indicator of inefficiency.  They see hospitals in much the same way as they see supermarkets.  An empty supermarket shelf isn’t earning, isn’t contributing to profit.  It must be filled.  Similarly an empty hospital bed must be filled immediately, or alternatively closed, all in the interests of efficiency.

There are major problems with this approach.  It is best to always have a number of empty beds, if possible, as this allows a hospital to cope with a sudden influx of patients.  Running at, or close to, 100% occupancy means that there is a crisis every week if not every day.  Running at less that 100% occupancy is in fact efficient, not inefficient.  And moreover, it is more humane and sympathetic.  A hospital that is efficient in the eyes of its managers will not be efficient in your eyes if it can’t provide you with the bed you need when you are ill.

There is overwhelming evidence that there are not enough beds in Northern Ireland as things stand.  Northern Ireland has 2.8 acute beds per 1000/population compared to 2.4 in England, 3.1 in Scotland, 3.3 in Wales and 3.3 in the South.  As a result waiting lists are much longer locally.  There are 28 people on a waiting list for every 1000 people in Northern Ireland compared to 20.7 in England, 16.1 in Scotland and 27.2 in Wales. The numbers of those waiting for more than 12 months is 5.62 per 1000 in Northern Ireland but only 3.85 per 1000 in Wales, 0.97 per 1000 in England and 0.23 per 1000 in Scotland. 

Staff have already made heroic efforts to cope with fewer beds.  Between 1990 and 2000 there was an increase of 25% in the number of patients treated in Northern Ireland hospitals and average lengths of stay in hospital fell by 31%.   Despite this, and our long and lengthening waiting lists, the Report concludes that “Northern Ireland does not need more acute beds”.  As can be seen, the opposite is the case.  We need more acute beds.

Is Demand Higher in Northern Ireland?

Hayes makes much of the argument that demand for health services is higher in Northern Ireland than in other regions of the NHS and the South.  The implication is that at least some of this demand does not reflect real need, is unnecessary and can be reduced. 

The argument partly rests on the fact that waiting lists are longer in Northern Ireland.  Over 60,000 people were waiting for elective (planned) treatment in the autumn of 2002 compared to 36,000 in March 1996.  The number waiting for eighteen months or more increased from 632 in March 1996 to 5200 in March 2001.  There are similar long waiting lists for outpatient appointments with 102,000 in the queue in March 2001 against 59,000 in March 1996.  The number waiting for more than six months increased from 7300 to 26,700 over the same period. 

It is perverse to use these figures to argue that demand is excessive locally.  Waiting lists are more a measure of the extent to which services are deficient than they are a measure of demand for services.

Emergency and non-emergency admission rates are higher in Northern Ireland compared to the rest of the NHS.  Once patients are admitted however they are not significantly more likely to have an operation (there are only 3% more operations per head of the population carried out in the North, when compared to England).  Perhaps patients are more likely to be admitted here because of social deprivation or because of geographical distance from hospital.  Once admitted they are treated well and not subject to unnecessary operations simply because they are there.  Perhaps there are too few admissions in England and patients are too often left to suffer at home.  

Rather than admissions being unnecessary, need may simply be higher locally, for a host of reasons.  The figures are also distorted by the fact that the private medical industry is much larger in England and carries out a larger proportion of elective (or planned) operations.  It is thus possible that there are in fact more operations per head of the population in England than in the North, especially in the more affluent areas, though need may be less.

Demand may appear to be higher in Northern Ireland at the present time for another reason.  The number of elective (planned) admissions fell in Northern Ireland in 1996/97 due to a sharp 3% cut back in spending in that year.  The slightly higher figures for Northern Ireland in 1999/00 may thus simply be a “catching up” blip in the statistics as surgeons struggle to get on top of their workload.

The Report concludes that “expected demand” in Northern Ireland in 2013 could theoretically be dealt with in between 3300 and 4100 acute beds.  This represents a reduction to the current acute bed complement of between 400 and 1200 beds (the actual figure would depend on the rate of emergency work at the time).

These figures are arrived at by assuming that in the future “levels of efficiency” in Northern Ireland will dovetail with those of England.  The measures of efficiency utilised are average length of stay in hospital, the percentage of procedures carried out on a day care basis (with no overnight stay in hospital) and percentage bed occupancy (the average percentage of beds actually occupied by a patient).  The problem with using these figures are legion. 

At present the average length of stay in Northern Ireland is 5.8 days compared to 5.3 in England.  The percentage of operations carried out on a day patient basis is 62.6% in Northern Ireland compared to 66.2% in England.  Average annual bed occupancy is 80.5% in Northern Ireland, 81.1% in England.  It can be argued that lengths of stay in England are too short already (leading to a high rate of re-admission when something goes wrong after admission) and bed occupancy rates are too high (leading to recurring bed crises and some well-documented cases of actual deaths).  Thus a convincing case could be made that England should aim towards our “efficiency” levels, rather than the opposite.  

 

In any case if demand is higher locally are these targets achievable?  If England reaches “higher” levels of efficiency by siphoning off much elective work to the private sector is this in the mind of Hayes and his co-thinkers?  Do they expect private medicine to grow locally?  Will private medicine be encouraged to grow locally?

Ultimately arguments about “high” and “unnecessary” demand on the NHS are patronising and a form of class discrimination.  The well off are “entitled” to whatever health care they wish, if they pay for it privately.  No one – not politicians, senior doctors or commentators – argues that they should not received unnecessary care.  If they have the cash, they can have the care.  The less well off, however, are a different matter.  They ought to moderate their demands and to accept that the NHS cannot provide everything.

 
Alternatives to hospital

It is often argued that large numbers of admissions to medical or surgical wards are unnecessary or, in the jargon of the NHS, “inappropriate”.  If we could only prevent these inappropriate admissions then there would be no crisis.  Several studies have examined this issue and contrary to expectations few found evidence for huge numbers of inappropriate admissions. 

In the most damming study, the author (Coast) found that 22% of admissions were designated as inappropriate in a rural area and 24% in an urban area (BMJ 1996;312:162-166 and Journal of Epidemiology and Community Health 1995;49:194-199).  A second study (Victor) found an inappropriate admission rate of less than 1% (Journal of Public Health Medicine 1994;16:286-290). 

Even if we accept that there are significant numbers of “inappropriate” admissions, given the increasing pressures on the system one would expect fewer, not more, as time goes by.   The term “inappropriate” is value laden in any case. Its definition varies from study to study and what may be “inappropriate” to the health economist may not be to the patient or the patient’s doctor, nurse or family.  It is also a term that is likely to be applied more to the poor than the well off.  The middle classes are more articulate in their demands on the NHS and are less likely to be labelled.  The poor may well be in hospital not just because they are ill but because their housing is poor and they have little support at home.  Is this appropriate? 

There certainly is ample evidence that patients sometimes spend too long in hospital.  This is often due to failings in other parts of the system with a lack of necessary home care and support.  Often the problem is not one of too many admissions to hospital but one of too few places in the community to which patients can be discharged.  It is also the case that the further away patients are from home the harder it is to discharge them – another argument against centralisation.  Over the last decades society has become more and more atomised and the sick and elderly cannot rely on family support to the extent to which they once did.  This is a factor in delaying discharge from hospital. 

In contrast to the above situation, many patients are discharged prematurely from hospital, before they feel up to going home and before their doctors or nurses wish them to go, because of a shortage of beds.

Hayes places considerable emphasis on the ability of day surgery (when one arrives in and leaves hospital on the same day as an operation) to reduce future demand for hospital beds.  Whilst there is some truth in this, and day surgery has expanded greatly in recent years (in 1985 17.7% of all admissions in England were treated as day cases; in 2000 the proportion was 38.9%) there is evidence that these operations often represent new work and are not an alternative to traditional inpatient care.  Thus increased numbers of day case procedures in Northern Ireland in the future will not reduce demand for hospital beds by as much as Hayes assumes. 

Hayes assumes a future bed occupancy rate of 95%.  This figure is too high.  It will not allow for the flexibility a responsive health service must have.  As one author puts it: “As for planning levels of bed occupancy, there is a failure to appreciate that planning for a mean occupancy of 90% guarantees that hospitals will have insufficient numbers of beds on a substantial number of occasions because of the inevitable variations in daily admissions.  Furthermore, it is often not appreciated that reduction in length of stay often require lower occupancy rates to retain sufficient flexibility to deal with random fluctuations in demand” (BMJ 1999;319:1361-1363).

In summary, Hayes cannot demonstrate that his proposals will significantly reduce demand for acute beds, nor can it be conclusively shown that large numbers of hospital admissions are unnecessary.

A Lack of Real Planning

Official documents and expensive reports are always couched in terms that suggest the experts know best, that they have studied the evidence carefully and that the way forward is clear.  The reality is somewhat different.   At a conference convened by the Anglia and Oxford region of the NHS to consider the future of acute hospitals in 1999 the participants agreed that the driving force behind change ought to be a desire to improve the quality of care but was in fact “the need to reduce costs and cope with staffing problems, new technology, and public expectations” (BMJ 1999:319:797-8).  Planning for the future is based on a response to financial stringency.  And when previous hospital closures have occurred “it is rare for the results of hospital reconfiguration to be evaluated” (BMJ 1999;319:1361-1363).

A similar process is evident in the Hayes Report – it is not proactive and forward thinking but reactive and restricted in its thinking by perceived wisdom concerning the value of smaller hospitals.

Today evidence-based medicine is the watchword – doctors and other health workers are expected to study research findings and then to implement them.  In contrast, evidence-based management and planning are nowhere in sight.  And planning appears to go out the window almost entirely when Private Finance Initiative (PFI) schemes are planned.  As one author has argued: “The quality of PFI planning conflicts with governmental initiatives to improve the evidence base and standards and quality of clinical practice.  PFI plans seem to have been absolved from these duties” (BMJ 1999;319:179-184).

Honest health economists (usually writing in professional journals rather than in the local paper) make interesting reading.  One admits that financial pressures are often the real reason for hospital closures, but that it is difficult to be open about this.  “The paradox of planning hospital changes is that the financial pressure that frequently provides the impetus for reform is often the very factor that is a barrier to implementation.  It is difficult to convince an already sceptical public of the need for change if the reasons for it are purely financial” (BMJ 1999;319:1262-1264).  The solution is to disguise the real reasons for hospital closure.  “The planning process has effectively been reversed, with services being designed to fit predetermined reductions in capacity.  The high costs of the PFI entail major reduction in service provision, acute bed capacity, and clinical staffing.  Justifying these reductions, it would seem, has become the main planning task”(BMJ 1999;319:179-184). 

Contrary to what the Hayes Report argues there is no consensus on the best way forward, and no evidence that centralisation should be pursued.  “A difficulty for planners is the lack of clear consensus on how to undertake many important parts of the planning process.  There is no agreed method for calculating even such basic building blocks as the demand for hospital care, the impact of ageing, the length of stay, or day care rates.  Public health departments may have undertaken needs assessment but no calculus exists to convert this into even simple measures to permit hospital planning.  Attempts to set nominative targets have failed because they are not grounded in science and are not sufficiently flexible.  Many of the methods used in these forecasts are poor and are often not updated between the initial plan and the eventual implementation” (BMJ 1999;319:1262-1264).

According to Nigel Edwards of the NHS Confederation and Anthony Harrison of the Kings Fund, “Analysis of trust business cases for rebuilding and other developments……..show wide variations in the assumptions made about almost every aspect of future hospital provision.  Despite the apparently increasing difficulty in meeting growing demand for hospital care many hospital plans envisage substantial reductions in the number of beds, and hospitals with large private finance initiative schemes expect reductions of 20-30%.  But whether these can be justified in terms of either future demand or levels of performance is unclear” (BMJ 1999;319:1361-1363).

Cross–border Co-operation

Hayes makes the not unreasonable point that the health service in Northern Ireland and the health service in the South should co-operate as far as is possible in order to enhance care for patients on both sides of the border.  This point has been seized upon by both Sinn Fein and the SDLP who argue that such North-South links have the potential to make a significant difference to health care.  This claim is more a reflection of their interests in promoting an all-Ireland agenda than anything else.  In a similar vein, John Dallat of the SDLP does not oppose privatisation of the post office in NI but instead argues that postal services should be considered on an all-Ireland basis.  The logic of this position is that all-Ireland institutions are of necessity “good”, whether or not they are public or private.  Presumably it would be reasonable to sack postal workers and reduce rural services so long as the remnants of the Royal Mail linked up with An Phoist and the letterboxes were painted green.

The bottom line is that both health care systems are cash-strapped.  Neither can “save” the other.  Integrating the two services will achieve little.

 

In recent years nationalists and republicans have argued that the North can only benefit economically from linking up with the South and that the so-called Celtic Tiger will lift the Northern economy and transform all our futures.  This argument is false.  At the present time the Southern economy is rapidly weakening.  The Celtic Tiger left a huge section of the population of the South behind, trapped in poverty and exploitation.  As the world recession unfolds job losses are mounting.  Tax revenues have recently fallen by 2% when an 8.6% rise was expected (Irish Times, April 4^th 2002).  Government spending rose by 20% over
the same period.  The southern economy, and still less the Southern health service, are not going to come riding to our rescue.  On the basis of capitalism there will always be too little to go around and both health services will always be under pressure, if not in outright crisis.  On the contrary, under socialism an integrated health care system would be natural and mutually beneficial.

There has been major investment in the southern health service in recent years (spending is up 60% from 4 years ago) and health spending is now proportionally higher that in the HNS – indeed it is approaching the European average.  The starting base was very low however as the southern service had been starved of adequate resources for decades.  Despite the recent increases in spending, the main hospitals expect to be in deficit by the end of the year and major cutbacks are taking place across the South.

Healthcare remains inferior in the South when compared to the NHS.  Life expectancy is significantly shorter.  The South has fewer GPs (0.45 per 1000 of the population) compared to the North (0.63 per 1000 of the population).  There are also fewer consultants in the South (0.33 per 1000 compared to 0.46 per 1000 in the North) and fewer nurses and midwives (7.9 per 1000 compared to 8.7 in the North).  The dissatisfaction of staff with poor wages and being taken for granted has made itself apparent in a numbers of strikes in recent years.  Two years ago nurses across the service went on strike and in 2002 Accident and Emergency nurses and staff in day-care facilities for handicapped took action. 

The South does have more acute beds (3.3 per 1000 population) compared to the North (2.8), England (2.4) and Scotland (3.1) and has an equal number with Wales (3.3).  These figures are for public beds only – there are many more private beds in the South and the total acute bed supply is likely to be significantly higher.

The Southern health system is a peculiar, and very unequal, mix of public and private.  There is absolutely no doubt that public care is inferior to private and the public hospitals have been under increasing pressure in recent years.  An average fee of £25 is paid when someone sees a GP.

Conclusion

 

We can clearly state that the conclusions of the Hayes Report are not supported by the evidence.  The proposals contained within the Report are driven largely by financial considerations.  We will now consider two of the claims of Hayes – the argument that centralisation is vital for reasons of safety and efficiency, and that the private sector will rescue the NHS – in more detail in Chapters Two and Three. 

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The Socialist Response to the Hayes Report: Chapter 2

 

CENTRALISATION OF SERVICES – IS IT JUSTIFIED?

 

Introduction

The centralisation of hospital services is an international phenomenon.  “Hospitals in all systems have to deal with rising expectations and, more often that not, a need to contain the costs of health care.  Outside the developing countries the generic response to this has been to reduce hospital stays and to improve the efficiency of the system, a strategy which seems to be a least partly successful.  The experience of the health systems in the United States and the United Kingdom shows that cost pressures and changes in health care delivery mean that this strategy will lead to hospital mergers and closures in the longer term” (BMJ 1999;319:845-8).

The NHS already has fewer acute beds per head of the population, and patients have a shorter average length of stay in hospital, than in 20 other OECD countries (1995 figures -see Table 2).

Table 2

            No of acute beds per                          Average length of stay in

                        1000 population (1995)                      days (1995)

Australia                     4.3                                           6.7

Austria                        6.6                                           7.9

Belgium                      4.8                                           7.8

France                         4.6                                           5.9

Germany                     6.9                                           11.4

Ireland                        3.4                                           6.7

Italy                            5.3                                           8.8

UK                              2.2                                           4.8

USA                            3.3                                           6.5

Source BMJ 1999;319:845-848                                 

Between 1978 and 1990-91 506 small hospitals closed in England.  The majority of these had less than 250 beds.  With the introduction of Trust hospitals in 1991 the Department of Health stopped collecting data on the total number of hospitals, though bed numbers are still collated, so we do not know how many more hospitals have closed in the last decade.  Overall two-fifths of the total bed stock closed between 1982 and 1994-95.  A quarter of acute beds closed (Table 3).  Since 1995 the rate of bed closure has slowed and in 2001 numbers actually rose by a few hundred in the aftermath of the then Health Minister David Blunkett’s admission that be closures had gone too far.  Overall, however, a further 13,000 beds have closed since New Labour came to power.

 

Table 3            Changes in numbers of NHS beds in England 1982 to 1994–95

Year                          All                       Acute     Geriatrics             Mental   Mental   Maternity

               Specialties            Care                                       Illness   HandicapCare

 

1982                        348104                 143535 55646                    83831                    46983       18108

1994-95                                  211812                 108008  36795                    41827                    13211        11971

% change             -39                          -25          -34                          -50         -72                -34

Source: BMJ 1999;319:911-914

The total number of beds per 1000 population in England has fallen from 7.4 to 3.9 over the period in Table 3.  The number of acute beds has fallen from 3.1 to 2.2 per 1000.  At the same time as the number of beds has been falling the amount of work has been increasing sharply, though there is some controversy as to what extent the NHS workload has actually increased.  

Are More Patients Being Treated?

The official figures demonstrate a two-thirds increase in the total number of patients treated in the NHS in England between 1982 and 1995.  The throughput rate (cases per bed) increased by 81% for acute beds between 1982 and 1995.  These  figures are not entirely accurate, however.

The introduction of the values of the market put the onus on NHS managers to prove that
their hospitals were increasing “throughput”.  Consequently procedures that had previously not been included in returns to the NHS Executive were included and one stay in hospital became several “episodes” of care if a patient was moved between different wards or between different consultants.

The increased throughput figures are probably thus a combination of three things: a real, and unquantifiable, increase in activity; the counting of what was previously not counted – a false increase; and double-counting and various other slights of hand – straightforward cooking the books.  Despite these caveats it is important to note that there has been a real increase in NHS capacity, because of new technology and new approaches, despite the decrease in bed numbers.  It does not necessarily follow that some beds could have been safely closed.  Instead, the same number of beds should have been maintained, thus allowing greater flexibility in the system and the ability to treat previously neglected illnesses.

The average length of stay in hospital has been declining since the birth of the NHS.  Between 1982 and 1994 the number of acute beds fell by 2.6% per year whilst the average length of stay fell by 3.1% per year.  This is largely a good thing – no one wants to remain in hospital unnecessarily – but everyone has a relative or friend who did not feel well enough to be discharged but were nevertheless asked to leave.  The average length of stay cannot fall forever (eventually it would reach zero) and the argument that it is already too short is supported by evidence of increasing rates of re-admission after discharges (when patients relapse and need to return to hospital).

Outpatient attendances in the NHS increased from 35.6 million in 1992 to 41.6 million in 1997-98, an increase of 16.8%.  Some of this increase at least, will be accounted for by the “more efficient” counting of cases already outlined.  Total casualty (accident and emergency) department attendances have not increased, fluctuating around a mean of 13.6 million over the last 20 years. Despite this a report in October 2001 described casualty services as being in crisis across the NHS and in the same month Belfast City Hospital nurses threatened to walk out when their department ground to a halt as dozens of patients were lying on trolleys because no beds were available. 

There is evidence that whilst we are not significantly more likely to attend an outpatient department or a casualty department than we were in 1982, we are more likely to be admitted to hospital.  Just why this is, is not clear.  The introduction of new technology and new interventions must play some role – there are now treatments available for certain conditions were before there were none.

Overall those figures do not bear out the argument that the NHS is in difficulty largely because of an overwhelming tide of spurious demand.  Could it just be that any increase in demand has been entirely manageable, any difficulties are a result of cutbacks?

Hayes utilises the fact that Northern Ireland has more acute beds per head of the population than England to argue that we have “too many” beds.  Given that almost everyone, including the New Labour government, now accepts that bed closures in England have gone too far it is more logical to argue that we have too few beds, and that England is in an even worse situation.  When David Blunkett accepted that bed closures had to stop and that bed numbers should in fact increase slightly (by 3000) he could do no other, given the weight of evidence.  His pledges mean little in the context of the implementation of the Private Finance Initiative, but it is a useful weapon for hospital campaigners to know that the case for no more bed closures has been conceded.

Is bigger better?

There seems to be an unstoppable tide in the favour of the closure of smaller hospitals and the merger of two or more hospitals into super hospitals.  The rationale for such action is the belief that bigger hospitals are more cost effective and safer.  It is argued that bigger hospitals reduce average costs through the operation of economies of scale and that outcomes improve because of increasing average volumes of activity per clinician (that is doctors specialise in a very small area and get better through more practice).

John Posnett, director of the York Health Economics Consortium, has argued in a recent article that “this logic is not support by the evidence” (BMJ 1999;319:1063-1065).  There is evidence that the most cost effective hospitals have between 200 and 400 beds.  Those with fewer than 200 are more expensive but so too are those with 400-600 beds.  There are still a large number of hospitals in England with fewer than 200 beds (see Table 4) and of course the closure of hundreds of smaller hospitals has not cured the ills of the English NHS.

 Table 4           Distribution of acute hospitals in England by size.

No of beds      No of hospitals           Share of total              Share of total

                                                            hospitals (%)              beds (%) 

<200                149                              36                                10

200-400           106                              26                                23

>400                154                              38                                68

The sparse evidence that there is suggests that two hospitals of 400 beds are more efficient
(in financial terms) than one single site hospital of 800 beds.  Generally when small hospitals are replaced by larger ones total management costs either increase or remain unchanged – which depends on the size of the new organisation.  There is no basis for the argument that replacing multiple small sites with super hospitals reduces overall management costs.

Sometimes new hospitals are cheaper than the ones they replace, in terms of total costs. 

This is simple because capacity – the number of beds – has been cut.  And of course new hospitals built under the PFI will eat up any savings which may result from reducing the number of sites in any case (this is explained further in Chapter Three).

The Hayes Report does accept that “the evidence on whether concentrating services in a reduced number of specialist centres results in improved outcomes is not clear cut”.

According to Posnett “the literature shows quite conclusively that there can be no general presumption that larger units produce better outcomes for patients.  The evidence of a positive relation between volume and outcome for a small number of defined procedures is reliable, but these effects operate at comparatively low levels of activity, certainly not large enough to justify notable concentration”.  What Posnett means by this latter remark is that hospitals do not need to be that large to gain the benefits that accrue from increased practice at a particular procedure for doctors.

In Posnett’s view most of the published evidence that demonstrates that outcomes in bigger hospitals are better is unreliable.  In the case of intensive care units, the supposed superiority of larger units disappears when the severity of patients’ conditions when they enter the unit is taken into consideration.  Smaller units admit more severely ill patients and this is why their outcomes are worse.

Why some doctors or hospitals have better outcomes than others is not well understood.  Greater levels of activity may not be the key.  The availability of support services (such as imaging and intensive care), good ongoing training for doctors and high quality co-operation between doctors and between other members of staff may be equally, or more, important.   

Posnett summaries his arguments in this way:  “On the basis of available research evidence, bigger is not better: at present there is no reason to believe that further concentration in the provision of hospitals will lead to any automatic gains in efficiency or patient outcomes.  Maybe the research base is inadequate, but the onus is on those who advocate the benefits of concentration to prove their case.   In the future as general practitioners assume an increasingly influential role in planning the provision of health services, the perceived benefits of accessible local services may begin to turn the tide of professional opinion” (BMJ 1999;319:1063-1065).

The NHS Centre for Reviews and Dissemination has also reviewed the evidence and concludes: “there is no compelling reason to believe that further concentration of hospital services will result in improved efficiency or lead to automatic improvements in the quality of outcomes.  In assessing the potential effects of increased concentration on access and utilisation the implications for disadvantaged groups in particular should not be overlooked” (Report 8,1997).  

The Doctors’ Views

The medical hierarchy appears to be of one voice on the future of small hospitals.  A joint working party of the British Medical Association or BMA (the main doctors’ trade union), the Royal College of Physicians of London and the Royal College of Surgeons of England argues that “comprehensive medical and surgical care of the highest quality requires the concentration of resources and skills into larger organisational units” (Provision of Acute General Hospital Services. London RCS, 1998).

The Royal College of Surgeons would really like to see super hospitals servicing populations of half a million or more.  This would allow the “dream set up” of 15 consultant surgeons, 15 consultant orthopaedic surgeons, 30 anaesthetists, 24 hour a day operating, an intensive care unit and 24 hour pathology and X-ray services.  This would mean only three acute hospitals in the North.  The Royal College of Physicians are in favour of eight to ten acute hospitals for a population of Northern Ireland’s size.

The medical Royal Colleges are professional bodies and not trade unions.  They provide advice to the government on the required numbers of doctors nationally and on the training needs of doctors.  All physicians must belong to the Royal College of Physicians and all surgeons to the Royal College of Surgeons (passing the required exams and receiving adequate training are the conditions of membership).  The Colleges undoubtedly play a useful role and help to maintain high standards, though they are somewhat archaic in their titles and procedures and tend to be dominated by senior doctors in London and the Home Counties.  As an extension of their role they have a lot to say about the optional configuration of hospital services.  The main thrust of their arguments is that large hospitals allow for improved training, necessary sub specialisation and thus improve outcomes. 

They surmise that if small hospitals (servicing populations less than 150,000) are to survive then they need to be comparatively overstaffed.  In essence, accepting the current restraints of the system, they issue edicts in the full knowledge that hospital closures will follow.  Public opinion is ignored and little consideration is given to the special needs of rural areas.

The guidance of the Royal Colleges, supposedly given on training issues, can be very damaging for local services.  To take one example, an accident and emergency department will lose its training recognition (the right to train junior doctors) if one of four “essential” services is removed from the hospital (the four are general medicine, general surgery, trauma and orthopaedics) and will thus have to close.  A knock-on effect leads to the closure of one department after another. 
 

In this way the Royal Colleges were instrumental in the closure of the South Tyrone Hospital, withdrawing training recognition from several departments.  The Colleges argue that closure is not their intention, or their responsibility.  In one sense this is true but it is evasive and disingenuous to try to avoid any responsibility.  The eventual outcome of the withdrawal of training recognition is entirely predictable.

Of course the government, ultimately responsible for closures, accept Royal College decisions with barely disguised glee.  The closure of the South Tyrone suited them down to the ground and they too were able to absolve themselves of responsibility.  Indeed it appears that no one was responsible!

Not all doctors support the views of the BMA and the Royal Colleges.  These bodies take a conservative stance, focus on the needs of doctors in isolation from other staff and patients, and are  London-orientated.   They do not focus on the needs of local people in rural areas.  They do not consider the possibility that good quality training is available in small hospitals.  They do not use their strength to bolster small hospitals.

Whilst the medical hierarchy are in favour of greater centralisation there are dissenting voices.  When the Joint Consultants Committee published a report in 1999 on the future of hospitals (Organisation of Acute General Hospital Services) its conclusions were attacked by Mr James Glancy, a consultant cardiologist and physician at County Hospital, Hereford.  In his view “the conclusions of this report represent a scandalous misrepresentation of what little data exists on comparison in outcomes between small and large hospitals ” (Hospital Doctor, 14th October 1999).  He added: “Yet again doctors’ leaders have shown how hopelessly out of touch they are with the grass roots of the profession and patients”.

Dr Susan Coe in Perth challenged the idea that smaller hospitals are not safe.  “I feel the need to challenge this idea that technology equals excellence.  There are many good doctors who choose not to live in  big cities and work in university hospitals.  They know that sometimes they will have to refer patients on to a more specialised practitioner.  They also know that their teaching hospital colleagues do not always get it right”  (Hospital Doctor, 7th October 1999).

Dr D Forbes, also writing from Perth, questioned the role of “staff from large hospitals who wield political and academic power”.  In his view “clinical networks” can be developed to allow for specialisation and the closure of units is not required.  Other letters in Hospital Doctor (30th September 1999) argued that smaller hospitals are in fact safer than large hospitals as one is less likely to contract serious, untreatable infections such as MRSA is in a small hospital.

The stated view of the BMA in Northern Ireland is that “hospitals servicing rural communities are not going to be staffed without considerable expansion and there’s not enough resources to do that “(Dr Caroline Marriott, chair NI BMA Central Consultants and Specialists Committee, quoted in Hospital Doctor, 9th December 1999). “Putting It Right” (published by John McFall in 1999) dismissed the idea that the then 17 acute hospitals could remain open as it would require a 50% increase in the numbers of consultant surgeons and physicians to achieve this.  Now the Hayes Report proposes just such an increase at the same time as it proposes the closure of six acute hospitals.  What has happened between the publication of the McFall report and the Hayes Report to justify this change in approach!  Surely the BMA should now be reconsidering their position – if the staff are there the rural and small hospitals can remain open.

The Issue of Accessibility

The medical hierarchy put a low premium on access to services, perhaps believing that everyone is as mobile as those in the moneyed circles they move in.  There is evidence, however, that the further away some services are the less likely they are to be utilised.  This applies in particular to consultations with general practitioners, to self-referral to accident and emergency departments and to attendance at breast and cervical cancer screening services.  It appears that distance is less often a problem when someone requires acute care – patients will seek help regardless of the distance faced – but there is evidence for a greater deterrent effect for the poor.  

Costs are shifted from the NHS to the patient as services become more concentrated, largely through increased travel costs but sometimes also through the need to arrange overnight accommodation.  According to Posnett: “This effect is unlikely to be uniform across different sections of the population and the evidence is consistent with large deterrent effects for particular groups, such as those with low personal mobility or those in particular socio-economic groups” (BMJ 1999;319:1063-1065).

And it can be argued that the closure of rural hospitals will cost lives.  Dr Kieran Deeny, chairman of the Omagh and District GP Association, wrote in the Belfast Telegraph (19/6/02) “A few years ago in our Carrickmore practice we had seven cases of meningitis in a 13 month period and I have no doubt that three of four children would have died had it not been for the close proximately of the Tyrone County and South Tyrone Hospitals”.

In the mid 1990’s an earlier report on the future of health care in Belfast – the McKenna Report- recommended that the City Hospital Accident and Emergency Department should close.  The Report was met by an avalanche of criticism.  One of the points raised was that the closure would reduce accessibility to good health care.

The Report, however, coolly stated that “accessibility is not the problem”.  It went on to say that 90% of patients drive to or are driven to hospital (to use A&E services).  The authors of this report are clearly immune to the realities of working class life in Belfast.  At night, and especially at times of increased tension, working class people are fearful of travelling outside their own area.

This is not an irrational fear but a very realistic one.  At such times one hundred yards might as well be one hundred miles.  More than half of working class households do not own a car.  Ninety-five percent of the households of those in “professional” occupations have a car, compared to only 38% of the households of manual workers.  If rioting has stopped the buses or if sectarian attacks make travelling with certain taxi firms hazardous, what are they to do?    

The Royal Victoria Hospital and the Belfast City Hospital are not directly comparable to hospitals in any other city on these islands, precisely because Belfast is not directly comparable.  To think otherwise betrays much about the cosseted middle class lives of the authors.  If local communities were represented on the various review groups these common sense points would not be missed.

Accessibility is also an issue in every other area of Northern Ireland.  Local communities are comfortable with their local hospitals, built up over decades.  Relatives can visit with ease, patients feel at home.  In England, hospitals are much further apart but it does not necessarily follow that a similar model should apply here.  Hospitals ought to be large enough to be viable but not so far apart that lives are put at risk.  In more rural areas, extra minutes can be vital.  Every town and village cannot have its own hospital but there should be no area without ready access to a good hospital.

Where hospitals already exist, and have done so for generations, a good argument needs to be made before such a facility is closed.  Local communities are perfectly entitled to be suspicious of closure plans which promise a better service a little (or a lot) further away.  This does not mean that from time to time, however, such a move would be a genuine advance.

Conclusion

In conclusion, there is little or no evidence in favour of centralisation of our acute hospital services.  It is difficult to demonstrate that the closure of smaller hospitals actually costs lives, just as it cannot easily be proven that larger hospitals are safer, but common sense tells us that, at least occasionally, the extra journey involved will lead to a fatal delay.  And the delay is more likely to be fatal in poorer households without easy access to a car.  People want their local hospital.  They provide good quality care for the majority of patients, they provide much needed local employment and they are often a vital hub of the local community.  In the absence of evidence that “bigger is better” the smaller rural hospitals should remain open.