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'The NHS formed back in 1948 is no longer fit for purpose... it's vital that our Executive is re-established quickly to drive through the changes we need,' says consultant

 

By Lisa Smyth

Mark Taylor is a consultant in general and hepatobiliary (liver, pancreas and gallbladder) surgery based at the Mater Hospital, and the lead surgeon for hepatobiliary surgery in the Belfast Trust. He was also part of an expert panel which made a series of recommendations aimed at ensuring a better future for the NHS in Northern Ireland.

Q. Can you describe a typical day at work?

A. There's no such thing, as anyone in healthcare will tell you.

Days are spent either in surgery, at clinics, on the ward, in meetings or doing the dreaded paperwork.

The unit provides a regional hepatobiliary and pancreatic (HPB) service to the other hospitals in Northern Ireland so often we are engaged in discussion with colleagues about HPB patients.

Many of the nurses within the unit have been with us for many years and there is a real family feel which makes such a difference.

However, the best and indeed the privileged part of the day is interacting with the patients, many of whom are extremely ill with severe pancreatitis, pancreatic and liver cancers, as well as gallbladder problems.

The worst part of the day is when it comes to breaking bad news - it never gets any easier.

Q. How has the health service and your role changed throughout your career?

A. Since I've been qualified - over 20 years now - I have seen the intensity of work in hospitals increase.

Patients who once spent four or five days in hospital are now discharged on the same day. Advances in operative and post-operative cancer care have changed dramatically, resulting in increased survival rates.

The introduction of keyhole surgery has resulted in quicker discharge from hospital after major surgery.

Separation of emergency surgery from elective practice has resulted in a greater number of patients having their gallbladder removed on their first admission to hospital with acute inflammation, rather than previously spending five days in hospital receiving antibiotics and then being sent home to remain on a waiting list for gallbladder removal.

In the field of HPB, advances in drugs, technology and operative procedures have changed surgical practice over the years.

When I first started training in HPB surgery, only a small number of patients with colon cancer with spread to the liver (metastases) underwent attempted liver resection.

However, liver resection now forms a major part of my surgical practice for patients with liver metastases.

This has been associated with a major increase in five-year survival for these patients.

Newer keyhole procedures for dealing with patients who have severe forms of pancreatitis have also lead to major improvements in the recovery and survival of this dreadful condition.

Q. What are the five main problems facing the health service at the moment?

A. Many would acknowledge that the health service that was formed in 1948 is no longer fit for purpose.

This is not unique to the NHS as many countries throughout the world are facing similar challenges.

The main issues would be an increasingly ageing population and so an increase in chronic conditions; rising demand for services as new treatments, techniques and investigations develop; over-reliance on reactive acute care and hospital services; a struggling primary care sector both in terms of resource and manpower; and smaller hospitals struggling to attract and retain staff.

Therefore, it is vital that our Executive is re-established quickly to drive through the necessary changes that we need to sustain the service for the future.

Q. Michelle O'Neill announced recently that she needs £31m to address waiting times. Is this enough?

A. £31m will certainly help to reduce waiting times, but we need more investment in the transformation process to bring about a new system that addresses the mismatch between demand and capacity.

Simply putting money into waiting list initiatives is not enough. It will take time to improve capacity, but we must recognise that clinicians and managers have been making every effort to ensure that the clinical impact on patients is kept to a minimum.

Q. How did you come to be involved in the Bengoa review?

A. I was part of a group of clinicians who met with the Health Minister following the Donaldson Report.

The minister then asked me if I would become part of the panel.

I initially said no, feeling completely inadequate for such a massive task.

However, on reflection and in discussion with my wife and colleagues, I felt it might be useful to have input from those working directly in the service, which I felt I could help facilitate.

I had the opportunity to work closely with the panel members and valued their expertise. I especially enjoyed working with Rafael Bengoa, who quickly got the Northern Ireland situation and was truly inspiring as a healthcare reformer and leader.

It was challenging to ensure that the report was inclusive of all the views of healthcare providers but also to ensure that there was a roadmap to drive forward change, and avoid the report being added to shelf with all the other reviews.

Q. How would you assess the response to the subsequent report by the public and politicians?

A. I think that the report has been well received, based on the many positive comments that the panel and I have received.

Politicians seem to be on board and I think that they might just realise that politics (with a big P) have no place in defining our healthcare system.

One of the important aspects of the report was to ensure that healthcare staff and patients are at the heart of reconfiguring health and social care.

Despite recent events at Stormont I remain optimistic that there is a real will to implement the changes that we need to have a world-class health service.

Q. You mentioned smaller hospitals struggling to attract and retain staff. Is it time that we have a mature debate about the need to reconfigure and centralise services?

A. The difficulty of recruiting and retaining staff in smaller hospitals is not peculiar to Northern Ireland. It is seen throughout the UK. I suspect the reasons are multi-factorial and include location, centralisation of certain services and career opportunities.

Smaller rural hospitals provide excellent care for their population, however, our report highlights the need to provide the best service in the best place regardless of location.

One criticism of the report was that we did not mention hospital closures. This was because the report was about systems of care and not buildings.

We need to begin a process where we think about what services a hospital provides and that may mean that not all hospitals provide all services.

There is collective responsibility to ensure that every person in Northern Ireland has access to the very best healthcare and that might require a person to travel.

As Sir Liam Donaldson said, in some circumstances, we are "trading a degree of geographical inconvenience against life and death".

Q. And how quickly is the change required?

A. Change is required now. In the Bengoa report it was noted that 'without systematic and planned change, already stretched services will undoubtedly be forced into unplanned change through fire-fighting and crisis'.

The stark options facing the health and social care system are to resist change and see services deteriorate to the point of collapse over time, or to embrace transformation and work to create a modern, sustainable service.

I urge our politicians, despite their differences, to work together to implement the previous minister's vision.

The suspension of the Assembly and the announcement of a general election on June 8 create political uncertainty which will have an impact on transformation. The lack of a budget alone is unacceptable.

Therefore, I urge our local politicians to establish an Executive as soon as possible so that a new health minister can continue the essential and critical change that our health service so needs.

The famous quote by Pericles comes to mind, "What you leave behind is not what is engraved in stone monuments, but what is woven into the lives of others".

We really can do so much better for our population. Let's get on with it.

Q. How important is it politics are taken out of the health service?

A. I believe that party political politics has no place in the health service, but we need the input of our politicians to make the changes necessary to sustain the service for the future.

I have been encouraged by the support the report has received from all sections of our political establishment.

Q. Is it important that we address the problems facing primary care in Northern Ireland?

A. I'm married to a GP so I'm acutely aware of the problems they face. Excessive workloads, fewer doctors and funding issues have created a critical situation that affects us all.

Our GPs provide an essential service and are a major support to us as hospital doctors.

Any dismantling of primary care, as we know it, will have a major impact on hospital services. It is vital that we work together to resolve the issues faced by our GPs.

Q. Pancreatic cancer has some of the lowest survival rates. Why is that?

A. Unfortunately, pancreatic cancer is often diagnosed at an advanced stage because the symptoms can be extremely non-specific in the early months.

The development of jaundice - yellow skin - leads to investigations looking for a tumour in the pancreas.

Often it may not be possible to remove the tumour at that stage.

Surgery followed by chemotherapy is the current strategy to try and treat pancreatic cancer. Sadly, we are only able to perform the surgery on about 25% of people.

Symptoms may include mid back pain, loss of appetite, indigestion, onset of diabetes without an obvious cause, unexplained weight loss, jaundice and pain on eating.

Someone who has these symptoms and they haven't been resolved through simple medication should be referred for assessment.

It is important to remember that these symptoms can be present in many benign - non-cancerous - conditions also.

Q. Are there any important research projects or trials for pancreatic cancer patients on the horizon?

A. Several cancer centres are now investigating treating such patients with anti-cancer drugs - chemotherapy - or radiation therapy to shrink the tumour so it is then possible to remove using surgery.

This therapy is known as neo-adjuvant therapy and we are using this for patients with tumours that look unresectable, those not able to taken out by an operation.

Sonodynamic Therapy (SDT) is currently being researched by Ulster University with extremely encouraging laboratory results demonstrating that SDT with a currently used pancreatic cancer chemotherapy (5-fluorouracil), results in a greater shrinking of pancreatic cancer tumours compared to chemotherapy treatment alone.

The treatment involves using very small bubbles known as microbubbles to deliver the drugs directly to the tumour.

Using sound waves the bubbles are burst in the tumour and release the drugs locally and not in the entire body.

Such technology may provide a minimally invasive and highly targeted treatment for pancreatic cancer with the ability to shrink tumours and spare healthy tissue.

Professor Chris Scott and Dr Richard Turkington of the CCRCB at Queen's University are currently leading research projects looking at new methods of delivering chemotherapy to people with pancreatic cancer, as well as researching methods to predict which patients will benefit from chemotherapy.

This will determine the best possible treatment to help improve outcomes and quality of life for patients.

The prospect of producing a clinical test that can identify patients with chemo sensitive disease could lead to new ways to treat pancreatic cancer, at the same time looking at alternative treatments in those who are resistant to chemotherapy.

It is vital that the research continues to achieve a break-through in dealing with this dreadful disease.

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