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Whisper it, but improved healthcare means fewer hospitals in Northern Ireland - not more

Those that are left must provide first-class treatment and that demands that our MLAs make hard choices

By Paul Gosling

Published 27/10/2016

Health services in Northern Ireland are set to undergo a radical transformation
Health services in Northern Ireland are set to undergo a radical transformation

"Transformation" and "transition" are difficult concepts for public bodies. There can be significant resistance to change from both service-users and workers, who want things to be as they perceive them to have always been - yet also better.

In the case of Northern Ireland's health service - and every other health service internationally, whether funded publicly, or privately - wanting things to be both the same in shape and also to be better is impossible.

As Health Minister Michelle O'Neill has pointed out, simply going on as before will potentially lead to 90% of our public funds going into healthcare. What is more, health will still probably be a service that fails to deliver the quality and quantity of care that we as patients demand.

It would be helpful to consider what our healthcare used to look like and what it needs to be in the future. In the old days - at least in our imagination - we used to drop in to see our GP, who would see us within a day and might refer us to the local general hospital for treatment, which would handle accidents and emergencies, births and many acute problems.

Compare that with the future. General hospitals will be replaced by specialist facilities, where physicians are familiar with patients' specific conditions. That specialist care will come at a cost - a longer journey. A population of 1.8 million people cannot expect specialist care just down the road: physicians need a throughput of patients with similar conditions, or else they will lose their capacity to be specialists.

This is just one part of the vision for tomorrow. We will have to say goodbye to the paternalistic model, where responsibility lies with the medical practitioner who treats us when our body goes wrong. Responsibility for our health will lie largely with us.

That means much more than drinking sensibly, not smoking and avoiding fatty and sugary food.

The comprehensive provision of broadband opens up possibilities for much greater levels of home care, especially for chronic conditions. Patients will have a Skype discussion with their GP, hooked up perhaps to a blood-pressure monitor that is connected to their smartphone. There will be a partnership between physician and patient on how best to manage an illness and its treatment.

That vision of the future is not spelt out in the Bengoa Report, but it is hinted at if you read carefully enough, for example on the use of the internet for health, or "eHealth", as it is termed.

The report explains that "the HSC (Health and Social Care service) should continue to invest in eHealth to support improved self-management, care at home and use of information to drive better population health outcomes."

We need grown-up politics in Northern Ireland, where our ministers and Assembly members are willing to say clearly that better health care requires fewer hospitals, providing that those left can provide first-class, specialist, health treatment.

That message was there in yesterday's Belfast Telegraph from Mark Taylor, a consultant at Belfast's Mater Hospital and a member of the Bengoa review panel.

"We need to move away from the mindset that every hospital must provide every service for every patient," wrote Taylor. "It is inevitable that the services we currently provide will have to change."

Professor Bengoa himself hinted at the problem in a radio interview, when he referred to the need for "political maturity" - which can be assumed to mean ministers telling the electorate the hard truths and then making the tough decisions.

Those tough decisions will clearly involve closing hospitals that provide duplicate, or inferior, care, or that do things that would be better and more efficiently done within a GP clinic (including some minor surgery), or within the home.

For some politicians, the toughest decisions may be to say that with such a small population Northern Ireland must engage in closer partnerships across the border (providing the border stays fully open, post-Brexit).

We have started that journey with children's heart surgery being based in Dublin and a cross-border cancer treatment centre at Altnagelvin Hospital in Londonderry. But that should be only a waymark towards the destination of greater co-operation on healthcare with the Republic.

Beware, though, the serious traps on our route to a future that is not fully mapped out. Modern healthcare facilities require substantial investments. Yet, it is impossible to accurately predict the shape of future healthcare delivery - much will change as new drugs and other treatments become available.

The move away from long-stay hospital provision towards shorter-stay use of beds and greater community care has caught some health trusts in England on the hop.

As a result, many are burdened with substantial financial costs through long-term Public Private Partnerships for hospitals that were designed for now out-of-date delivery models.

Those costs are one of the main reasons behind the financial crisis in the NHS in England - Northern Ireland must beware of copying that mistake as it reshapes its hospital estate.

Just as significantly, the healthcare debate often focuses disproportionately on how to treat acute illnesses, marginalising the issue of chronic conditions associated with ageing. The issue of managing social care for the elderly is every bit as challenging as planning the hospital and GP infrastructure.

In my opinion, we are a million miles away from establishing the right structures and systems for social care provision for the elderly (and also for others, such as those with learning and other serious disabilities). While most of the social care provision, across the UK, has been privatised, there is a lack of sustainability in much of the private social care sector, leaving many residents in vulnerable and unsatisfactory circumstances.

Simply saying, as some have, that provision should transfer from the public to the private sectors is an inadequate response.

That policy needs to be backed by financially sustainable arrangements and also the establishment of new and different types of providers that are dedicated to respecting the wishes and needs of those they serve.

It is not only healthcare that needs to undergo a major transformation into a sustainable future.

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