The challenge of change
22 November 2012
One of the first things Edwin Poots did when he took up the post of health minister in Northern Ireland was to announce a review of health and social services.
The resulting document, TYC (Transforming Your Care), was published in December last year and contained 99 recommendations — including greater use of technology, and reducing the number of acute hospitals.
BMA Northern Ireland has long campaigned for change to the health service, and welcomed TYC as a way to ensure doctors can deliver safe, high-quality, sustainable services in the future.
The team that created TYC, led by Health and Social Care Board chief executive John Compton, aimed to explain why there needed to be change in the healthcare system, and set out evidence for the best way of achieving it.
The changes it identified included managing increasing demand, and tackling health inequalities.
The review is the biggest overhaul of health and social services in a generation, yet it has failed to make much of an impression on the general public.
Stop someone on the street and ask them what they think about TYC, and it is likely you will be met with a blank stare.
The fact is that most people just do not care — unless local hospitals are under threat.
But as history shows, public sentiment is not enough to retain services, and Mr Poots has already proved he is willing to defy it when it comes to service reconfiguration.
This is, after all, the man who reduced the opening hours of the emergency department in his own constituency.
BMA Northern Ireland GPs committee chair Tom Black said: ‘We have been calling for change for a long time, but what we needed was the political will for that to happen and I think Edwin Poots might be up to the job.’
A public consultation is under way on the review, which closes on January 15. The consultation document is 213 pages long — a daunting challenge for even the most interested reader.
Few sexy proposals
Few of the proposals are sexy enough to make headlines, and they provide very little detail about how objectives will be achieved. That is a source of concern for the BMA.
BMA Northern Ireland council chair Paul Darragh said it was essential that health officials worked with doctors during service reconfiguration.
‘We are supportive of the broad principles of TYC, but there are certain caveats,’ he said. ‘There must be meaningful consultation, it cannot just be a listening exercise, and there must be medical leadership.’
Many of the proposals in TYC rely upon support from medical professionals — particularly GPs, as their workload is likely to increase considerably.
As he has a politically safe seat, Mr Poots might not need overwhelming public support for TYC, but he certainly needs to keep doctors on side.
More care in the community
Under TYC, more care is to be delivered in the community.
While there are obvious benefits to this proposal, BMA Northern Ireland consultants committee chair John Woods has expressed some reservations.
‘We are being told this will mean consultants holding clinics in local health centres, but I am unsure whether this will prove to be an efficient use of resources,’ he said.
‘If you have consultants spending time travelling to see patients, it means they have less time for clinics and they are not on hand if there is a medical emergency in the hospital.’
At the same time, TYC calls for a reduction in the number of acute hospitals in Northern Ireland.
Northern Ireland’s population is less than 1.8 million, so it is hard to justify having 10 acute hospitals and increasingly difficult to staff them 24 hours a day. As a consequence, the proposed move has been welcomed by the BMA.
One size does not fit all
Dr Darragh said: ‘We have to provide specialist care where it is necessary. We can’t provide it at every hospital we have.’
But is it wise to implement this as a blanket policy across all of Northern Ireland?
After all, it is impossible to compare reconfiguration of acute services in the three acute hospitals in Belfast city centre with those in the Northern Health and Social Care Trust, where doubts remain about the future of the Causeway Hospital in Coleraine.
Pamela Logue, a GP at a practice in Portrush, County Antrim, believes this is an example of centralisation not being the best option.
She said: ‘We are very concerned about the future of the Causeway, and I really don’t see how we can function without it.
‘Public transport is practically non-existent. How are my patients who can’t drive going to get to clinics in Belfast or elsewhere?’
The state of the roads is also a major concern.
Dr Woods said: ‘The Causeway is a special case, and some thought must be given to improving the infrastructure — although in the current financial climate it is difficult to imagine whether improvements will be made before reconfiguration begins.’
So is the money there to make TYC a success?
Certainly, the consultation document makes no reference to the cost of improving roads and public transport as reconfiguration happens.
However, as one of the main themes of TYC is to bring services closer to patients, people will only have to travel further afield for specialist care.
In many cases, this will mean more work happening in the community, and the BMA has warned resources must follow in the same direction.
High GP workloads
Dr Black said: ‘The workload of GPs is already extremely high.
‘It is necessary that there is investment in facilities and staff to enable the primary sector to cope with the additional workload being proposed by TYC.’
Mr Poots has given assurances this will happen, but doctors remain sceptical.
‘We have heard this before and it hasn’t happened, so time will tell,’ Dr Black said.
‘The trusts have always been reluctant to take money away from the hospitals.’
To make matters worse, health officials are on a possible collision course with family doctors, who have expressed serious doubts about their ability to deliver services if proposed changes to the GP contract go ahead.
Doubts about delivery
Doctors want to support TYC, but it may be that the aspirations of the review prove impossible to deliver.
TYC is ambitious, and the time frame for change is tight.
While doctors have expressed some serious concerns about aspects of the review, there remains broad clinical support for reconfiguration of the health service in Northern Ireland.
Dr Darragh said: ‘The health service can simply not carry on the way it has been.
‘Change has already happened. For example, it has happened in our emergency departments, but TYC is allowing us to deliver change in a managed way.
‘Doctors have been asking for change for a long time, and it is essential we are involved in the decision-making process if TYC is to have any chance of success.’