The Socialist response to the Hayes Report: Chapter One
THE HAYES REPORT DISSECTED
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.
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.
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).
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 4th 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.
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.
Introduction Chapter 2