A HEALTHY FUTURE?

 

 

 

The future of Northern Ireland's

health service:

a reply to the Hayes Report and the Socialist Alternative

 

 

 

 

 

 

CIARAN MULHOLLAND

 

 

 

 

A SOCIALIST PARTY PUBLICATION


Contents

 

Preface

 

Introduction

 

Chapter 1

THE HAYES REPORT DISSECTED

 

Chapter 2

CENTRALISATION OF SERVICES -
IS IT JUSTIFIED?

 

Chapter 3

PRIVATISATION BY STEALTH

 

Chapter 4

WHY IS THE NHS UNDER ATTACK?

 

Chapter 5

NEW LABOUR IN POWER:
DID THINGS GET ANY BETTER?

 

Chapter 6

THE ALTERNATIVE TO HAYES

 

 

 

 

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.

 

 

Chapter 1

THE HAYES REPORT DISSECTED

 

Chapter 2

CENTRALISATION OF SERVICES -
IS IT JUSTIFIED?

 

Chapter 3

PRIVATISATION BY STEALTH

 

Chapter 4

WHY IS THE NHS UNDER ATTACK?

 

Chapter 5

NEW LABOUR IN POWER:
DID THINGS GET ANY BETTER?

 

Chapter 6

THE ALTERNATIVE TO HAYES

 

 

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