Call to reduce hospital numbers
Liam Donaldson’s governance review calls for a radical change in how Northern Ireland delivers health services, in order to improve quality and safety for patients. agendaNi reports on his findings.
Northern Ireland has too many hospitals and public and political pressure is holding up necessary changes, according to a review of the province’s health and social care system. Sir Liam Donaldson’s report explains that proposals to close local hospitals “tend to be met with public outrage” but stretching the workforce over a range of small facilities was putting the most vulnerable members of the public at risk.
A similar region in Britain would be served by four hospitals rather than the current 10.
The former Chief Medical Officer for England was commissioned to look at how the Health Service can improve the quality and safety of its care. Donaldson proposed an impartial, international panel of experts to configure reconfigure services with all political parties undertaking to accept its recommendations in advance. That proposal has been ruled out by Health Minister Jim Wells but the report is stimulating debate about improving health at a time when pressure on services is a major public worry.
Demands on hospital services are “excessive and not sustainable”. Donaldson’s report followed an unprecedented peak in pressure on A&E departments – due to the shortage of primary care services and increased frailty within an ageing population.
“High-pressure hospital environments,” he warned, “are dangerous to patients and highly stressful for staff.” Transforming Your Care needed a new, costed and timetabled implementation plan – backed up by a much greater role for pharmacists and giving paramedics more responsibility for pre-hospital care.
The review team was “puzzled” that most people it met did not mention the Regulation and Quality Improvement Authority. Its light-touch role “seems very out of keeping” with that of health regulators elsewhere and a stronger approach was needed.
The report goes further. It questions the rationale for a health regulator for such a small region and says that this role could be outsourced to Healthcare Improvement Scotland. This approach is already taken in the treatment of long-term psychiatric inmates. Cases from Northern Ireland are referred to Scotland as the patient population in this field is too low for a similar facility here.
Donaldson strongly criticised the practice of classifying all child deaths as serious adverse incidents. A child, for example, may have a terminal condition but the current reporting system implies that the quality or safety of care was poor and the death could be avoided.
“This can be enormously distressing for families and is gruelling for staff,” he stated. “It is cruel, unnecessary and liable to undermine public confidence in children’s services.”
The review also recommends a limited list of ‘never events’ i.e. serious and largely preventable patient safety incidents that should not occur if the available preventative measures have been implemented.
An institute for patient safety is also proposed. This unit would analyse incident reports and the causes of incidents and involve patients and their families in a patient safety programme. Front-line staff needed to have a greater say in finding the solutions as this “often sparks great interest and commitment to patient safety”.
Donaldson also calls for a small number of metrics for benchmarking, a unit to promote self-care, a clinical leadership academy, and a small technology hub. The latter facility should not primarily deal with hardware and software companies but instead should identify technologies which have proven benefits and are supported by management and clinical staff.
The Patient and Client Council, in his view, is not sufficiently independent and needs a revised constitution with more patients and clients on its board. Complaints should be resolved locally but patients and families should be able to refer their complaint to an independent service or, as a last resort, to the Ombudsman.
In response, Jim Wells confirmed to the Assembly that the following proposals will be taken forward:
• a review of commissioning arrangements;
• an extended role for pharmacists;
• a statutory duty of candour to improve openness;
• the proposed reforms of the serious adverse incidents process;
• a regional morbidity and mortality review system;
• a ‘never events’ list; and
• unannounced inspections of acute hospitals (from April).
Wells also affirmed that local is not necessarily best.
“Too often the discussion around the Health Service can be overly simplistic, and focused on a simple choice between closing or keeping open a particular facility,” he stated.
This leads to a “save our service” mentality but, in reality, this was about “saving a structure”. The real choice we face is an uncomfortable one for the public and its political representatives alike: “Do we want a world class service – or a service on our doorstep which, while convenient, may be sub-optimal and compromise quality and safety?”
The public consultation on the Donaldson report runs to 30 April and responses can be submitted to qualityandsafety@dhsspsni.gov.uk
Improving primary care
Many people attending A&E over Christmas and new year were unable to get an appointment with their GP. Under the current GP contract, practice opening hours are 8am to 6.30pm on weekdays but the Coalition Government has pledged seven-day access to general practice in England. Jim Wells has said that a seven-day service in Northern Ireland would require a significant increase in the available workforce and finances. This is a reference to the failure to recruit junior doctors into general practice – although 250 recently-trained GPs from here have chosen to work overseas. The province currently has 1,100 GPs but faces a shortfall of 234. A quarter of existing GPs are expected to retire by 2020. BMA spokesman Tom Black has called for a dedicated local recruitment campaign and warned that Transforming Your Care has transferred extra work to primary care without an increased workforce.
