Hospital network reform avoids closures
An uncosted plan to reform Northern Ireland’s hospital network will require “every square inch of current acute hospital capacity”, Health Minister Mike Nesbitt MLA has outlined.
“According to Professor Bengoa, the cost of not doing reform is that, by 2040, health will absorb the entire – the entire – Northern Ireland Executive Budget. There will be nothing for schools or infrastructure — nothing for anything except health. We have to do it,” declared Health Minister Mike Nesbitt MLA when asked about the cost of not transforming the health service.
Nesbitt was taking questions from MLAs in the Assembly shortly after the publication for consultation of a new plan to reform Northern Ireland’s hospital network.
Hospitals: Creating a Network for Better Outcomes navigates away from the politically sensitive subject of hospital closures – despite that being the recommendation of successive health reviews stretching back to 2001 – through a reconfiguration of services provided by existing hospitals, rather than closing facilities.
In essence, patients will be asked to travel further for certain types of care but will be seen faster, as some services are consolidated in a bid to avoid duplication and competition for resources.
Details of exactly what this consolidation will look like is absent from the plan, as is any form of costing – with critics understandably cynical given the framework is the latest in a line of healthcare reviews, all of which have been unsuccessfully implemented.
The Minister has stated that the framework should not be viewed in isolation “but as an important piece of the overall puzzle that will deliver better outcomes”.
Interestingly, the framework was published shortly before a visit to Northern Ireland by Raphael Bengoa who led the delivery of the 2016 Systems, Not Structures review, a foundation for the 10-year Health and Wellbeing 2026: Delivering Together strategy.
Bengoa’s visit could be read as an attempt by those leading health reform to emphasise that work remains ongoing, and perhaps re-energise the conversation around why change is necessary.
Talk of radical reform to the hospital network first emerged in 2001, when the Maurice Hayes review recommended, amongst other things, reducing the total number of hospitals. The 2011 Compton Review included a recommendation to cut the number of acute hospitals from 10 to five, while in 2014, the Donaldson report suggested closing some local hospitals in recognition that expertise was being too thinly spread across Northern Ireland’s network.
Bengoa’s report was the fourth health review in less than a quarter of a century that has suggested cutting or changing the number of acute hospitals, but change to date has been piecemeal.
A number of barriers have curtailed health transformation, primarily, political instability as well as a shortage of public finances. A further recognised barrier is that closing services is deemed politically unpopular.
Navigating this, Nesbitt has made it clear in his foreward to the new framework that “no acute hospital will close”. Instead, the framework indicates the need to develop regional centres of excellence or surgical hubs for some inpatient services.
“The reality is that we will continue to need every square inch of current acute hospital capacity,” the framework states, adding: “The roles of some hospitals will change to better deliver the health needs of the community and keep pace with modern medicine, as well as contribute to regional delivery. Services may be relocated in some cases from their existing locations, but all hospitals will continue to play a central and vital role in our health service and in their local communities.”
The framework categorises Northern Ireland’s acute hospitals into four specific main types: local hospitals; general hospitals; area hospitals; and regional centres. Outlining that it is unsustainable for all hospitals to provide all services, the Department of Health says that the framework will seek to identify the core services in each of these types of hospitals and consider the key challenges to sustainably deliver these. However, while the framework proscribes a future action plan, no timeline has been set for delivery.
Challenges
Importantly, the framework highlights that hospital network reform is not without challenges, and pinpoints three key areas where action will be required.
1. On workforce challenges, the plan says that actions will need to be taken to proactively address challenges in working across HSCT areas such as travel, recruitment, retention, and equity in the division of workloads.
2. In relation to transport and travel challenges, including ambulance services, the plan recognises that the movement of both patients and staff between services and sites will require cross-departmental working alongside other key partners to address challenges around road infrastructure, the public transport network, and digital connectivity in rural areas.
3. On patient pathways, the plan states: “Patient pathways or a person’s route to treatment must be at the heart of system reconfiguration and discussed at the earliest possible opportunity. Pathways must be mapped with serious consideration given to stakeholders required to ensure pathways work in a seamless way and in the end create a more efficient and effective outcome for both patients and staff.”
Hospitals: Creating a Network for Better Outcomes proposes a total of 13 actions ranging from a review of the Department of Health’s Transport Strategy, through to designating Causeway as an elective care centre, and the definition of a suitable level of protected bed base, diagnostic and theatre capacity for regional specialist services.
Opening the consultation to the plan in early October 2024, Minister Nesbitt said: “While every hospital cannot provide every service, each hospital will still play a vital role, not just in their local communities but as a valued part of a planned regional system.
“This document can help assure communities that reconfiguration of services is not about cutting costs or closing hospitals. It is about managing change in a controlled way and demonstrating the benefits. It’s about showing how each hospital can fit into the network and best serve patients.
“Change is happening. We see that with the increasing shift towards centres of excellence such as standalone elective care hubs. This is reform in action but there is much more to do. A collaborative approach can better sustain our network to the benefit of patients and staff.”
However, publication of the document was met with some scepticism from MLAs. Diane Dodds, the DUP’s health spokesperson described the plan as “underwhelming”, and pointed to a lack of detail in the publication.
“Eight years on from the Bengoa Report, why is the focus still on principles? Surely we have had all the frameworks we need?” she stated.
Similarly, the SDLP’s Health Spokesperson Colin McGrath MLA said: “Without concrete proposals or timescales there is genuine concern that transformation could once again be allowed to drift. We have heard multiple health ministers pay lip service to the notion of transformation but what we need now is delivery to transform our health service and make it fit for purpose to provide patients with the care they need.”
Health Minister Nesbitt has indicated that Hospitals: Creating a Network for Better Outcomes was the first of a series of planned announcements and publications aimed at setting health and social care services on a clear path to recovery.
Following the publication of the plan, the Minister has set out plans to publish a major review of maternity services and a three-year strategic plan for the remainder of the mandate.
Highlighting that the current financial position makes progress more difficult, he adds: “While the Programme for Government sets out the limits that the present budgetary situation places on efforts to reduce waiting lists, I will continue to make the case for significantly more funding for health.
“I have no time for the argument that money alone is the solution to the health service’s ills. Equally, anyone who suggests it is not part of the answer is sadly mistaken.”
