Better Healthcare
Dr John D Woods chair of the Northern Ireland council of the British Medical Association (BMA) talks to Owen McQuade about the challenges facing healthcare in Northern Ireland.
The aim of the BMA is to improve doctors’ working lives and “we believe if we look after doctors’ wellbeing they can look after patients’ wellbeing and improve the health of the population. ‘Looking after doctors, so they can look after you’ is our mission statement,” explains Dr John Woods, the chair of the BMA in Northern Ireland.
The BMA is both a professional association and acts as a representative body and trade union for its members. The range of activities the body carries out includes public health orientated activities such as arguing for presumed consent for kidney and organ transplantation – Woods highlights that there is a bill on this going through the Assembly at the moment – advocating for minimum unit pricing on alcohol and tobacco restriction – “all things that our members feel will improve the general health of the population.”
When asked what are the biggest challenges in healthcare at the moment, Woods responds that the biggest pressure is the increasing demands on the health service and those arise predominantly because the population is ageing. As a result of successful medical care, more people are living longer but with more significant illnesses. “I have seen this in my own career in that patients are increasingly older but more so their medical needs are much more complex. While I look after patients with kidney disease increasingly such patients also have disease of their lungs or heart and that really makes the whole picture in terms of treatment much more difficult,” reflects Woods.
The demographic challenge comes against a backdrop of higher expectations. “The public want the best possible care available. Trying to deliver that with limited budgets is a big challenge. The health budget has not been increasing at the rate that demand has been rising. In particular increasing to meet the needs of an ageing population,” observes Woods.
Healthcare in Northern Ireland
The BMA broadly agreed with the vision for Transforming Your Care (TYC) and “felt it was moving in the right direction but it was more about getting the necessary funding to get it implemented – implementation fell behind the vision,” says Woods.
The representative body also welcomes the Health Minister’s recent vision: “We think that it is on the right track. Doctors recognise that they want to make the health service as efficient as possible. The Minister spoke about reducing the layers of bureaucracy in the health service and we would agree with that,” says Woods.
There will be a consultation on the future of the Health and Social Care Board and the BMA “fully intends to reply to that.” The BMA also believes that the idea of a panel of experts to look at the future of the health service is also a good one and would like to participate in that process as clinicians.
In discussing the impact of Transforming Your Care and the difficulties in shifting the focus of health care towards primary care, Woods comments: “It’s partly about budget. Healthcare inflation runs ahead of normal inflation, partly because of the ageing population and also because of the pace of technological change – there are more and more things we can now do. Unfortunately, healthcare does become progressively more expensive per capita with time.”
The health service in Northern Ireland is also facing a lot of workforce problems.
This is most pronounced in general practice, with “significant difficulties” in attracting young doctors into general practice. The problems facing primary care include a significantly increased workload with a 76 per cent increase in total GP consultations 2004-2014 and a 37 per cent increase in prescriptions administered by GPs between 2004-2014. “While the total health spend in Northern Ireland has increased the increase for general practice is less than one per cent. GPs here are already struggling to retain the current primary service and maintain the best access and highest quality service for patients.”
“We have also been advocating for some time that training places for new GP’s should be increased but the number of places are still lagging behind the need,” says Woods.
There are recruitment difficulties in hospitals in some specialities, including emergency medicine. This is a well-recognised problem and there has been a significant amount of emigration of emergency doctors from the UK to other countries, partly due to a reaction to their working conditions. Another area where there is an issue is radiology, which is partly driven by technological change as there is now more scanning and imaging and as a result more doctors are needed to interpret test results.
The BMA sees clinician involvement as central to the success of any reform process. When asked if they have enough input into the running of the health service, Woods replies: “Medical engagement in the reform process is essential and we have been arguing for it to improve. Clearly within medical teams clinical engagement is very high – those people feel a very strong bond working together collaboratively to improve things for the patient.”
Woods explains that doctors over the last decade have felt disengaged from the structures of health trusts in secondary care. “They feel they have little influence over the process. They often believe they have innovative processes to improve care but they have difficulty getting those taken forward. Doctors would like a good co-operative relationship with managers. I think everyone appreciates the need to work together to make patient care as good as possible.”
Innovation
A key aspect of reform and change in healthcare is innovation. Woods highlights a couple of local examples of innovation that have led to improved healthcare for patients.
The first example is in his own area of expertise, nephrology which is the care of people whose kidneys are failing or have failed. If they have totally failed the best form of treatment is to get a kidney transplant. “My colleagues over the last six years have really improved the rate of kidney transplantation in Northern Ireland. We have gone from 40 to 45 kidney transplants a year to over 100 for this current year. A whole range of things were done: faster, streamlined evaluations of donors and recipients led to an increase in the amount of ‘live donors’ and improved laboratory techniques compressed the time taken in carrying out matching tests,” explains Woods.
Another innovation is in general practice. GPs are coming together into federations, which are larger non-profit organisations with 40 to 50 GPs working collaboratively to improve care. “That’s an innovation GPs have adopted themselves across Northern Ireland.
At present they want to retain the individual practice identity but want to work in the wider collaborative group. There is an opportunity to improve the overall care for many patients. It may be, for example, one or two GPs within that group may develop expertise in an area like joint disease and would work closely with specialists in secondary care collaboratively to help those patients. That would be welcomed by specialists in secondary care as they would have someone to work closely with in primary care,” says Woods.
Discussing the practicalities of seven day working, Woods highlights two aspects of the debate: emergency care and moving routine procedures to the weekends. “There does appear to be some evidence that outcomes for patients admitted to hospitals at the weekends are not as good, but it’s not perhaps as black and white as Jeremy Hunt would like you to believe. We are fully committed to improving emergency care. If you are admitted at the weekend, almost invariably you are admitted as an emergency and we are committed to making that care as good on a Sunday as it would be on a Wednesday.”
Although the outcomes appear to be less good for people admitted at the weekends, it is not clear why that is the case. For example, it may be that people who are sicker are admitted at the weekend – there is some evidence for that. “It is not as simple as having more doctors. One thing our members have said to us is that there is little point them being there offering a very limited service; everything else they need to function needs to be there as well. Sorting out emergency care is the first priority, so that it is equivalent over seven days a week,” adds Woods.
On the issue of non-emergency work at the weekend, Woods points to some of the arguments from government in the UK centres on doing more routine work at the weekend. “It is an efficiency argument, using equipment more efficiently. The problem is we fail to see how you don’t need more resources to do that. If you want to run everything across seven days like it is on a Wednesday, you need to have 7/5ths resources to do the same.” Woods stresses that the emphasis should be on emergency care and more routine work should be done at the weekend if patients want it but that will require a significant investment to do that. “One would question if that is the right thing to do in the absence of the doctors you need to provide it. It is an appropriate long-term aspiration but it is not where the problem is currently,” he adds.
On the recent changes proposed for secondary care the BMA is clear that the debate needs to focus more on outcomes for patients rather than just on physical buildings.
“People in Northern Ireland get very fixed on actual buildings. We should think about this differently: What services do people need, what does that look like and then what infrastructure do we need to support that, rather than reducing the conversation to what will be the number of hospitals.” He explains that one of the drivers towards bigger hospitals is that it is much better if your care is provided by someone who does a lot of that type of operation or care.
Woods gives an example of how this works out practically: “If you have a heart attack the best treatment is often a primary angioplasty procedure by a cardiologist. In Northern Ireland cardiologists have worked innovatively to provide that service 24 hours a day but it can only be provided currently on two sites across Northern Ireland. It is a service we can only hope to provide on a small number of sites. That is driving us towards larger institutions, whilst at the same time patients want care closer to their homes.
“Clearly we are going to need lots of sites where healthcare is provided. We will have many sites but what an individual site does may be quite different.”
Profile: Dr John D Woods
Armagh born and bred John D Woods trained at Trinity College Dublin. He worked as a junior doctor in Northern Ireland and Guy’s Hospital London. Unusually, he did all his speciality training in the United States. He has been a consultant Nephrologist for 17 years. A few things stand out from his experience in the US: “Morale was higher because junior doctors felt valued and were listened to. Resources were better back then in the US but I think the health service here has caught up. Doctors also focused on things only doctors can do and junior doctors had less admin.”
Other interests involve his family and with five children takes up most of his time. John is also a keen sailor and has an interest in current affairs and US politics.
