Edwin Poots interview: time for change

Health Minister Edwin Poots shares his vision for the service with Owen McQuade: more primary care, listening to front-line staff and separating emergency and elective services. The new Minister expects to make difficult decisions but believes better results are achievable.

“I want to see a Health Service that is responsive to the needs of the people that are using it,” Edwin Poots states. “I want to see a Health Service that is local and therefore I want to see an enhancement of primary care and the availability of more services at that primary care level. And I want to see a Health Service that leads in specialisms and is not lagging behind the rest of the world in terms of the care that’s provided for our people.”

His third term as Minister will involve overseeing a Health Service for all 1.8 million residents of Northern Ireland, costing £4.31 billion this year. The responsibility is heavy but Poots takes a calm tone as he reviews his portfolio. It is currently planned that he will hold the brief until Jim Wells succeeds him in mid- 2013.

The financial constraints cannot be ignored but his priority is better outcomes for those who use the service. Those improvements are achievable but a “fairly significant change” is needed to make them happen, especially a major shift from acute to primary care.

Poots values localism but sees its limits. Keeping acute services in local hospitals can put some patients at greater risk.

His practical example is thrombolysis, breaking down blood clots by using drugs, after a person has suffered a stroke, which can allow 15 per cent of stroke patients to make a significant recovery. Relatively few hospitals can offer that service.

“You ask the question and someone says: ‘I strongly support having a local A&E in this area.’ And that’s fine but you’re not going to have the facilities, the consultants on hand, the scanning facilities to offer that sort of treatment,” he states. “So the Ambulance Service is going to take you directly to a hospital that does have that facility.”

He sees a clear contrast between going to a local hospital that is 10 minutes away, but leaving in a wheelchair after a month, or treatment in a hospital 30 miles away with the prospect of making a full recovery.

“I think that for the individual, that’s a very easy decision to make,” the Minister affirms. “And for people who are making an argument about localism all the time, I support localism but it shouldn’t be to the detriment of the best outcome for the patient and we can’t offer that service at every local hospital.”

Primary benefits

While medical professionals understand that argument, it is put to him that the public is still wedded to a local hospital. Poots responds by explaining what enhanced primary care centres would deliver.

Normally, a patient with a chest infection is referred by a GP to a hospital, where they wait in A&E and are often admitted. If x-rays were available onsite, the doctor could carry out a diagnosis and decide what action to take.

A seriously ill patient could be referred directly to a ward, bypassing A&E entirely. Patients with less serious conditions would not need an admission at all, and therefore avoid contracting other illnesses inside hospital. Older people, in particular, would benefit.

“It’s also considerably better for our economy because we’re not treating someone for something they shouldn’t have had in the first instance,” Poots comments. “You’re treating them for the initial illness in a more effective way.”

Pre-med preparations and diabetes clinics could also be carried out locally, rather than involving hospital visits.

Meanwhile, in acute services, there are “significant opportunities to provide better healthcare” if the best use is made of new technology. Catheter labs, which install stents quickly after a heart attack, can drastically reduce coronary-related deaths.

“And that’s why I have a commitment to ensuring that people go to the right place for the right treatment,” he continues, “and ultimately you have a far better chance of getting the right result in those circumstances and I will not be deflected from doing that by people who make very simplistic arguments that an ambulance needs to get to the nearest hospital straight away.”

On that point, he expects a continual improvement in ambulance services and points out that the paramedic’s care is “key to saving a person’s life” at the scene of a major trauma before taking them to the right facility for further treatment.

Maximising efficiency

“We do need to shift the focus where we have a number of hospitals carrying out the same types of service and we need to probably bring them on to a lesser number of sites,” he notes, alluding to the Belfast hospitals. The Minister sees “little point in having two hospitals within a mile of each other carrying out exactly the same service”.

Inefficiency can also be driven out by more segregation of emergency services and elective procedures. He explains that “if every hospital has an emergency service in association with the elective procedures, that will inevitably lead to patients’ care being delayed and operations cancelled as the emergencies come in.” Instead, some hospitals should carry out elective procedures only while others concentrate on A&E.

In 2009-2010, the average hospital stay in Northern Ireland lasted 5.8 days, slightly behind Scotland (5.3) and England (5.6), similar to the Republic (6.0 in 2009) and ahead of Wales (7.5).

Poots has questioned why the length of stay is longer and suggests that a registrar should be allowed to discharge a patient rather than a consultant, as is currently the case. The decision is ultimately a clinical one and the registrar often does most of the work with the patient.

Culture change

Speaking to the Chief Nursing Officer’s conference in June, Poots promised “greater involvement of frontline professionals in decision-making and service development” as they know “better than anyone else” what was working well or where improvements can be made.

He has been “fascinated” by responses by front-line staff, he continues. Nurses in Daisy Hill Hospital, in Newry, have identified a better way to flush out cisterns in the nephrology unit, which resulted in fewer infections among people using that service. Another nurse in Belfast City Hospital has reduced the number of consultations for live kidney donors from three to one. Transplant numbers rose from single figures to 40 in a year, taking patients off dialysis and letting them resume a normal lifestyle.

In both cases, there was a “double-edged sword” i.e. a better outcome for the patient and a cost saving.

Staff consultation already takes place at a local management level but invest-to- save decisions “have to come further up the line.” He wants a “very good access” between people on the ground and those senior managers.

“There’s no point in having a fantastic idea but we talk amongst ourselves as to how it can make it better but it doesn’t actually get to the decision-maker,” he states. “I want to ensure that people who see solutions on the ground are able to get those potential solutions to the decision-makers and allow the decision- makers to move this on and move it on quickly, because ultimately that will have far better outcomes.”

Private and voluntary

The private and voluntary sectors have a key role to play in the changes that lie ahead. Offers from the voluntary sector “which would have saved us money” were previously rejected. He encourages voluntary organisations to come forward with ideas and sees mental health and learning disability as a particular opportunity.

Domiciliary care also presents “great opportunities” for social economy projects. One existing example in Colin, in West Belfast, was set up with an initial £25,000 investment and now makes over £360,000 in profits, which are ploughed back into community projects. It has employed over 60 people and has trained many more: “There was an area of deprivation which was able to get a hand- up and I would like to see more of that happening.”

Poots adds: “Some people recoil whenever you mention the private sector, as if it is something bad.” Instead, he praises the private sector’s influence on social care, contrasting hospital geriatric units 30-40 years ago with the comfortable residential, care homes and nursing homes provided today. More one-to-one care is provided at a lower cost. All three sectors can help people stay at home for as long as possible.

Joining up

The historic under-funding of mental health and learning disability makes driving out inefficiency “all the more important for me” so that area can get new investment. He wants to take the “huge challenge” on and raise public awareness of suicide and the risk factors.

A silo mentality, Poots claims, has held back action on mental health with departments being reluctant to take on extra responsibilities, in case that involves more cost. Four have a role to play:

• his Department of Health, Social Services and Public Safety;

• the Department of Education;

• the Department for Social Development; and

• the Department of Culture, Arts and Leisure.

“If there is a better outcome and there is an additional cost, we need to identify which department or departments should be picking up the tab for that and where the major benefit lies,” he states. “I suspect it will be across a number of departments that will end up picking up the cost for it but we can dramatically improve outcomes and, if we do improve outcomes, that will ultimately lead to a better economy for all of Northern Ireland because we spend an awful lot of money on mental health. We lose an awful lot of money as a consequence of mental health and people not being available for our labour force and so forth.”

The Civil Service has not been strong enough on working together but he will “push that very hard” with his staff and expects other ministers to do the same.

Decisions

Asked to choose one area where he wants to see movement by the end of his term, he says he thinks differently: “It’s not where I’m coming from on the Health Service. It’s my intention to be holistic and it is my intention to be a Minister that leads change and challenges for change.”

Primary care must be “moved centre stage” to offer the right service to people at a local level. This will also involve upskilling in that service, with a range of allied health professionals supporting that service.

One of his key messages is that everyone can help to improve society’s health. The goal of public health is that fewer people need to use the Health Service because they are looking after themselves: “We will be getting those messages out to people as to how they can make a contribution and how they can change their lifestyle for their own betterment but also for the benefit of others.”

There are also “tremendous opportunities” for improving cancer results and the outcomes of heart attacks and strokes. That said, hard choices must be faced to improve health.

“Ultimately, having ministerial office isn’t about taking easy decisions all the time,” he contends. “Very often, it’s about taking difficult decisions. The scale of the problem within the Health Service is one that’s going to require a series of difficult decisions.”

He expects people will accept those changes if they are explained clearly and debated. People should also see benefits as the change works through the system.

“This isn’t a debate about money,” Poots stresses. “It’s a debate about providing a better Health Service and money is very much a secondary issue. We have a budget of £4.3 billion, which is a very large budget, and that’s been growing for quite a number of years.”

He notes, though, that “there has been quite a bit of waste traditionally within the Health Service and we need to drive that waste out to ensure that every penny of it spent is well spent.” While not sure whether this goal will be achieved, he adds that “it’s one that I’ll aspire to and I’ll drive towards that.”

Profile: Edwin Poots

A DUP MLA for Lagan Valley since 1998, Edwin Poots was previously Culture, Arts and Leisure Minister (2007-2008) and Environment Minister (2009-2011). He entered elected politics as a Northern Ireland Forum member for Lagan Valley (1996-1998). Poots also contested the constituency at the 1997 and 2001 general elections. He represented Downshire, on Lisburn Borough (later City) Council from 1997 to June 2010, succeeding his father Charles.

Married with two sons and two daughters, he has a farming background and was educated at Greenmount Agricultural College.