Does Northern Ireland have too many hospitals?

A recent report into health services in N Ireland has said that there are ‘too many hospitals’. The report also has a lot to say about the organisational structure of the NHS here.

This isn’t the first time that hospital provision here has been questioned; decades ago, an MP in the old Stormont described N Ireland as having a hospital at every bus stop. So how many acute district hospitals (DGH) would be appropriate? It’s easy enough to calculate a number if you accept that a DGH should have a population base of between 250,000 and 500,000. Many such observations have been based on experience in England.

However, what works there may not be appropriate here. In England about 80% of the population live in urban areas, the long term legacy of the industrial revolution there. Beforehand, about 80% of people lived in the country. In N Ireland about 64% of us live in urban areas. The population density of England is 406 per square kilometre, here it’s 130 people per square kilometre.

So, we have a much more rural population than England, and there are many less of us. Should this affect hospital provision? Think about Scotland for a minute; there are small populations in the Outer Hebrides (26,000), Orkney (21,000) and Shetland (23,000). On a purely rational, economic basis, none of these places would have any hospital provision.

In N Ireland a little less than half the population live in the greater Belfast area; the remainder live in smaller towns or in the country; rural population is more like that in the Scottish islands than that in the English countryside.

Hospital provision can’t simply be an economic or mathematical concept; it must take patients’ needs into account. While large hospitals can offer ‘better’ treatment and a greater range of services, they may also be remote and impersonal.

Maternity provision is a useful proxy for studying hospital ‘activity’. If it was once recommended that a maternity unit should have 1,000 delivers per year, this has increased to 3,000 and there are calls, in England, for units of 5,500 to 6,000 births per year. The idea behind these numbers is that doctors and midwives in large units would have, between then, have greater experience, and this should translate as better and safer maternity care. In N Ireland only about 0.2% of deliveries are home births; there are around 25,000 births in hospital here. Only the Royal Maternity hospital has more than 5,500 births per year; and it, and the Ulster and Craigavon hospitals are the only ones with more than 3,000 per year. (In Shetland, there are about 130 births a year in the local hospital.)

If the 3,000 figure is taken as a baseline, then there should only be 8 maternity units in N Ireland; if the 5,000 figure is used, then there should be 5 units. There are 11 hospitals here offering consultant-led and/or midwife-led maternity units.

If there really are ’too many hospitals’ here, there is another, associated problem. The location of many hospitals in historical, and may have been initially appropriate. Is this still true today?

Perhaps N Ireland should develop a model of provision somewhere between the English mega-hospitals and the very rural ones of remote Scottish islands. Such a model will almost certainly be more expensive than a few very large hospitals.