A health check for our health service

3 Nov 2017 Nick Garbutt    Last updated: 3 Nov 2017

Pic: Jesse Orico, Unsplash

When Sir Liam Donaldson reviewed Northern Ireland’s health care system in 2014 he said politicians were incapable of implementing the necessary reforms. 

Instead he called for an international panel of experts to be brought in to say what needed to be done and that all parties should sign up for their conclusions in advance. Donaldson argued that politicians did not provide the solution, they were part of the problem.

His recommendation was dismissed out of hand by elected representatives who argued, with some justification, that what he was suggesting was profoundly undemocratic.

But that was before our Executive and Assembly collapsed. If his idea had been accepted reform would be well under way by now and our ailing health service would be well on the way to recovery.

So what is happening now?

The Department of Health has published an update on progress 12 months on from the landmark Health and Wellbeing 2026: Delivering Together report which set out the reform agenda. It is fascinating, not least because it gives us a rare insight on what civil servants do, how they interact with Ministers and most importantly what they cannot do when there are none.

It is a must-read for anyone with an interest in how policy is formed, developed and implemented. This in turn informs us as to the type of governance we are heading into for the foreseeable future.  

There is no ambiguity about the way it describes the reform programme: “The direction of travel in Delivering Together secured universal buy-in at political, system and service user level and is now the single roadmap for radical health and social care transformation.”

And it adds that “transformation is not an option, it is an imperative.”

So the reforms have all-party support and are essential if the health service is to be fit for purpose. Currently, the report states it is operating on a 20th Century model which is not suitable for current and future needs.

But how can civil servants progress this in the absence of Ministers? After all Ministers are responsible for making and implementing policy decisions and so how long can the Department of Health totter on without one?

The first thing to note is the inevitable time lag between policy announcements and implementation. This is  something that many pundits and politicians either don’t realise or conveniently forget.

The perception that nothing is happening at all neglects to factor in that there is considerable scoping work to be done in order to flesh policies out. This will often involve considerable consultation before programmes are shaped, budgets put in place, and then, if appropriate work goes out to tender. You cannot just whisper in Sir Humphrey’s ear and expect immediate transformative action. The wheels of government move much more slowly than that – and all that work falls to public servants.

What emerges from the document is a litany of initiatives worked up and ready but not implemented because they require ministerial sign-off.

Progress is supposed to be driven by a Transformation Advisory Board which includes Rafael Bengoa whose ideas underpin the reform. It met once in February and hasn’t got together since. This is because it is supposed to be chaired by the Health Minister which, of course, we don’t have.

This in itself is not fatal to making progress - its sister body the Transformation Implementation Group does however meet fortnightly and civil servants are still taking advice from Bengoa and other experts

Some initiatives have got off the ground, however most of the work that would start to make a difference is stalled. In several cases the preparatory work has been completed but they cannot be implemented without ministerial sign-off. As the weeks and months go by these projects are multiplying.  

Take community pharmacy, for example. Expanding and developing the role of pharmacists is important, and is already happening elsewhere.  Pharmacists know more than GPs about drugs, they are routinely visited by 10% of the population and would be well placed to treat minor illnesses, drive health promotion in their areas and also to deliver medicines to isolated and vulnerable people with no transport. The net effect would be to massively reduce the strain on overstretched GP surgeries.  The report states that the development of a new framework for Community Pharmacy has begun, with a Memorandum of Understanding signed in January 2017, and the design of services and cost investigation completed by June 2017. However concluding this work is dependent on budget and consideration by an incoming Minister

The really big one is restructuring the entire system. This is the area where there is most to gain. We have too many hospitals and we need to shift attention from acute provision to care based in communities. A public consultation on the Criteria for Reconfiguring Health and Social Care Services was concluded in February 2017, and the report is awaiting consideration by an incoming Minister.

Northern Ireland’s unacceptably long waiting lists has caused considerable controversy in recent weeks. A plan to address this was published in February. However there is no money to implement it.

The bedrock on which our health system rests is adult social care. It is the means by which people, especially older people with long term health conditions can be cared for in their own homes rather than in much more expensive hospitals. Currently it is so significantly under-funded that many patients are occupying hospital beds because care packages are not available for them.

An Expert Advisory Panel was set up to identify reform proposals for adult social care. It has completed its work. However civil servants have decided that it should be considered by an incoming Minister, prior to publication and public consultation. This seems overly conservative as delaying consultation inevitably builds in delay to urgently required change. If the adult social care system deteriorates much more the entire system is endangered.  

Other stalled issues include reconfiguring perinatal services; the future role of the Public Health Agency and how the service should be reconfigured after the Health and Social Care Board is finally scrapped.

That’s even before we get onto workforce planning, which has not been a strong point for the Department of Health. It does have a new strategy, but yet again it will require sign-off by an incoming Minister.

The one piece of good news is that under the funding arrangement provided for by the confidence and supply agreement between the DUP and the Tories, £200m will be made available for transformation. A further £50m will be invested in mental health services over five years. It will be interesting to see how the civil service could possibly spend this on reform in the absence of Ministerial sanction.

It is hard to avoid the conclusion that, given James Brokenshire’s understandable reluctance to impose full blown direct rule, that no Executive equals no meaningful reform. As we have seen reform is not an option it is an imperative.

Little wonder then that frustration oozes from the document:

“The new models of care will see citizens interact with the HSC system in a different way. This can only happen with the understanding, commitment and involvement of the population, which will require an ongoing and open public debate, and strong political leadership.

“Whilst progress can continue to be made in bringing forward proposals for change, difficult decisions will be required... The nature of these decisions and their impact on the population warrants Ministerial consideration.

 The financial position remains challenging and this is not anticipated to change. The Executive agreed that transformation cannot happen without investment. It is inevitable that the pace of transformation will be impacted by the level of funding available.”

Or to put this another way: no Minister, no funds, no progress.



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