The former Basque Minister charged with sorting out our health service

It’s not quite what Sir Liam Donaldson envisaged in his landmark report. He wanted an international panel whose findings would be binding on government. This was because he believed that a combination of populist stances by local politicians, and media coverage were preventing the necessary reform.

Hamilton’s panel has both local and international representatives and its findings will not be binding.

However the two international members are significant appointments.

The chair is Rafael Bengoa who was Regional Minister of Health and Consumer Affairs in the Basque Country between 2009 and 2012.

During that time he implemented a transformation of the region’s health service during a period of even harsher austerity than we now face in Northern Ireland.

Interestingly Hamilton’s predecessor Edwin Poots went to visit him in 2012 to compare notes on the Northern Irish and Basque health systems: both devolved, both based on the free health care model.

At the time Poots said: “I want to identify where we can adapt solutions developed elsewhere, including in the Basque Country, to our own health and social care system and am keen to share our own learning so we can provide the best possible care for the people we serve with the budgets given.”

The Ministers agreed at their meeting to co-operate on reform.

Poots said: “We are already on the same path, so it makes sense that we should share our learning. Over the coming weeks, we will seek to place formal, agreed arrangements around the areas on which we will co-operate.”

And Bengoa added: “We all have separate mechanisms and tools which address the similar challenges we face and drive our own reform agendas. We need to find a system where we can bring these together to assist our countries – and others – in improving healthcare delivery.”

So at the time the two governments were comparing notes and preparing to co-operate on reform.

Today the reforms in the Basque Country are in place, Bengoa is now advising governments around the world, whilst Transforming Your Care has stalled (perhaps because of the very factors Donaldson identified). Given what Bengoa said in 2012 he was presumably impressed by Transforming Your Care and perhaps therefore the issue is not around policy but more to do with effective leadership of change. In any event he seems perfectly placed to work out what has gone wrong and what needs to be done, and presumably has the political skills to persuade others.

In the Basque Country Bengoa recognised from the start that improvements to health care would not come from additional resources, because there weren’t any, but through transformation of the way health care is delivered

He said: “We wanted a narrative that mobilised nurses and doctors, citizens and the rest. We’ve all tried to set a vision before. It really does work if the vision gives a structure to guide policy changes. Improving the care of chronic conditions was our central narrative

These reforms were motivated by recognition that, within the prevailing economic context, future improvements to health system performance were not likely to “emerge from additional income but rather from the transformation of the health service delivery mode

Bengoa said: “The main issue was not to focus on a specific outcome or the low hanging fruit of cost containment measures. We believed that in order to drive deep reform, we needed to put a more compelling narrative on the table.”

The key elements were:

• Focus on stratified population health combined with a predictive risk approach (ie identifying those people in the population who were most at risk)
•  Health promotion and the prevention of chronic illnesses
•  Greater responsibility and autonomy for patients
•  Continuous care for patients with chronic conditions
•  Efficient interventions adapted to patient needs (patient-centred care)

To those who have read Transforming Your Care, this all sounds eerily familiar. Yet the Basque Country faced an additional obstacle: unlike Northern Ireland its health and social care systems were not integrated, so that hurdle needed to be overcome.

Addressing the challenge of managing costs, Bengoa acknowledged that driving reform was at times costly: “Some of these programmes have been expensive. For example, we established a call centre to help triage cases for a population of 2,200,000 that cost us €14 million.”

Additionally, the entire Basque population has been stratified according to risk, allowing for more efficient allocation of available resources and the promise of long-term savings: “Local planners now have information on who will be most costly to treat. They are now beginning to intervene based on risk before a patient requires acute care. This saves us cost down the road.”

Another key feature of the Basque reform programme was local empowerment. Bengoa said:” In most countries, politicians are changed following elections and subsequently managers as well. If everything has been managed top–down, the probability of those projects fading away with their political promoters is very high. On the contrary, if many projects have been bottom-up they are ‘owned’ locally and will tend to better survive any political turnovers.

The second international panel member is Professor John Øvretveit who is a global expert in implementation research based at the Karolinska Institute in Sweden which he describes as a “cathedral of medical science”. He often talks about his interest in raising to awareness some of the constraints that affect what we do, constraints that we are not always aware of at the time. 

We would therefore expect him not just to be well placed to evaluate reform, but also to have much to say about how reform should be implemented and how some of the constraints that have clearly impeded the search for change in Northern Ireland can be removed.