Another report warns the health service is crumbling
This week another report laid bare the perilous state of Northern Ireland’s health service.
The NI Affairs Committee (NIAC) at Westminster published Health Funding in Northern Ireland – with a headline warning of imminent systemic collapse.
As things stand, we are watching a slow motion car crash. The vehicle has hit the wall and the crash test dummies are beginning to move, in their raggedy way, towards doom.
Unfortunately that is a metaphor and we are not watching the smash we are amidst it. We – our society, our loved ones and ourselves, anyone and everyone who relies on the health service – are the dummies.
Fortunately, the metaphor is imperfect. Doom is not inevitable. It won’t be easy but we can uncrash the car and (to a significant degree) avoid the damage to come.
NIAC’s work reiterates the same central findings of papers dating back almost a decade, from Transforming Your Care (2011), the Donaldson report (2014), Bengoa (2016) and the last government’s ten-year strategy for health, Delivering Together (also 2016).
Our population is ageing and, accordingly, the number of people living with chronic conditions is rising incredibly fast. This both vastly increases the demand for health and care services of our population, and also changes the nature of this demand.
This cannot be solved by simply spending more money (even if our public finances were much healthier than they are). Instead, we must shift care out of hospitals; focus more on prevention and early intervention; support people to live independently; and rationalise acute services.
These findings are not new – and they could hardly be more pressing.
However, the NI Affairs Committee does not stop there. It also has some interesting, and alarming, points to make about specific aspects of the health system, including cancer care, adult social care, and mental health provision.
While health transformation is an immediate, red-alert situation, there are three major stumbling blocks. The first is our absence of government, which means making decisions and directing change are curtailed, because our civil servants are only allowed to make choices within certain parameters.
The second is financial – change costs money, and we have none spare. The third is that transformation on this scale is chaotic but there is an obvious need for adequate health and social care to continue at all points throughout and in parallel to the process of reform. This is very difficult.
Cancer is, to a certain extent, emblematic of the problems we face. As the population ages the cancer rates are likely to rise. Cancer will add significantly to the number of people living with long-term health needs.
Northern Ireland is the only part of the UK without an up-to-date cancer strategy (although one has been commissioned by the Department of Health). We are also behind the curve, compared with the rest of the UK, on providing patients with certain new and innovative treatments.
Per the NIAC report: “The Committee recommends that the Department of Health commit to a baseline assessment to identify where gaps in the HSC workforce are contributing to delays in the diagnostic pathway for cancer patients. The Department should subsequently bring forward a strategy for closing those gaps through the recruitment and retention of an adequate workforce alongside innovations in technology and service delivery, to be published in draft by summer 2020…
“We recommend that the Department set out, in response to this report, clear timescales for its programme of work in developing a new cancer strategy and provide regular updates on progress made. This timescale should set out the key milestones where Ministerial decisions should be made.”
As well as calling for regular updates on the modernisation of treatments in NI, the committee made specific recommendations about screening for bowel cancer and cervical cancer, both of which could be improved locally.
Staffing is a major issue in adult social care. Wages are poor but the job is difficult and demanding, with the committee noting the independent care sector “is struggling with competition from the low wage sector, particularly hospitality and retail” but that retention of staff – and the related development of skills amongst the workforce – is a huge priority.
Related to this, short-term budgeting puts huge pressure on providers, which already work within incredibly tight margins, meaning they have little room to develop any aspect of their business practice.
This, again, is compounded by the fact that social workers are overburdened by bureaucratic requirements.
“The Committee recommends that the Department conduct a review of social care roles across the board to identify inconsistencies in roles, responsibilities and salaries as a step towards consolidation of the social care workforce. This review should be completed by summer 2020. The Department should further set out what steps are being taken to progress the proposals set out in Power to People for equalising pay and conditions across the social care workforce in response to this report…
“[T]hree-year minimum budget allocations are needed for the Department of Health. This should facilitate the Department moving towards a minimum five-year partnership model with community and voluntary providers in which commissioning and investment are based on progress towards agreed outcomes…
“The Committee recommend that a task force be established with the remit and the authority to remove unnecessary and duplicated paperwork and streamline existing paperwork—though this should not be at the expense of high-quality assessments or casework.”
Northern Ireland has higher rates of poor mental health than the rest of the UK. However, only around 6% of our health budget goes on mental health provision. In England, for example, this proportion is almost double that of NI.
Nor do we have a dedicated mental health strategy. Although good care and support exists, it is part of a fractured, siloed whole.
The NIAC report said the “dominant themes” of Child and Adolescent Mental Health Services were “underfunding and fragmentation” and also raised concerns about the impact on services when extra money, gained from the DUP’s confidence and supply arrangement with Theresa May’s government, runs out.
And, of course, local suicide rates remain tragically high.
“The Department should increase its level of investment in mental health as a share of the overall health budget in line with recent increases in other UK jurisdictions, with the aim of reaching 13 per cent in the long-term…
“The Committee recommends that the Department consult widely with professionals, service users, staff, and the community and voluntary sectors on where funds would be most effectively deployed and to make this information clearly available to the public so that decisions can be properly scrutinised…
“We recommend that spending on CAMHS is brought into line with the HSCB’s own recommendation of 10 per cent of the mental health budget. To ensure that funding is deployed strategically measures should be taken to better integrate the commissioning of services and develop a culture of multi-disciplinary and multi-sectoral team working.
“The recent review into CAMHS conducted by the Northern Ireland Commissioner for Children and Young People contained a number of recommendations based on wide-ranging consultations with key stakeholders. We agree with the Commissioner’s recommendation that a long term and sustainable ‘funding and practice partnership’ model be established for driving change”
Calls for transformation of the health service are abstract. The health service is massive and it is perhaps not always clear precisely what that means.
The more detailed focus placed on cancer services, adult social care, and mental health provision provides a closer glimpse of what is breaking apart around us (note also that NIAC mentioned that oral health in NI is poor and need renewed focus, and local community pharmacies are a valuable resource that need greater support)/
Of course, the top line of the story is the same top line as every story about our health system for a decade – the urgent need for transformation.
“Transformation of Northern Ireland’s health and social care services in line with the aims and recommendations of Bengoa and Delivering Together is needed urgently if services are to keep pace with the increasingly complex and evolving needs of an aging population. The Committee welcome funding ring-fenced for this purpose. However, the current model of non-recurrent funding over a two-year period is not suited to delivering the truly transformative and sustained change required. We recommend that, if an Executive is not in place by the end of this year, the UK Government work with the Department of Health and the Department of Finance to secure a multi-year funding settlement ring-fenced for transformation.”
The time for change is now.
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