Community transport, health transformation and public service collapse

A valued community transport programme is at risk of closure after the Department for Infrastructure (DfI) discontinued its funding.

The dial-a-lift service is delivered by eleven separate organisations through Rural Community Transport Partnerships. It makes around 200,000 trips per year, helping people get to healthcare appointments, collect prescriptions or pick up groceries. The service relied on £2.2m annual funding from DfI to support its work.

This is bad news, directly. Older and vulnerable people rely on these services to do essential things. However, the problems go much deeper. Any loss of such services points to the ongoing dysfunction within Northern Ireland’s wider public services.

Joined-up thinking. Joined-up working. These jargon terms have become buzzwords of best practice, and have have risen to the top of organisational thinking in the public and third (and also private) sectors in the past ten or fifteen years.

The reason these terms persist is because they represent good, important ideas. In any complex system different parts should work together to support one another. This makes everything better.

The loss of community transport would look more like joined-up failure.

To understand why, look at the health system – and plans for health transformation.

Rationalisation

There are several problems with Northern Ireland’s health system. Waiting lists are ridiculous and, broadly speaking, will only get worse without several systemic changes.

Some of these changes involve improving public health in general, to lessen the need for clinical interventions throughout people’s lives, and making individuals’ homes the hub of care to – so far as is possible – move care out of bricks-and-mortar public buildings and into people’s living rooms. Those are not the issue here.

Some other changes involve a radical transformation of specialist care and treatments.

NI’s specialist services are, in general, spread over too many physical locations. Too many emergency departments. Too many centres for things like, say, stroke care and cancer care and different types of surgery and so on.

The reason there are too many is not because we are paying too many consultants (we could probably do with a few more) – it is that smaller sites are less efficient than larger, centralised hubs where all our experts (and all the younger clinicians developing their own expertise) can work in concert to ensure a much more robust service that delivers better results for the same money – and where, if we spend more money, we will get more bang for our buck.

The trade off is clear. Centralised services will, by definition, take place on fewer sites. In general, people will have to travel further, perhaps much further, to get the care they need.

That is a difficult pill to swallow, but you get what you pay for. The cost is high, the result is better results from the health service. Better results – a dry turn of phrase. What this actually means is more people living longer, more people living healthier. The benefits are measured in healthy, happy days and weeks and years.

Or, to quote the Donaldson Report (one of NI’s many major health reviews of the past 10 or so years, all of which say different versions of the same thing), published in 2014: “A proportion of poor quality, unsafe care occurs because local hospital facilities in some parts of Northern Ireland cannot provide the level and standard of care required to meet patients’ needs 24 hours a day, 7 days a week. Proposals to close local hospitals tend to be met with public outrage, but this would be turned on its head if it were properly explained that people were trading a degree of geographical inconvenience against life and death.”

Transport

It’s worth looking closer at the specific service at risk of closure.

The Community Transport Association is a charity that supports the organisations handling the dial-a-lift service.

Director Noeleen Lynch said: “If we lose this service it will cause severe and irreversible damage to disabled people, who live in rural areas with no public transport nearby.

“Elderly and disabled people rely on this service for medical appointments and basic food shops, so you're talking about an impact on peoples' lives and livelihoods should funding be reduced or discontinued.”

Funding is guaranteed until the end of April but, without news of further support, community transport organisations face agonising choices about what can be delivered.

“In that situation unfortunately, some community transport organisations may be forced to begin winding up. This will have a devastating impact on vulnerable people in rural communities.”

A spokesperson for DfI said the service’s importance is recognised but the department needs to make “extremely difficult decisions” in the absence of a proper budget for 2023-24.

“To minimise uncertainty and operational difficulties, a funding commitment has been given to community transport providers for April 2023. Further decisions for the remainder of the year will be subject to the budget outcome.”

Wrong direction of travel

Reform of our health services is essential.

To quote another of those major papers on transformation, 2016’s Bengoa Report: “The stark options facing the HSC system are either to resist change and see services deteriorate to the point of collapse over time, or to embrace transformation and work to create a modern, sustainable service that is properly equipped to help people stay as healthy as possible and to provide them with the right type of care when they need it.”

But, in this world of joined-up thinking, merely centralising specialist services won’t be enough. The people who need those services still need to be able to get to them and, even as things stand today, dial-a-lift services are a small but significant part of that whole system.

As health services begin to get a bit further away, the role for community transport will only increase.

The people who use dial-a-lift tend to be older or otherwise vulnerable. That same cohort is more likely to need specialist healthcare, and is more likely to be able to travel larger distances without help.

If all NI’s community transport disappears before summer that doesn’t mean it can never come back – but the direction of travel is all wrong, and supporting established services is simpler than creating something from the ground up.

Reducing community transport options is a terrible move that has emerged, unwelcome, from a desperate situation.

Why is this happening?

The reason for the removal of funding is plain. There is no clear budget and DfI has no minister. Instead, civil servants are nominally in charge.

Senior officials have no scope for joined-up thinking or joined-up working. They are trying to balance their individual departmental (or agency) budgets in the least-damaging way possible, while working entirely in their own silos, providing a zombie facsimile of ministerial work. This is not their job, it shouldn’t be their job, and no doubt they would prefer an actual elected representative was in place, truly accountable to the Executive, the legislature and the general public.

It is important to state that, even if Stormont does come back in some stable form, Northern Ireland’s problems will not be any smaller. Public services and public finances will remain under strain.

But at least we can pick our battles.

A full Executive would wield a larger budget than civil servants currently enjoy. They could also spend that budget how they see fit.

It is impossible for all of NI’s challenges to be addressed in the short- or even medium-term. But we can fix some of them, and fix them properly.

An Executive, armed with an agreed Programme for Government (which should be the urtext of joined-up thinking for any parliamentary mandate), could at least make some things better.

It could commit to health reform.

It could commit to the wider measures required to make that reform effective.

It could, for example, not close community transport options that already help your granny in West Tyrone get to her GP appointments.

No Executive can do everything, but they all can do something. Stormont needs to get back to work.

UPDATE: The day after this article first appeared, it was announced that funding for community transport services will no longer cease in April. However, the additional support from the Department for Infrastructure only covers three months. As things now stand, financial support will end on June 31.