Our health service: running out of time and money

In the past few days the Department’s permanent secretary Richard Pengelly has made two separate speeches which both illustrate the depth of the crisis in health and social care and the need for an urgent public debate about the choices that confront us if services are to survive.

Senior civil servants are invariably invited to make keynote speeches at conferences not in any expectation that they will electrify the audience with what they have to say, but because their presence bestows prestige on the event. It’s usually ten minutes of platitudes before the real business gets underway.

So those who turned up for the Chartered Institute of Public Finance and Accountancy and for the Healthcare Financial Management Association conferences got rather more than they bargained for when Mr Pengelly rose to his feet.

At the first event Pengelly was blunt. He told his audience that the Department did not have the money to do everything it was being asked to do – in fact it is facing a projected £20 million deficit for this financial year.

“Why wouldn’t I want to reduce waiting lists, increase pay for hard pressed staff and reduce the pressure on those staff by recruiting and training more colleagues?  Why wouldn’t I want to improve mental health provision and focus on suicide prevention, commission new drugs for patients with cancer and other serious conditions?

“The truth is I simply can’t afford to do all these things – in fact, I can’t afford to do all the things we currently do.”

At the second event he went even further: “We are certainly in a defining period for health and social care in N Ireland. Budgets remain under intense pressure. At the same time, demand for care continues to grow.

“Something has to give in that situation. We can see it in our growing waiting lists and the impact these have on public confidence in the system. And it’s also very evident in the rising tide of frustration within our workforce.”

This is unusual language for a civil servant, clear evidence that the cracks are widening and deepening in a service which is no longer fit for purpose and on a trajectory that will lead, sooner or later, to its collapse.

In both speeches Pengelly said he wanted to see a full debate on priorities for health and social care one which will inevitably lead to hard choices about how we can best deploy diminishing resources.

Let there be no mistake about this. Our health and social care system in its current form is not sustainable. Costs are rising year on year as the population ages. And falling birth rates will inevitably lead to fewer and fewer taxpayers having to pay for it. Something has to give.

Pengelly and his staff are hamstrung by two other factors. It is not in their gift to increase their own budgets and, although some progress is being made on reform, the big ticket, highly sensitive measures required (re-configuration of hospital services for example) cannot be progressed without government and we don’t have one.

Therefore kick-starting a debate is the best he can do for the present. This is welcome. There is still widespread ignorance and misunderstanding about the system, especially in the area of adult social care.

Day and daily there are demands for more spending from a wide range of interest groups. These are invariably legitimate and well thought through but they can have the effect of setting groups against each other, not just across civic society but within the civil service as well.

For example, most of us want more invested in mental health services. It’s a really urgent priority. But against a backdrop of the Department not being able to respond to existing demand, which of existing services needs to be cut in order to fill this need?

Another. Salaries within Health and Social Services in Northern Ireland are falling below those in the rest of GB. This is not only unfair it will only exacerbate staff shortages which are already biting hard. But with a finite budget, where does the Department get the extra money from?

Should monies be allocated from other Departments who have suffered deep cuts? If so which? 

And before we even start to answer that question we need to be aware that only 20% of health indicators relate to the work of medical professionals. Poverty, poor housing, inadequate education, environmental pollution and limited access to affordable healthy foods are all factors that can impact negatively on health.  Therefore improving our health is 80% dependent on issues that are not in the Department’s remit at all.

In this context transferring over more funds from other Departments doesn’t look quite such a bright idea after all, even before you consider the impact on core services that they provide.

The reality is that the kind of changes we require to achieve an effective health and social care service involve painful choices for all of us, not just Mr Pengelly.

If we want better acute services, we’re going to have to have fewer, better more specialist hospitals. The fetish around preserving local hospital buildings has got to end and be replaced by the pursuit of better care. That will necessitate local politicians speaking up for better outcomes rather than exempting their own constituencies from necessary reform. The general public needs to realise that if you have a serious condition your better going to a centre of excellence than a building at the end of your street. To date reform has foundered on precisely this issue.

Health is free at the point of delivery as it should be. But it is not free. We pay for it through our taxes and if it needs more money, we need to pay more for it. Of course if we got more out of Amazon and Google and the super rich that might help but it does not alter the fundamentals. More funding involves higher taxation. Either we are prepared to pay more or not.

Social care is even more misunderstood. There is a general perception that it, like health care is free at the point of delivery. People are often only disabused of this when they or a family member end up in a care home.

For this reason attempts to reform, or even debate, adult social care are doomed from the outset because people can’t get beyond the outrage they feel when they discover that something they thought was free is not. At a Westminster level both Labour with its “Death Tax” and the Tories with their “Dementia Tax” have scars on their backs for trying to fund adult social care appropriately. And although both parties have tried to do something about it they have also been utterly unscrupulous in attacking their opponents for developing policies to address it.

Next month NICVA is to host a workshop on the expert panel review of adult social care in Northern Ireland, Power to People which has been organised by the Department.

Power to People described adult social care in Northern Ireland as “collapsing in slow motion” and laid out a series of proposals for reform. These were widely welcomed. But without accompanying costings.

This needs to be addressed. Power to People’s proposals will cost more than the existing system – so therefore if the debate is to have any substance we need to know how much more, and to start to address the sensitive and difficult question of where the extra money will come from. 

Finally, whilst health and social services are devolved to Northern Ireland, we have no tax-raising powers. The Northern Ireland government gets its budget from monies allocated by Westminster via the Barnet formula. There will always be a limit to what we can do alone. The future of health and social care services is also part of a broader UK-wide debate.