The biggest blockage to health reform?

22 Jan 2016 Nick Garbutt    Last updated: 22 Jan 2016

If you ever needed proof of the dysfunctionality of Northern Ireland’s health service it was delivered from an unexpected source this week, argues Scope editor Nick Garbutt. 

The Northern Ireland Confederation for Health and Social Care published an election manifesto this week. It has the support of many charities working in the health sector and received positive coverage from the media.

It’s a good read, and provides an excellent summary of what needs to be done in order for our health services to be transformed to make them fit for purpose.

But probe a little further and it becomes clear that the report is symptomatic of a deep malaise.

The report contains very little that anyone else could possibly disagree with, which explains why so many professional bodies and charities involved in health care have signed up to it. Politicians across the divide also want to see Transforming Your Care implemented. Earlier this month Health Minister Simon Hamilton appointed a task force to examine what needs to be done. It will report back in the summer, after the Assembly elections.

Everybody is lined up. Government wants change, so do clinicians and so too do managers in this excellent exposition of what needs to be done. So given that everybody wants, or at least says they want the same thing, why is nothing happening?

There are some interesting clues in the report.

NICON represents managers right across the health service. Its members are therefore responsible for the operational management of the service and many of their “asks” are actually for things for which they, themselves are responsible.

On the surface that sounds a bit like the Chief Constable and his senior team asking politicians to get them to catch more burglars or for Louis Van Gaal and his Manchester United players writing to the board to ask them to make sure they play more attractive football.

Unless of course there is another factor at play, something not often publicly acknowledged, and reading between the lines of the document this does start to emerge.

One of the demands in the manifesto is for a proper workforce plan. This is a growing and vitally important issue for the health service to ensure that as it changes over time it has the right people with the right skills in place to meet present and future needs.

But as we have shown in the past with this piece there is no such strategy in place, this has impacted on the nursing shortage for which it has not properly planned and is exacerbating by present policy.

But workforce planning is not the responsibility of Health Minister Simon Hamilton or any of the politicians on the hill, it falls within the remit of the Human Resources department of the Department of Health, and is therefore a health manager’s job.

Similarly it is not politicians who are exacerbating the nursing brain drain by failing to award newly qualified professionals permanent jobs leading to many moving to England and Scotland, but health managers at the Trusts, many of whom are members of NICON and presumably support the manifesto!

At this point the temptation is to blame individual bureaucrats. But it is not as simple as that. All the evidence we have is that they want change as well. Something isn’t working.

The manifesto provides another clue in its call for cultural change within the health service and “greater empowerment” at all levels.

This hints at something all those who work within the health service are acutely aware of: the rigid command and control management structures that are in place, and the culture of fear that seeps through every part of the service.

Together these have several impacts: they work against innovation, whistle blowing, helpful input on service improvements from “junior” staff a fear of failure and an obsessive mistrust of the media which leads in turn to decisions not being taken because of actual or potential adverse publicity.

This is not a picture of an organisation that is in any condition to execute the transformational change required and starkly illustrates the scale of the task ahead. Yet again this is a management rather than a party political issue. It suggests that the culture of the organisation is so all pervading that even those running it are powerless to change it. It has a malevolent life of its own.

And that’s even before we come onto another issue raised in the manifesto: and that is the need for strong political leadership of the change programme. To date all parties have expressed enthusiasm for Transforming Your Care, and yet whenever any hospital or other locally based service is threatened with closure, politicians of all parties take to the streets to protest, instead of explaining to voters that this is a policy they have signed up to and which will result in better services.

Minister Hamilton is acutely aware of this and there are moves afoot to try to persuade all political parties to exercise discipline and consistency in regards to the reform programme that they are currently welcoming in principle but blocking in practice.

The scope of the task force review has yet to be published. It does seem clear though that what is required is not so much a blueprint for what needs to be done. Everyone knows what that is anyway, but more how it can be done.

The NICON manifesto is an important document. It is also a cry for help. It is becoming increasingly clear that in order to transform the services health authorities provide, those authorities will also require radical, root and branch reform, starting with the command and control culture and the fear that that inspires.



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