Northern Ireland reforms its healthcare

Northern Ireland’s health and social care system – integrated since 1973 – is set for major reform. Simon Hamilton, the minister for health, social services and public safety, has announced a substantial overhaul of the organisational structures in Northern Ireland.

Reform is badly needed, with 373,000 patients on healthcare waiting lists for initial out-patient appointments, diagnostic tests, or in-patient treatment. That amounts to one in five of Northern Ireland’s population.   Yet Northern Ireland also spends the most per head of any of the UK’s four national healthcare systems.

At the core of Hamilton’s reform proposals is the abolition of the Health and Social Care Board, the strategic body which sits between the Department of Health, Social Services and Public Safety and the individual health trusts. The board employs nearly 500 staff and is to be wound down by April 2017.   The Department is to be advised on future policy by a new Improvement Institute.

The closing down of the Board and the creation of the Improvement Institute were recommendations from the former chief medical advisor to England, Sir Liam Donaldson, in his report for the Northern Ireland government, ‘The Right Time, the Right Place’. (Sir Liam actually recommended the Institute be composed of international experts, while the minister decided the composition would be of Northern Ireland appointments.)

Sir Liam described a system that was under intense media and political focus, with a series of investigations in recent years that examined serious failings in service standards that led to unnecessary deaths.   The service, said Sir Liam, was characterised by too many in-patient beds, too many hospitals and senior staff that were less well paid than elsewhere.

“The public would be better served if their care system could compete to attract the very best managerial talent,” suggested Sir Liam. “The pressure to keep salaries down may be penny-wise and pound-foolish.” Moreover, he argued, a rationalisation of healthcare facilities “would represent better value for money and more appropriately meet the needs of the population”.

At the heart of the problems in Northern Ireland, concluded the report, was the way in which the health and social care system is designed and operates. “It is not clear who is in charge of the system, and the commissioning system is underpowered,” said the report. Political and media pressure had stood in the way of making the necessary reforms, explained Sir Liam. Despite the concept of an integrated health and social care service in Northern Ireland, what Sir Liam found was a failure to co-operate and a number of service silos operating in isolation.

A previous review, ‘Transforming Your Care’, had been undertaken in 2011 by John Compton, then head of the Health and Social Care Board. Sir Liam found general support by professionals for the reforms proposed in that earlier report, which also proposed the rationalisation of provision. But, concluded Sir Liam, “the widespread feeling, though, is that Transforming Your Care is simply not being implemented.”

The core of Sir Liam’s recommendations amounted to creating a simpler and more effective governance system and creating a culture in which the quality and improvement of service is paramount.

Simon Hamilton made clear that much of his focus in carrying forward the reforms will be on improving the commissioning function. “From conversations I have had with clinicians it is clear that many feel that our commissioning system doesn’t work, they don’t understand it and, worst of all, it actually inhibits innovation,” he said.  Hamilton added: “We have too many layers in our system.” In future, his department will “take firmer, strategic control of our health and social care system with our trusts responsible for the planning of care in their areas and the operational independence to deliver it.”

John Simpson is visiting professor of economics at Ulster University and former chair of the Eastern Health and Social Services Board. He says he lacks confidence that minister Hamilton will carry out the full range of measures proposed by Sir Liam, such as hospital closures. “The short answer is that he has avoided that,” says Simpson. “The language is that he is in favour of improvements, but not at the detail of the Donaldson report. He may be saved by the extra money from Barnett consequentials [through higher funding of the NHS in England], but that is no excuse for not doing the things that are necessary.”

Integration of health and social care has for many years been argued by many commentators as the key to achieving both cost savings and better healthcare outcomes. Despite the mixed experience in Northern Ireland, other parts of the UK are proceeding towards greater integration.

In England, the first major experiment with integration is being launched as part of ‘DevoManc’, the devolution of more public service responsibility to an elected mayor in Greater Manchester. Here the first directly elected mayor will from April next year lead on both services. The King’s Fund has welcomed the proposal, saying it could lead to cost savings and greater responsiveness to local needs. “The unanswered question is how much freedom public sector leaders will have to depart from national policies in taking greater control of NHS resources,” said Chris Ham, King’s Fund chief executive.

In Wales, there has been limited integration of health and social care since public services reorganisation in 2009. The Social Services and Well-being Act requires from next year integration of health and social services planning. This is backed-up by a new National Commissioning Board, promoting best practice in commissioning and procurement for health, care and well-being. Its membership will come from across the health boards, local government, Welsh government and provider organisations, to take a lead role in setting the future direction of service delivery. Ministers will be able to impose greater co-operation between health and social care bodies, if they believe this is not happening sufficiently through voluntary arrangements.

Scotland initially integrated health and social care in 2000. Those arrangements were strengthened in 2007, when the management of the NHS and oversight of adult social care became the responsibility of the cabinet secretary for health and wellbeing at a political level and the Scottish Government Health and Social Care Directorates at the level of officials. The Director-General for Health and Social Care is also the chief executive of the NHS in Scotland. Continuing the integration of health and social care is described by the Scottish government as one of its major programmes of reform.

The experience across the UK suggests that while it is widely accepted that health and social integration offers potential benefits, it can be difficult to achieve. The detailed arrangements for service management are perhaps much more important than the principle of service integration.

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