The media hype on our latest could-do-better Health Service report Systems not Structures: Changing Health and Social Care, was more positive than I expected. BBC wheeled out the usual pundits. John Compton welcomed the report saying it was good to say things over and over again until the public finally heard the message. Dr George O’Neill was unusually positive but that seems to be because his Accountable Care System (ACS) approach got a good airing. At least George understands ACSs which is more than can be said for the rest of us but with no experience of how ACSs might work in a nationally funded public health care systems such ours it is a bit of a gamble to say the least.
Professor Bengoa, the genial Spanish academic parachuted into N. Ireland to save our health service has done his work, smiled for the cameras, spoke to the Assembly and now flown home. He leaves a report full of jargon which most of us struggle to understand when he describes a model in which, and by which, our health services will sustainably meet our health needs. He tells us our health service must transform to become; fit for purpose, more responsive, more efficient. Nobody disagrees.
Yet we have just wasted 10 years when transformation should have happened in the commissioning model. The commissioning model replaced a primary-care fundholding model that had brought some significant efficiencies to our health service but was ideologically problematic for Labour who crashed it when they took power in 1999. The commissioning model was designed to buy services from five health trusts and primary care organisations in the context of a change strategy Transforming Your Care (TYC). But in the end this model was deemed to have failed by Liam Donaldson – another expert parachuted in – and on the foot of his report the DoH did away with the Health Board – it will cease functioning in March 2017. The Donaldson Report, The Right Time, The Right Place (Jan 2015) recommended a review of commissioning and Richard Pengelly, Permanent Secretary DoH headed this review that ultimately led to Professor Bengoa as head of a “Panel of Experts”. Accepting that commissioning has failed Professor Bengoa and his team were asked to come up with a new model and is now proposing an Accountable Care System approach. I think.
Why did the commissioning model fail? The simple answer is that the structures created to support commissioning were too complex and as a result allowed too much interference with decision making by those who quietly prefer the status quo; the system, the media, politicians, healthcare professionals and the unions.
Local Commissioning Groups, set up in shadow form in 2007, began working on local commissioning in 2009 following creation of the single Health and Social Care Board under the HSC (Reform) Act (NI) 2009. The five LCGs’ legal remit was simple; identify the health needs of your population, develop and implement services to address these needs and, when in place, work out if the services are effective in addressing the health need they were designed for; if they are continue to fund then; if not decommission them.
Sir Liam’s Donaldson’s report said local commissioning was merely tinkering with a few well-meaning projects. LCG committees initially could have been accused of lacking ambition but over time they provided a clear opportunity to achieve the transformation set out in John Compton’s strategy Transforming Your Care. Yet LCGs simply weren’t allowed to. LCG committee members became frustrated with a system that failed to properly resource or support real, local decision making. Indeed the system of commissioning that evolved in the HSCB was unnecessarily complicated with myriad groups within the Health Board, but also outside, acting in a commissioning role.
Commissioning in the HSCB was only one of eight directorates and therefore within a system that had a strong culture of command and control, it was inevitable that each of the directorates would develop into silos each with a strong hierarchy that worked against change and for the status quo. This is what Donaldson meant when he said that managers “look up rather than out”. Partnership working, it was hoped, would break-down barriers if silos developed. Silos were deeper and more rigid than was initially expected and as a result partnership working became more difficult.
Under the commissioning model there were successes; Percutaneous Cardiac Intervention, Stroke Services, Reablement, Glaucoma services, Mental Health Hubs, Pathways for four clinical priorities; COPD, Diabetes, Frail Elderly and Stroke. But the HSCB was unnecessarily fragmented and there seemed to be no clear plan that one group owned.
As the next model of health care for N. Ireland becomes clearer – and it might be Accountable Care Systems – I hope that some lessons have been learnt from the commissioning model. The vested interests supporting the status quo in our health service are much more powerful than we appreciate. Rather than simply repeating a message that we must change we need to actively counter these vested interests if we are to succeed in creating a health service that truly addresses the public’s real health needs.
Terry Maguire is a community pharmacist working in Belfast. He was a member of Belfast LCG from 2007 -2015 and was its Chair in 2014-2015.