Real politics prefers a health service Status Quo…

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.

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  • Korhomme

    I had a go at reading Prof Bengoa’s report; I really didn’t understand what he was getting at. I could not see what was envisaged for the future.

    I didn’t see, but perhaps I missed it, reference to the divided nature of N Ireland. One half, roughly, or the population lives in the greater Belfast area; the other half doesn’t. Sorting greater Belfast might be easy enough — it isn’t that dissimilar to the SE of England. Sorting the rest is more difficult. Scotland has the Hebrides, Orkney and Shetland all of which are isolated communities, yet all have, for example, hospital provision. Rural NI isn’t quite so isolated, but like the Scottish islands, it isn’t anything like SE England. How do you attract services to relatively isolated areas? Do we have the support infrastructure for them? Do we need a ‘two-model’ system?

  • Declan Doyle

    An all island approach to health is the best way forward.

  • Am Ghobsmacht

    As in a ‘reduction in duplication of services’?

  • Old Mortality

    Indeed it might, in which case a lot of us can look forward to choosing between VHI and its various competitors whatever they call themselves at the moment. It’ll be a bargain at less that €1,000pa.

  • Declan Doyle

    You can also look forward to not having to wait two weeks for a gp appointment.

  • Declan Doyle

    At administrative level yes

  • lizmcneill

    But how much is that in pesos, I mean sterling?

  • Am Ghobsmacht

    Just administration?

  • Old Mortality

    That’s one benefit of private health insurance but I don’t think it’s enough to persuade a population weaned on ‘free’ healthcare.
    Delays in appointments can be a useful means of filtering out those with trivial complaints who may just be wanting a free prescription for paracetamol rather than going out and buying it.

  • Old Mortality

    A big purge of the public sector? Count me in, but I don’t think it’ll sell very well to the general populace.

  • Declan Doyle

    No purge, just a realistic redustribution with a cap on recruitment until such time as the numbers become reasonable and in line with international norms.

  • Declan Doyle

    That must explain the surge in UK citizens shelling out for private appointments.

  • Declan Doyle

    Absolutely. Front line staff are needed, in fact we need more in both jurisdictions.

  • Old Mortality

    What have international norms go to do with it? Surely the ambition should be to have as few as possible at the lowest possible cost. a publicly funded health service should not be treated as a job creation scheme.