All of the party leaders, before the recent election, committed themselves to taking politics out of health. Is that realistic? I would suggest not. But what we can do is we can take politics out of the day to day running of Health and Social Care. That is an entirely different prospect.
Bevan’s original idea of the Health Service was that it would dramatically improve the health of the population. Demand would decrease and cost would be reduced. This has not happened and we now have an infinite demand with finite resources.
We spend almost half the block grant on Health and Social Care: the equivalent of over ten million pounds a day. That delivers only eighteen per cent of the health and well-being of each of us.
We need to work with and support the other social determinants which are responsible for the other eighty two per cent of our health and well-being.
So with budgets short and political will scarce: how do we go about this?
We had difficulties with policing, a very contentious issue. One of the ways of addressing some of the problems, not all, was to set up the Policing Board. It is composed of politicians, as well as the good and the great, who can challenge, question and demand explanations from the Chief Constable.
The Chief Constable is directly responsible for day to day operational matters of policing and cannot be over ruled by the Policing Board. If they do not like what the individual is doing the only recourse is dismissal.
Therefore I would suggest we need to have a situation where there is a Chief Executive with absolute authority over operational matters. The Chief Executive would be answerable to a board that has the right to question, has the right to demand explanations, and if necessary sack the individual but cannot overrule any decision.
This board would consist of politicians and some of the good and the great and it would be assembled according to the dHondt formulary set out in the Northern Ireland Act 1998. The Department and the Minister could develop policy in strategy. But they could not nor could the Board if set up overrule the Chief Operating Officer.
My hope is that the report by Professor Raphael Bengora will suggest a similar scenario and will help drive forward the necessary changes. Also in the background is the long delayed O’Hara report of the Hyponatraemia Inquiry which when released will certainly have significant implications for the governance and accountability of those who operate in our Health and Social Care system.
What should an ideal health care system look like?
It should be universal, it should be free at the point of need not want, its focus should be in preventing illness and health promotion and in fact it should run a wellness service not an illness service. Our priorities should be given to self-management and we should be supporting carers. This is also the self-management of minor illness, which was the case when I started my career, but now appears to have disappeared. Everyone wants an instant response and instant solution to trivial, not life threatening, episodes of illness.
The focus should be on Primary Care. By that I mean in a broader sense including District Nurses, General Practitioners, Pharmacists, Dentists: the whole team that delivers most of our health and well-being outside of hospital.
There needs to be a greater emphasis on identifying people who need extra support. The gold standard is to have proper integrated care not the present service which lacks evidence of integration at the coal face. Ideally all involved in Health and Social Care should work for a single organisation, but that is probably a step too far at present. Greater efforts are needed to improve information technology and develop co-ordinated care.
We also need a different model of delivery. When I first qualified I was trained in acute episodic curative illness. All of my patients with chronic diseases attended the medical outpatients at hospital and now the medical outpatients have disappeared. My hospital colleagues are super specialists for the most part and chronic disease management is in the hands of general practice. Yet we are using the same acute episodic curative model for conditions which we will never cure, and will eventually result in the death of the individual. There has been no increase in funding or numbers of health care professionals in Primary Care to deal with these significant and increasing demands.
In summary, whilst it is not possible to take politics out of health, politics can be removed from the day to day running of health. A body similar to the Policing Board with the equivalent of a Chief Constable in charge of operational matters needs to be agreed by our elected representatives with a consensus ten year vision based on the Bengora Expert Group report for Health and Social Care.
The Health Board would consist of politicians based on the dHondt principles and the good and the great. They would be able to hold the Chief Executive to account and question operational decisions. But they could not change or overrule and if they were not happy they could sack the individual. Change is needed urgently as time is running out.